Geriatric Medication Safety: How to Protect Elderly Patients from Harmful Drug Interactions

Every year, over 1 in 3 hospital admissions for people over 65 are caused by medication problems. It’s not just about taking too many pills-it’s about taking the wrong ones. For older adults, even common drugs can trigger falls, confusion, kidney damage, or internal bleeding. The stakes are high, and the solutions are clearer than ever.

Why Older Adults Are at Higher Risk

As we age, our bodies change in ways that make medication use riskier. The liver and kidneys don’t filter drugs as efficiently. Body fat increases while water content drops, meaning drugs like benzodiazepines or antidepressants linger longer in the system. Many older adults take five, ten, or even more medications daily-this is called polypharmacy. And when you stack drugs, the chances of dangerous interactions spike.

A 2025 JAMA Network Open review found that seniors prescribed even one potentially inappropriate medication (PIM) are 26% more likely to have an adverse drug event. With two or more PIMs, that risk jumps to over 60%. These aren’t rare outliers-they’re routine. A 72-year-old on a blood thinner, an anticholinergic for overactive bladder, and a NSAID for arthritis? That’s a triple threat. One study showed these combinations lead to emergency room visits 3 times more often than expected.

The Beers Criteria: Your Clinical Compass

The American Geriatrics Society (AGS) first published the Beers Criteria in 1991. Since then, it’s become the most cited tool in geriatric care, with over 1,200 research papers referencing it. The 2023 update is the latest version, and it’s more precise than ever.

It lists 139 medications or drug classes that should be avoided or used with extreme caution in adults 65+. These aren’t random guesses-they’re based on decades of clinical data. For example:

• Tramadol was added because it raises the risk of hyponatremia, especially when taken with SSRIs or diuretics.
• Aspirin for primary heart disease prevention is now discouraged for anyone 70+, not just 80+, due to bleeding risks.
• Indomethacin and ketorolac (strong NSAIDs) are flagged for all older adults-no exceptions.

These aren’t just suggestions. They’re now part of CMS Measure 238, a federal requirement for emergency departments treating older adults. Hospitals must track how often patients are prescribed two or more drugs from the same high-risk class-like two different benzodiazepines or two anticholinergics. If they don’t, they lose reimbursement.

What’s New: The Alternatives List

In July 2025, the AGS released something groundbreaking: the Beers Criteria® Alternatives List. This isn’t just about what to avoid-it’s about what to use instead.

Clinicians have long struggled with deprescribing. You take away a drug, but then what? The Alternatives List answers that. It gives 47 evidence-backed options across 12 categories:

• For insomnia: sleep hygiene, cognitive behavioral therapy (CBT-I), melatonin-not benzodiazepines.
• For overactive bladder: timed voiding, pelvic floor exercises-not oxybutynin or tolterodine.
• For chronic pain: physical therapy, acetaminophen (at safe doses), topical capsaicin-not opioids or NSAIDs.

Thirty-eight percent of these alternatives are non-drug solutions. That’s huge. It means doctors aren’t just swapping one pill for another-they’re rethinking care entirely.

Real-World Successes and Failures

Some hospitals are getting this right. At the Mayo Clinic’s emergency department, a team of pharmacists, geriatricians, and ED doctors cut PIM prescriptions by 38% in six months. How? They redesigned workflows. Pharmacists joined morning rounds. They had direct access to prescribing systems. They didn’t just flag drugs-they offered alternatives.

At the University of Alabama at Birmingham, pharmacist-led medication reconciliation cut 30-day readmissions due to drug problems by 22%.

But not every program works. In one survey of 850 emergency physicians, 41% said their EHR systems flooded them with Beers Criteria alerts-even for appropriate prescriptions. A 78-year-old on warfarin for atrial fibrillation? The system still warns about bleeding risk. Clinicians get so used to ignoring the alerts that they start overriding them all. One doctor called it “alert fatigue.”

And there’s another problem: rigid rules can backfire. A Reddit post from a doctor described how a 68-year-old with strong heart disease risk factors was denied aspirin because the system said “no aspirin after 70.” The patient had no bleeding history. The rule didn’t fit the person.

What Works in Practice

The most effective programs share three things:

1. Multidisciplinary teams-pharmacists, geriatricians, nurses, and social workers working together. Studies show these teams reduce PIMs by 37%, compared to just 22% with computer alerts alone.
2. Deprescribing conversations-not just stopping drugs, but talking to patients about why. A 2025 study found that 42% of seniors agreed to stop a medication when the doctor explained the risks in plain language.
3. Customized EHR alerts-not blanket warnings. Smart systems now filter alerts by clinical context: “Don’t warn about warfarin if the patient has atrial fibrillation.”

The GEMS-Rx toolkit, designed for emergency departments, gives providers quick-reference cards and scripts for talking to older patients. Eighty-nine percent of users said it made their job easier.

The Bigger Picture: Demographics and Dollars

By 2030, 74 million Americans will be over 65. Right now, 17% of the population is. Medication problems already cost the U.S. healthcare system $528 billion a year. CMS is responding: hospitals that don’t follow geriatric safety protocols face 0.5% reimbursement cuts. The market for tools and software to support this is growing at 14.3% per year.

But there’s a gap: only 3.2% of pharmacists specialize in geriatrics. Meanwhile, 16% of all prescriptions go to older adults. We’re training too few experts to care for too many patients.

What You Can Do

If you’re caring for an older adult:

• Ask: “Are all these medications still needed?”
• Bring a complete list to every appointment-including supplements and OTC drugs.
• Ask if non-drug options exist for pain, sleep, or bladder issues.
• Watch for signs of side effects: confusion, dizziness, falls, nausea, or changes in urination.

If you’re a provider:

• Use the 2023 Beers Criteria and the 2025 Alternatives List together.
• Partner with a clinical pharmacist. Even 0.5 FTE per 20,000 ED visits makes a measurable difference.
• Don’t follow rules blindly. A 70-year-old with no bleeding history and high cardiac risk might still benefit from low-dose aspirin.

What’s Coming Next

By 2026, CMS will expand Measure 238 to track deprescribing-not just prescribing. That means hospitals will be rewarded not just for stopping bad drugs, but for successfully switching to safer ones.

The AGS is also developing AI-driven alert systems for EHRs. Instead of bombarding clinicians with every Beers Criteria flag, future systems will use patient history to prioritize the most dangerous interactions. This could cut alert fatigue by half.

The future of geriatric care isn’t just about avoiding harm-it’s about rebuilding care around the person, not the pill.