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

Every year, over 1 in 3 hospital admissions for people over 65 are caused by medication problems. Not because they didn’t take their pills, but because the pills themselves were dangerous for their age. This isn’t rare. It’s systemic. And it’s fixable.

Why Older Adults Are at Higher Risk

As we age, our bodies change in ways that make medications behave differently. The liver and kidneys don’t process drugs as quickly. Body fat increases while water content drops. This means a dose that was safe at 50 can become toxic at 75. A single pill that’s fine for a younger person can cause confusion, falls, or kidney failure in someone older.

Then there’s polypharmacy-the habit of taking five, ten, or even more medications at once. It’s common. About 40% of adults over 65 take five or more prescription drugs daily. Many of these were prescribed by different doctors, over years, without ever being reviewed as a whole. The result? Dangerous interactions. Duplicate prescriptions. Drugs that no longer serve a purpose but keep getting refilled.

The numbers are stark. Older adults are 91% more likely to be hospitalized because of a bad drug reaction. They’re 60% more likely to lose mobility or independence after a medication error. And if they’re prescribed a potentially inappropriate medication (PIM), their risk of a serious adverse event jumps by 26%-and gets worse with every extra PIM.

The Beers Criteria: The Gold Standard for Safe Prescribing

Since 1991, the American Geriatrics Society (AGS) has published the Beers Criteria®-a living guide that tells clinicians which drugs to avoid in older adults. The latest version, updated in 2023, lists 139 medications or classes that pose too much risk for most people over 65.

Some are obvious: benzodiazepines like diazepam for sleep, or anticholinergics like diphenhydramine (Benadryl) for allergies. These can cause delirium, falls, and memory loss. Others are less expected. Tramadol, once seen as a safer opioid, is now flagged because it can trigger dangerous drops in sodium levels-especially when mixed with diuretics or antidepressants. Even aspirin, long thought to be harmless, is now cautioned against for primary heart disease prevention in people over 70, because bleeding risks outweigh benefits.

What makes the Beers Criteria powerful isn’t just the list-it’s how it’s used. Epic, the biggest electronic health record system in the U.S., now includes Beers Criteria alerts in 87% of its geriatric-focused installations. When a doctor tries to prescribe a flagged drug, the system pops up a warning. Sounds smart, right? But here’s the catch: in many hospitals, these alerts fire for every patient over 65-even when the drug is perfectly appropriate, like warfarin for atrial fibrillation. Clinicians start ignoring them. One emergency doctor reported override rates of 65%. Alert fatigue is real. And it kills.

The Missing Piece: What to Prescribe Instead

For years, doctors knew what not to give. But they didn’t know what to give instead. That changed in July 2025, when the AGS released the Beers Criteria® Alternatives List.

This isn’t just a list of safer drugs. It’s a toolkit. It gives 47 evidence-backed alternatives across 12 categories. For insomnia? Try cognitive behavioral therapy (CBT-I), not zolpidem. For chronic pain? Consider physical therapy, acetaminophen at safe doses, or topical NSAIDs instead of oral opioids. For overactive bladder? Pelvic floor exercises, not oxybutynin.

Here’s the kicker: 38% of the alternatives aren’t drugs at all. They’re behavioral, physical, or environmental changes. And that’s the point. Geriatric care isn’t about adding more pills-it’s about removing the ones that hurt and replacing them with real solutions.

A 2023 survey of 1,200 primary care doctors found that 68% struggled to find safe alternatives when trying to stop a PIM. The Alternatives List answers that. It turns a problem into a plan.

How Emergency Departments Are Leading the Change

Emergency rooms are where many older adults first get caught in the medication trap. They come in with a fall, confusion, or nausea-and leave with a new prescription that makes things worse.

That’s why the Geriatric Emergency Medication Safety Recommendations (GEMS-Rx) were created in March 2024. It’s a focused set of guidelines for ED discharge. It targets eight high-risk classes: antipsychotics, benzodiazepines, anticholinergics, NSAIDs, opioids, and others. It gives ED staff a quick checklist to review before sending someone home.

