Which OTC sleep aid is associated with a higher risk of confusion and falls in older adults due to its anticholinergic effects?

• A. Second-generation antihistamines (eg, loratadine)
• B. First-generation antihistamines (eg, diphenhydramine)
• C. Nasal corticosteroid sprays
• D. Non-sedating antihistamines

Answer: (B)

In older adults, medications with anticholinergic effects can impair cognition and balance, increasing the risk of confusion and falls. Diphenhydramine, a common first-generation antihistamine found in many OTC sleep aids, crosses into the brain and blocks acetylcholine receptors. This causes sedation but also cognitive blunting, delirium, and slower reaction times, all of which raise the likelihood of falls and confusion in the elderly.

By contrast, second-generation antihistamines like loratadine have minimal central anticholinergic activity and are far less sedating. Nasal corticosteroid sprays act locally in the nose with little systemic absorption, so they don’t contribute meaningfully to confusion or fall risk. Non-sedating antihistamines are designed to avoid CNS effects as well.

So, the first-generation antihistamines stand out as the option linked to a higher risk of confusion and falls due to their anticholinergic effects.