TOPLINE:

Analysis of over 16 million emergency department (ED) encounters revealed that about 1 in 15 (6.5%) older adults received potentially inappropriate medications (PIMs) at discharge. Prescription rates declined with advancing age, from 8.3% among patients aged 65-74 years to 1.8% among those aged 95 years or older. Skeletal muscle relaxants and first-generation antihistamines were the most commonly prescribed high-risk medications.

METHODOLOGY:

• Researchers conducted a cross-sectional analysis of 8,838,252 unique patients (16,130,160 ED encounters; mean patient age, 76 years; 57.3% women) using the Epic Cosmos multisite collaborative dataset from January 2023 to May 2025.
• The primary outcome was the prescribing of PIMs from medication classes according to Geriatric Emergency Medication Safety Recommendations (GEMS-Rx) at ED discharge, excluding medications administered during the visit.
• Secondary outcomes were the most commonly prescribed PIMs and the variation in ED-level PIM prescription rates across 1842 EDs with ≥ 25 eligible encounters; the results were stratified by medication class and patient age decade.

TAKEAWAY:

• PIM prescribing occurred in 6.5% of encounters, declining steadily with age from 8.3% among patients aged 65-74 years to 1.8% among those aged 95 years or older.
• Among 1842 EDs, the median PIM prescription rate was 5.89%, with a coefficient of variation of 0.48.
• Skeletal muscle relaxants were the most frequently prescribed PIMs (3.7% of encounters), followed by first-generation antihistamines (2.1% of encounters).
• The most commonly prescribed medications were methocarbamol (1.9% of encounters), cyclobenzaprine (1.6% of encounters), and meclizine (1.2% of encounters).

IN PRACTICE:

"Internal medicine physicians should be aware of this source of high-risk prescriptions, which warrant careful attention during care transitions from the ED," the authors of the study wrote.

SOURCE:

The study was led by Mark Iscoe, MD, MHS, Yale School of Medicine, New Haven, Connecticut. It was published online as a research letter on February 9, 2026, in JAMA Internal Medicine.

LIMITATIONS:

The study was limited by the inability to capture recommendations for over-the-counter PIMs, the reliance on diagnostic codes that may not accurately identify GEMS-Rx exceptions, and the lack of information on prior prescriptions, prescription fills, adherence, and downstream adverse effects. Additionally, the exclusive use of Epic electronic health records (EHRs) at all sites potentially limited generalizability to all US hospitals. The EHR-based methods could not capture case-level nuances such as shared decision-making discussions and prior patient experiences with medications, which may have provided context for prescribing decisions.

DISCLOSURES:

The study was supported by a Clinical and Translational Science Award grant from the National Center for Advancing Translational Science of the National Institutes of Health and by a grant from the National Institute on Aging. One author reported receiving grants from the National Center for Advancing Translational Science of the National Institutes of Health during the conduct of the study. Detailed disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.