Geriatric Medication Safety: How to Protect Elderly Patients from Harmful Drugs

Every year, over 1.3 million older adults in the U.S. end up in the hospital because of dangerous drug reactions. Most of these cases aren’t accidents-they’re preventable. The problem isn’t that doctors are careless. It’s that the body changes with age, and many medications prescribed for younger patients become risky-or even deadly-for seniors. This isn’t theoretical. It’s happening in emergency rooms, nursing homes, and living rooms across the country. The solution isn’t just stopping bad drugs. It’s replacing them with smarter, safer options-and doing it in a way that respects the person behind the prescription.

Why Older Adults Are at Higher Risk

As we age, our bodies don’t process drugs the same way. The liver slows down. The kidneys filter less efficiently. Fat increases, muscle mass decreases. That means a drug that was safe at 50 can build up to toxic levels by 75. Even a standard dose of a common painkiller or sleep aid can cause confusion, falls, or internal bleeding in someone over 65.

And it’s not just one drug. Most older adults take five or more medications daily. This is called polypharmacy. It’s not always avoidable-managing diabetes, heart disease, arthritis, and depression often requires multiple drugs. But when those drugs interact, or when one drug masks the side effects of another, the risks multiply. A 2025 JAMA Network Open review found that seniors prescribed just one potentially inappropriate medication (PIM) were 26% more likely to suffer a serious drug reaction. With two or more PIMs, that risk jumps to over 50%.

The Beers Criteria: The Gold Standard for Safe Prescribing

Since 1991, the American Geriatrics Society (AGS) has published the Beers Criteria®-a living list of medications that should be avoided or used with extreme caution in older adults. The latest version, released in 2023, identified 139 drugs or drug classes as potentially inappropriate. These aren’t random picks. Each was backed by clinical studies showing clear harm in older populations.

Some examples? Benzodiazepines like diazepam (Valium) and lorazepam (Ativan). These are often prescribed for anxiety or insomnia, but they cause dizziness, memory loss, and increase fall risk by up to 60%. Anticholinergics like diphenhydramine (Benadryl) and oxybutynin (Ditropan) are linked to confusion and dementia-like symptoms. Even common NSAIDs like indomethacin and ketorolac can cause kidney failure or stomach bleeding in seniors.

The 2023 update added tramadol, a painkiller many assume is safe because it’s not an opioid. But tramadol can trigger dangerously low sodium levels (hyponatremia), especially when taken with antidepressants or diuretics. It also raised the aspirin warning age from 80 to 70-because even low-dose aspirin for heart protection can cause life-threatening bleeding in older adults, particularly men.

What makes the Beers Criteria powerful isn’t just the list-it’s how widely it’s used. Epic’s electronic health record system now flags these drugs in 87% of its geriatric installations. That means when a doctor types in a prescription for a 72-year-old, the system pops up a warning. But here’s the catch: alerts alone aren’t enough. A 2024 Health Affairs study showed that hospitals using Beers Criteria alerts alone reduced dangerous prescriptions by only 18%. When pharmacists joined the team, that number jumped to 35%.

The Missing Piece: What to Use Instead

For years, doctors knew what drugs to avoid-but not what to prescribe instead. That’s why, on July 23, 2025, the AGS released something groundbreaking: the Beers Criteria® Alternatives List.

This isn’t just a list of safer drugs. It’s a toolkit. For each of the 12 most common PIM categories, it offers 47 evidence-based alternatives. And here’s the key: 38% of those alternatives aren’t drugs at all.

Instead of prescribing a sleeping pill for insomnia, the Alternatives List suggests:

• Behavioral sleep therapy (CBT-I)
• Reducing evening caffeine
• Increasing morning sunlight exposure
• Establishing a consistent bedtime routine

For chronic pain? Replace NSAIDs with:

• Physical therapy
• Acupuncture
• Topical capsaicin or lidocaine patches
• Low-dose gabapentin (used cautiously)

For overactive bladder? Skip oxybutynin and try:

• Bladder training
• Timed voiding
• Weight management
• Pelvic floor exercises

This shift-from just stopping bad drugs to actively replacing them with better options-is what’s making the difference. A 2023 survey of 1,200 primary care doctors found that 68% struggled to find safe alternatives when trying to deprescribe. The Alternatives List gave them a roadmap.

