Geriatric emergency medication safety recommendations

High-Risk Medications to Avoid for Geriatric Patients at ED Discharge

High-Risk Therapeutic Class (AVOID)	Alternative Options (Preferred)	Valid Exceptions^ (Use with Caution)
Barbiturates Examples: phenobarbital	Epilepsy Use other anticonvulsants Examples: lamotrigine, levetiracetam) Agitation Treat pain first with acetaminophen then low-dose opioid Severe agitation Use low-dose second-generation antipsychotic Examples: olanzapine, risperidone, quetiapine (Lewy body dementia)	Seizure disorders Benzodiazepine withdrawal Ethanol withdrawal
Benzodiazepines Examples: diazepam, lorazepam, midazolam	Epilepsy Use other anticonvulsants Examples: lamotrigine, levetiracetam Agitation Treat pain first with acetaminophen then low-dose opioid Severe agitation use nonpharmacologic approach then low-dose second-generation antipsychotic Examples: olanzapine, risperidone, quetiapine (Lewy body dementia)	Seizure disorders Benzodiazepine withdrawal Ethanol withdrawal Severe generalized anxiety disorder Palliative care
First-generation antihistamines Examples: diphenhydramine (Benadryl), doxylamine, hydroxyzine (Vistaril), meclizine	Allergies Use intranasal saline or steroid (e.g., fluticasone, beclomethasone), topical antihistamines (e.g., azelastine), or second-generation antihistamines (e.g., 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)	Insomnia: use melatonin, ramelteon, doxepin (<=3 mg). 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.
Sulfonylureas	Metformin, long-acting insulin (eg, glargine).

^Indications for use where high-risk medication benefit may outweigh risks.

See Also

• Geriatrics (main)