Geriatric emergency medication safety recommendations

Therapeutic Class	Alternatives	Exclusions
Barbiturates	Epilepsy: use other anticonvulsants (e.g., lamotrigine, levetiracetam). Agitation: treat pain first with acetaminophen then low-dose opioid. Severe agitation: use low-dose second-generation antipsychotic (eg, olanzapine, risperidone, quetiapine [Lewy body dementia]).	Seizures disorders, benzodiazepine or ethanol withdrawal, barbiturates are acceptable to use.
Benzodiazepines	Epilepsy: use other anticonvulsants (eg, lamotrigine, levetiracetam). Agitation: treat pain first with acetaminophen then low-dose opioid. Severe agitation: use nonpharmacologic approach then low-dose second-generation antipsychotic (eg, olanzapine, risperidone, quetiapine [Lewy body dementia]).	Seizure disorders: benzodiazepine or ethanol withdrawal, severe generalized anxiety disorder, and end of life, benzodiazepines are acceptable to use.
First-Generation Antihistamines	Allergies: use intranasal saline or steroid (eg, fluticasone, beclomethasone), topical antihistamines (eg, azelastine), or second-generation antihistamines (eg, fexofenadine, loratadine). Vertigo: use short-term steroids and canalith repositioning maneuvers.	For allergic reactions, first-generation antihistamines are acceptable to use.
Metoclopramide	For nausea, use ondansetron.	For gastroparesis, metoclopramide is acceptable to use.
First-Generation Antipsychotics	Second-generation antipsychotics (eg, olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone).
Nonbenzodiazepine, Benzodiazepine Receptor Agonist Hypnotics (Z-drugs)	For insomnia, use melatonin, ramelteon, doxepin (�3 mg).68-70 For anxiety, use mirtazapine, buspirone, serotonin– norepinephrine reuptake inhibitor (serotonin and norepinephrine reuptake inhibitor, eg, duloxetine, venlafaxine, desvenlafaxine).
Skeletal Muscle Relaxants	Treat musculoskeletal pain first with nonpharmacologic agents (eg, heat, ice, massage) then with Tylenol, short-course NSAIDs, lidocaine patch, diclofenac gel.

See Also

• Geriatrics (main)