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.	Acute allergic reactions
Metoclopramide	Nausea Use ondansetron	Gastroparesis
First-generation antipsychotics Examples: haloperidol, prochlorperazine, promethazine	Second-generation antipsychotics Examples: olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone
Nonbenzodiazepines (Z-drugs) Examples: zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta)	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 Examples: Baclofen (Lioresal), dantrolene (Dantrium), cyclobenzaprine (Amrix)	Treat musculoskeletal pain first with nonpharmacologic agents (e.g., heat, ice, massage) then with acetaminophen, short-course NSAIDs, lidocaine patch, diclofenac gel.
Sulfonylureas	Metformin, long-acting insulin (e.g., glargine)

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

See Also

• Geriatrics (main)