GrandGuard: Taxonomy, Benchmark, and Safeguards for Elderly-Chatbot Interaction Safety

Integrating large language models (LLMs) into patient-facing healthcare systems offers significant potential to improve access to medical information. However, ensuring clinical safety and factual reliability remains a critical challenge. In practice, AI-generated responses may be conditionally correct yet medically inappropriate, as models often fail to interpret patient context and tend to produce agreeable responses rather than challenge unsafe assumptions. Unlike clinicians, who infer risk from incomplete information, LLMs frequently lack contextual awareness. Moreover, real-world patient interactions are open-ended and underspecified, unlike structured benchmark settings. We present CareGuardAI, a risk-aware safety framework for patient-facing medical question answering that addresses two key failure modes: clinical safety risk and hallucination risk. The framework introduces Clinical Safety Risk Assessment (SRA), inspired by ISO 14971, and Hallucination Risk Assessment (HRA) to evaluate medical risk and factual reliability. At inference time, CareGuardAI employs a multi-stage pipeline consisting of a controller agent, safety-constrained generation, and dual risk evaluation, followed by iterative refinement when necessary. Responses are released only when both SRA and HRA are less than or equal to 2, ensuring clinically acceptable outputs with bounded latency. We evaluate CareGuardAI on PatientSafeBench, MedSafetyBench, and MedHallu, covering both safety and hallucination detection. Across these benchmarks, the framework consistently outperforms strong baseline models, including GPT-4o-mini, demonstrating the importance of context-aware, risk-based, inference-time safety mechanisms for reliable deployment in healthcare.

Caregivers seeking AI-mediated support express complex needs---information-seeking, emotional validation, and distress cues---that warrant careful evaluation of response safety and appropriateness. Existing AI evaluation frameworks, primarily focused on general risks (toxicity, hallucinations, policy violations, etc), may not adequately capture the nuanced risks of LLM-responses in caregiving-contexts. We introduce RubRIX (Rubric-based Risk Index), a theory-driven, clinician-validated framework for evaluating risks in LLM caregiving responses. Grounded in the Elements of an Ethic of Care, RubRIX operationalizes five empirically-derived risk dimensions: Inattention, Bias & Stigma, Information Inaccuracy, Uncritical Affirmation, and Epistemic Arrogance. We evaluate six state-of-the-art LLMs on over 20,000 caregiver queries from Reddit and ALZConnected. Rubric-guided refinement consistently reduced risk-components by 45-98% after one iteration across models. This work contributes a methodological approach for developing domain-sensitive, user-centered evaluation frameworks for high-burden contexts. Our findings highlight the importance of domain-sensitive, interactional risk evaluation for the responsible deployment of LLMs in caregiving support contexts. We release benchmark datasets to enable future research on contextual risk evaluation in AI-mediated support.

Language models are increasingly being deployed for conversational support in informal caregiving contexts, where interactions often extend beyond information-seeking: caregivers seek emotional reassurance, guidance, and help, while navigating uncertain, relationally complex care decisions. Yet most safety evaluations assess model behavior under generic prompts, leaving a critical question unexamined: does a model's safety profile change with its support role? We study this by operationalizing four expert-reviewed support roles grounded in social support theory: Inform, Coach, Relate, and Listen, and comparing them against two baseline controls: a basic prompting condition and a retrieval-augmented generation (RAG) condition. We evaluate across three language models (GPT-4o-mini, Llama-3.1-8B-Instruct, and MedGemma-1.5-4b-it) on 5,000 real-world queries from online Alzheimer's Disease and Related Dementias (ADRD) communities. We find that the LLM's support role systematically shapes both the prevalence and composition of interactional risks. Furthermore, a human evaluation study reveals a perceived quality--safety tension: more directive, information-oriented roles are rated as more helpful and trustworthy despite exhibiting elevated interactional risk profiles. We release ~90,000 support role-conditioned model responses with risk annotations as an ecologically grounded resource for research on safer LLM-mediated conversational support.