Geriatric emergency medication safety recommendations

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

Therapeutic Class	Alternatives	Exclusions^
Barbiturates Examples: phenobarbital	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 (e.g., olanzapine, risperidone, quetiapine [Lewy body dementia]).	Seizures disorders, benzodiazepine or ethanol withdrawal, barbiturates are acceptable to use.
Benzodiazepines Examples: diazepam, lorazepam, midazolam	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 Examples: diphenhydramine (Benadryl), doxylamine, hydroxyzine (Vistaril), meclizine	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)	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).

^Exclusion criteria: valid indications to prescribe potentially inappropriate medications at ED discharge for older adults.

See Also

• Geriatrics (main)