Can chronic unnecessary use of cetirizine (antihistamine) in the elderly population with dementia increase the risk of falls?

Chronic Cetirizine Use and Fall Risk in Elderly with Dementia

Yes, chronic unnecessary use of cetirizine in elderly patients with dementia should be avoided due to increased fall risk, particularly because cetirizine has sedative properties at recommended doses and elderly patients with dementia are already at substantially elevated baseline fall risk. 1

Understanding Cetirizine's Risk Profile

Cetirizine is classified as a second-generation antihistamine, but unlike other agents in its class (fexofenadine, loratadine, desloratadine), cetirizine may cause sedation even at recommended doses 1. This distinguishes it from truly non-sedating second-generation antihistamines and makes it particularly problematic in vulnerable populations.

Why Elderly Patients with Dementia Are at Higher Risk

• Baseline fall risk is already nearly doubled: Elderly individuals with dementia living at home have a 1.89-fold higher risk of falls compared to those without dementia 2
• Medication use is a critical modifiable risk factor: The most recent 2025 Lancet Healthy Longevity guidelines emphasize that "use of concomitant drugs" is among the key risk factors requiring assessment in individuals with dementia and frailty 1
• Polypharmacy compounds the problem: Both frailty and dementia are associated with high polypharmacy burden, and unnecessary medications should be deprescribed 1

Specific Concerns with Cetirizine in This Population

Sedative Effects

• Cetirizine causes sedation at standard doses, unlike fexofenadine, loratadine, and desloratadine which do not 1
• Sedative effects persist longer than plasma drug levels, meaning next-day impairment can occur without subjective awareness of drowsiness 1, 3
• Older adults are more sensitive to psychomotor impairment from antihistamines with sedating properties, increasing risk of falls, fractures, and subdural hematomas 1, 3

Anticholinergic Properties

• While cetirizine has fewer anticholinergic effects than first-generation antihistamines, it still possesses some anticholinergic activity 1
• Anticholinergic medications should be discontinued when possible in patients with dementia and frailty due to their potential adverse effects 1
• Anticholinergic effects can worsen cognitive impairment, which is already present in dementia patients 1

Evidence-Based Recommendations

Medication Review and Deprescribing

The 2025 Lancet guidelines explicitly recommend systematic medication review and deprescribing of unnecessary or inappropriate medications using STOPP/START or Beers criteria 1. This is particularly critical because:

• Medication review is a key intervention strategy for fall prevention in individuals with dementia and frailty 1
• Psychotropic medications (which include sedating antihistamines) carry an odds ratio of 1.7 for falls 1
• Medications with anticholinergic properties increase fall risk with an adjusted odds ratio of 1.6 4

Safer Alternatives When Antihistamines Are Necessary

If antihistamine therapy is truly indicated (not "unnecessary" as stated in your question):

1. First choice: Fexofenadine, loratadine, or desloratadine - these do not cause sedation at recommended doses and are strongly preferred for older adults 1, 3
2. Avoid cetirizine in elderly patients with dementia due to its sedating properties at standard doses 1
3. Never use first-generation antihistamines (diphenhydramine, hydroxyzine) - these carry even higher risks of sedation, anticholinergic effects, falls, and fractures 1, 3

Clinical Algorithm for Decision-Making

1. Assess necessity: Is the antihistamine truly needed, or is this "unnecessary" chronic use? 1
2. If unnecessary: Deprescribe immediately as part of comprehensive medication review 1
3. If necessary for allergic rhinitis:
   • Switch to fexofenadine, loratadine, or desloratadine 1, 3
   • These agents have equivalent efficacy without sedation risk 1
4. Implement multimodal fall prevention: Physical exercise, environmental modifications, gait assessment, and ongoing medication monitoring 1

Critical Pitfalls to Avoid

• Do not assume all second-generation antihistamines are equivalent: Cetirizine's sedating properties make it inappropriate for elderly patients with dementia, unlike fexofenadine, loratadine, or desloratadine 1
• Do not overlook "unnecessary" medications: The question specifically mentions "unnecessary use" - this should trigger immediate deprescribing 1
• Do not ignore the cumulative effect: Even mild sedation from cetirizine, combined with baseline dementia-related fall risk (OR 1.89), creates unacceptable cumulative risk 2, 1
• Do not wait for a fall to occur: Proactive medication review is recommended for ALL individuals with dementia and frailty, not just after adverse events 1