How Emergency Rooms Are Leading the Change

Emergency departments are on the front lines. Seniors come in with falls, confusion, or stomach bleeding-and often, the root cause is a medication they’ve been taking for years. That’s why the Geriatric Emergency Medication Safety Recommendations (GEMS-Rx) were created in March 2024.

GEMS-Rx focuses on just eight high-risk drug classes that are most likely to cause harm when prescribed at discharge: antipsychotics, benzodiazepines, anticholinergics, NSAIDs, opioids, certain diabetes drugs, proton pump inhibitors, and anticoagulants. It gives ED teams a simple checklist: Is this drug necessary? Is there a safer alternative? Has the patient been reviewed by a pharmacist?

Results speak for themselves. In a July 2025 Medscape survey of 850 ER doctors, 72% said GEMS-Rx reduced high-risk prescriptions by nearly 30%. At Mayo Clinic’s Rochester ED, a team of pharmacists, geriatricians, and ER physicians cut dangerous prescriptions by 38% in just six months. But it took 12 weeks of training and workflow changes to get there.

Not every hospital can afford a full geriatric team. But even small steps help. A simple pharmacist review before discharge, or a printed handout with alternative options, can make a difference. The GEDC Toolkit, developed by the Geriatric Emergency Department Collaborative, offers free resources like deprescribing scripts and STOPP/START quick-reference cards. Over 89% of early adopters called them “highly useful.”

The Real Challenge: Alert Fatigue and Overcorrection

Technology isn’t perfect. Many hospitals use EHR systems that trigger Beers Criteria alerts for every patient over 65-even when the drug is clearly appropriate. A warfarin prescription for atrial fibrillation? Alert. Low-dose aspirin for a patient with a history of heart attack? Alert. A beta-blocker for controlled hypertension? Alert.

That’s called alert fatigue. When doctors see too many warnings, they start ignoring them. In one Epic-using hospital, 65% of Beers alerts were overridden-even when the drug was clinically necessary. Dr. Lisa Chen, an emergency physician, put it bluntly on a geriatric ED Facebook group: “We’re being trained to override, not to think.”

And there’s another danger: deprescribing too aggressively. Not every older adult needs every drug stopped. A frail 85-year-old with advanced dementia might not benefit from stopping a statin. But a 70-year-old with no heart disease, taking aspirin daily for “prevention,” might be better off without it.

That’s why experts like Dr. Joanne Schnur warn against rigid rules. The Beers Criteria are guides-not laws. The goal isn’t to eliminate all medications. It’s to match the right treatment to the right person, with their goals, values, and life expectancy in mind.

What Works in Real Life

The most successful programs don’t rely on software alone. They combine:

• Pharmacists trained in geriatrics (Board Certified in Geriatric Pharmacy, or BCGP)
• Geriatricians who understand frailty and comorbidities
• ED teams trained in deprescribing conversations
• Clear documentation for CMS Measure 238

At the University of Alabama at Birmingham, a pharmacist-led medication reconciliation program cut 30-day readmissions for drug-related problems by 22%. At Mayo Clinic, they now require a pharmacist to review all discharges for patients over 70. At smaller rural hospitals, they use simplified GEMS-Rx checklists and train nurses to flag high-risk prescriptions.

It’s not easy. It takes time. It takes training. But the cost of doing nothing is higher. In 2025, medication-related hospitalizations for seniors cost the U.S. healthcare system $2.8 billion. And that number is rising as the population ages.

What’s Next

By 2026, CMS will expand Measure 238 to track not just dangerous prescriptions-but also deprescribing events. That means hospitals will be measured not just on how many bad drugs they avoid, but on how many they safely remove.

The AGS is also working on “Beers Criteria Digital Integration Standards,” expected in early 2026. These will help EHR systems use AI to understand context-so alerts only fire when truly needed. For example, if a patient has atrial fibrillation and is on warfarin, the system should know that’s not a Beers Criteria violation.

The future of geriatric medication safety isn’t about more alerts. It’s about smarter care. It’s about asking: “Is this drug helping this person live better-or just prolonging a list of side effects?”

The answer isn’t always simple. But the question is worth asking-for every 70-year-old, every 85-year-old, every grandparent who deserves to take only what they truly need.