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

Every year, more than 177,000 older adults in the U.S. are hospitalized because of dangerous drug reactions. Many of these cases aren’t accidents-they’re preventable. The problem isn’t that doctors are careless. It’s that the body changes after 65, and most medications were never tested for people over 70. What works for a 45-year-old can be dangerous for an 80-year-old. And when someone is taking five, six, or even ten different pills, the risks multiply fast.

Why Older Adults Are at Higher Risk

As we age, our kidneys and liver don’t process drugs the same way. Muscle mass decreases, fat increases, and fluid balance shifts. That means a standard dose of a blood pressure pill or sleep aid can build up in an older person’s system, leading to dizziness, falls, confusion, or even kidney failure. One study found that seniors are 91% more likely to be hospitalized due to a bad drug reaction than younger adults.

Polypharmacy-taking five or more medications-is common. About 40% of adults over 65 take at least five prescriptions. Many of these drugs interact in ways doctors don’t always catch. Take a patient on warfarin for atrial fibrillation, ibuprofen for arthritis, and a sleep medication. Each one is fine alone. Together? They raise the risk of bleeding, kidney damage, and falls. And the worst part? Many of these drugs are still prescribed routinely, even when safer options exist.

The Beers Criteria: The Gold Standard for Safe Prescribing

The American Geriatrics Society (AGS) created the Beers Criteria® in 1991 to help doctors avoid harmful medications in older adults. It’s updated every three years, and the latest version came out in 2023. It lists 139 medications or drug classes that should be avoided-or used with extreme caution-in people 65 and older.

Some of the most dangerous include:

• Benzodiazepines like diazepam and lorazepam-linked to falls, confusion, and memory loss
• Anticholinergics like diphenhydramine (Benadryl) and oxybutynin-cause brain fog and increase dementia risk
• NSAIDs like indomethacin and ketorolac-can cause stomach bleeds and kidney failure
• Tramadol-now flagged for causing dangerously low sodium levels, especially when mixed with antidepressants or diuretics
• Aspirin for heart disease prevention-no longer recommended for healthy adults 70+ because bleeding risks outweigh benefits

These aren’t just suggestions. The Centers for Medicare & Medicaid Services (CMS) now requires emergency departments to track whether older patients are prescribed two or more high-risk drugs from the same class. That’s called CMS Measure 238. Hospitals that don’t comply risk losing money.

The New Alternatives List: What to Use Instead

In July 2025, the AGS released something new: the AGS Beers Criteria® Alternatives List. This isn’t just about stopping bad drugs-it’s about replacing them with better ones.

For example:

• Instead of benzodiazepines for anxiety or insomnia, try cognitive behavioral therapy (CBT), sleep hygiene, or melatonin
• Instead of anticholinergics for overactive bladder, consider pelvic floor exercises or timed voiding
• Instead of NSAIDs for joint pain, use physical therapy, heat/cold therapy, or acetaminophen (with caution)
• Instead of antipsychotics for agitation in dementia, try environmental changes, music therapy, or structured daily routines

Thirty-eight percent of the alternatives are non-drug options. That’s huge. It means doctors don’t need to swap one pill for another-they can often remove pills entirely.

Why Computer Alerts Alone Don’t Work

Many hospitals use electronic health record (EHR) systems like Epic to flag risky prescriptions. But here’s the problem: the alerts fire for every patient over 65-even when the drug is clearly needed. One emergency physician in Boston told me her team overrides Beers Criteria warnings 65% of the time because the system doesn’t understand context. Warfarin for atrial fibrillation? It’s safe and necessary. But the system flags it anyway.

A 2025 study showed that EHR alerts alone reduce risky prescriptions by only 22%. But when you add a clinical pharmacist to the team? The drop jumps to 37%. Why? Because pharmacists don’t just see alerts-they talk to patients, review all medications together, and know when to bend the rules.

What Works in Real Hospitals

At the Mayo Clinic Rochester ED, a team of pharmacists, geriatricians, and ER doctors redesigned how medications are reviewed before discharge. They used the AGS Alternatives List and created simple checklists. In six months, they cut high-risk prescriptions by 38%.

The University of Alabama at Birmingham did something similar. They assigned pharmacists to do full medication reconciliations for every older patient leaving the ER. Result? A 22% drop in 30-day readmissions due to drug problems.

These programs didn’t happen overnight. They took 12 weeks of training, workflow changes, and buy-in from doctors. But the cost savings were clear: each avoided hospitalization saved the system an average of $12,000.

The Human Side: When Rules Can Hurt

Not every rule fits every patient. Dr. Joanne Schnur wrote in JAMA Internal Medicine that blindly following the Beers Criteria can harm frail older adults with limited life expectancy. If someone has advanced cancer and is in pain, stopping an opioid just because it’s on the list could cause unnecessary suffering.

The key is personalization. A 92-year-old with dementia and no family support needs different care than a 70-year-old who hikes every weekend and takes no other meds. The Beers Criteria are a guide-not a law. Doctors need to ask: What’s the goal of care? Is this drug helping or hurting?

What You Can Do

If you or a loved one is over 65 and taking multiple medications:

1. Ask your doctor: “Is this medication still necessary?”
2. Ask: “Are there non-drug options I could try first?”
3. Bring a full list of all medications-including vitamins, supplements, and over-the-counter drugs-to every appointment.
4. Ask for a pharmacist consult. Many clinics now offer free medication reviews.
5. Don’t stop a drug on your own. Some medications need to be tapered slowly to avoid withdrawal or rebound effects.

The Future Is Here-But It’s Not Everywhere

The tools to fix this problem exist. The Beers Criteria. The Alternatives List. CMS measures. Clinical pharmacists. But they’re not evenly distributed. While 78% of big-city trauma centers have formal geriatric medication safety programs, only 31% of rural emergency departments do.

The demand is growing. By 2030, 74 million Americans will be over 65. The cost of medication-related hospitalizations is projected to hit $528 billion a year. We can’t afford to keep doing this the same way.

The solution isn’t more pills. It’s better thinking. Slower prescribing. More conversations. And a system that puts the patient-not the protocol-first.