Results are clear. In a July 2025 survey of 850 emergency physicians, 72% said GEMS-Rx cut high-risk prescribing by 29%. At Mayo Clinic’s ED, a team of pharmacists, geriatricians, and ER doctors slashed PIMs by 38% in six months. But it didn’t happen overnight. They spent 12 weeks training staff, redesigning workflows, and adding pharmacist-led medication reviews at discharge.

And it’s not just about stopping bad drugs. It’s about catching the ones that were never started. The STOPP/START criteria (Screening Tool of Older Person’s Prescriptions/Screening Tool to Alert Doctors to Right Treatment) look for both inappropriate prescriptions and missed opportunities. For example: an older adult with osteoporosis not on a bone-strengthening drug. Or someone with heart failure not on an ACE inhibitor. START fills those gaps.

What Works in Practice: The Teams That Get Results

The most effective programs don’t rely on software alerts alone. They rely on people.

A 2025 JAMA Network Open meta-analysis found that when clinical pharmacists and geriatricians worked directly with ER teams, PIM reduction hit 37.2%. Alone, computerized alerts only achieved 22.1%. Why? Because humans can judge context. A machine doesn’t know if a patient’s daughter is their main caregiver. Or if they’ve been on a drug for 15 years with no side effects. Or if they’re in hospice and need comfort over caution.

Successful programs share three traits:

1. They have a dedicated pharmacist on the team-ideally one with Board Certification in Geriatric Pharmacy (BCGP). There are only 1,247 of these specialists nationwide.
2. They use structured tools: deprescribing scripts, quick-reference cards, and checklists built into the workflow.
3. They don’t stop at discharge. They connect with primary care to ensure continuity.

At the University of Alabama at Birmingham, pharmacist-led medication reconciliation cut 30-day readmissions for ADEs by 22%. At Mayo, they reduced high-risk prescriptions by nearly half. These aren’t outliers. They’re models.

The Real Barriers: Alerts, Time, and Training

It’s not all progress. Many hospitals still struggle.

63% of hospitals surveyed in early 2025 said integrating Beers Criteria into their EHRs was a nightmare. Alerts are too broad. Too loud. Too frequent. Some systems flag a drug even when the patient has a clear, documented reason to take it-like NSAIDs for severe arthritis. That’s not safety. That’s noise.

Then there’s time. Most primary care visits last 15 minutes. Deprescribing takes longer. It requires asking: Why are you on this? Is it still helping? What happens if we stop? Few doctors feel trained to have these conversations.

Training helps. The Geriatric ED Guidelines 2.0 recommend at least 8 hours of focused education. But only 3.2% of pharmacists specialize in geriatrics-despite the fact that older adults take 16% of all prescriptions. The workforce gap is real.

And then there’s the risk of overcorrection. Dr. Joanne Schnur warned in JAMA Internal Medicine that blindly removing all PIMs can harm frail patients with limited life expectancy. A drug that’s risky for a healthy 75-year-old might be the only thing keeping a 90-year-old with dementia from screaming in pain. Context matters. Goals matter.

What’s Coming Next

The field is evolving fast. In 2026, CMS will expand its Measure 238 to track not just dangerous prescriptions, but also deprescribing events. That’s huge. It means stopping a bad drug will count as a quality improvement.

The AGS is also working on ‘Beers Criteria Digital Integration Standards’ for 2026-AI-driven alerts that understand clinical context before firing. Imagine a system that knows this 72-year-old has atrial fibrillation and a history of stroke, so warfarin isn’t a red flag. That’s the future.

And the demand is growing. By 2030, 74 million Americans will be over 65. Medication-related problems are projected to cost $528.4 billion annually by then. Without change, they’ll become the biggest driver of geriatric healthcare spending.

What You Can Do

If you’re caring for an older adult-whether a parent, spouse, or patient-ask these questions:

• Why is this medication still being taken?
• Has it been reviewed in the last six months?
• Is there a non-drug option we could try first?
• What happens if we stop it?

Don’t assume it’s safe just because it’s been prescribed for years. Don’t let a doctor dismiss your concern with, ‘It’s fine.’ If a drug is on the Beers Criteria list, it’s not fine. And there’s always a better way.

Geriatric medication safety isn’t about limiting care. It’s about respecting it. It’s about giving older adults the dignity of being treated with care-not just pills.