Potentially Inappropriate Medications in Hospitalized Older Patients in Tabuk, Saudi Arabia Using 2023 Beers Criteria: A Retrospective Multi-Centric Study

Introduction

During the past century, people’s life expectancy has dramatically increased. Older populations of 65 to 69 years are prescribed an average of 14 medications, and 80 to 84 years of age receive 18 medications.¹ The number of older people in Saudi Arabia is on the rise and is expected to reach 10 million by 2050, as reported by the United Nations.² With regard to the healthcare system, the older population has an increased morbidity burden.³ They are prone to multiple disease conditions and are therefore prescribed multiple medications.⁴

Prescribing multiple medications is termed polypharmacy and is commonly prescribed to older adults. Although there is no specific definition of polypharmacy, prescribing five or more medications concurrently is termed polypharmacy,⁵ and polypharmacy has been proven to be associated with declining physical and mental wellness in the older population.⁶ Despite this, older persons are prescribed ten or more medications, which can be life-threatening.⁷ The use of medications that carry more risks than benefits is known as inappropriate medication, especially when safer medications may be used in their place.⁸ Polypharmacy in older people elevates the risk of inappropriate medication use, which might increase the risk of medication interactions, morbidity, mortality, and healthcare issues.⁹ Pharmacokinetic and pharmacodynamic properties change with ageing, and this also influences the effect of medications.¹⁰

Studies on the prevalence of possibly inappropriate medications among older patients in many nations have been conducted, but the results have not consistently demonstrated the incidence of inappropriate prescriptions because each nation has a unique clinical practice environment.^11,12 In China, the prevalence of PIMs was 73.4% in 2018¹¹ and in the United States it was 30%.¹² Therefore, effective optimization techniques are required to enhance the prescribing of medications for older patients.¹³ There is a requirement for an easy, affordable, and quick tool for screening to be used frequently to direct the practice of prescribers and lower inappropriate prescribing rates in older people. The tool used should be specific and sensitive, and the screening tool must provide positive clinical outcomes.¹⁴

Several tools have been developed to identify potentially inappropriate medications for older adults. The Beers Criteria are used to identify potentially inappropriate medications (PIMs) in older population. The American Geriatrics Society (AGS) is updated every three years and provides a medication list that is harmful or inappropriate for older people.¹⁵ The 2023 Beers Criteria provide five categories: medications considered potentially inappropriate, medications that are potentially inappropriate in patients with certain diseases or syndromes, medications to be used with caution, potentially inappropriate drug–drug interactions, and medications that require dose adjustment based on kidney function.

PIMs lead to a high risk of falls in older patients, decreased cognitive function, increased hospitalizations and mortality and increased healthcare costs.^16,17 Antipsychotics, benzodiazepines, opioids and anticholinergics are common PIMs used in the older population.¹⁸ These medications should be used cautiously in older patients who really need them, keeping in mind that the benefits should outweigh the harm. Despite the familiarity of the Beers Criteria among clinicians, the proportion of PIMs in older adults is still on the rise.¹⁹

Although several studies have been published on PIMs in the older population using the Beers Criteria, no study has been conducted using the 2023 Beers Criteria. Hence, this study aimed to evaluate PIMs in older patients according to the Beers Criteria 2023 guidelines. To the best of our knowledge, this is the first multicenter study to assess PIMs in Tabuk using the 2023 Beers Criteria in older patients.

Materials and Methods

Study Design, Setting and Participants

This was a retrospective cross-sectional study in an inpatient setting. Electronic medical records were used to extract the data. Subjects aged ≥65 years, admitted to two government hospitals from June 2022 to May 2023, and prescribed five or more medications were included. Medical records with incomplete data, liver cirrhotic patients, chronic kidney disease stage 4 or 5 patients, dialysis patients and patients admitted to the intensive care unit or oncology department were excluded from this study. The sample size was calculated with a 99% confidence interval, 50% response distribution, and ± 5% margin of error. The desired sample size was calculated using the Raosoft sample size calculator software to be 419 participants.²⁰ This study was conducted in accordance with the Declaration of Helsinki and approved by the Tabuk Institutional Review Board (TU-077/022/131).

Data Collection

Demographic details such as age, gender, height, weight, diagnosis, comorbid conditions, drug allergy or intolerance history, and prescription medications (generic name of the medication, dose, dosage, frequency, route of administration, duration of use) were extracted from the data records. Medications of older patients were assessed for PIMs using the 2023 Beers criteria.¹⁵ Creatinine clearance was calculated using the Cockcroft-Gault Equation:²¹

PIMs were categorized into medications considered potentially inappropriate, medications that are potentially inappropriate in patients with certain diseases or syndromes, medications to be used with caution, potentially inappropriate drug–drug interactions, and medications need dose adjustment based on kidney function.

Statistical Analysis

The data were analyzed using SPSS version 27. Descriptive analysis was performed for categorical and continuous variables and the results were expressed as means and standard deviations, numbers, percentages and p-values when necessary. Logistic regression was used to assess the influence of age, gender, number of medications and comorbidities on PIMs. A regression coefficient (Exp B) with a 95% confidence interval (CI) was reported, and the level of significance was set at p < 0.05.

Results

Based on the inclusion criteria, 420 patients’ records were reviewed during the study period. Among them, 48% of the study population was male and 52% was female. The majority of the study population was in the age group 65–74 years (50.95%). The mean age of participants was 75.52 ± 8.70 years. Among the 420 study participants, the majority suffered from hypertension (72.38%) followed by diabetes mellitus (49.52%) (Table 1).

Table 1 Characteristics of the Study Population

Based on the patient characteristics, Table 2 shows the frequency of PIMs among the participants. The frequency of PIMs increased as the number of diseases increased, and a similar pattern was observed for the number of medications. The prevalence of PIMs was similar between men and women.

Table 2 Distribution of PIMs as per Patient Characteristics

The categorization of the PIMs is presented in Table 3. A total of 716 PIMs were identified. The proportion of medications considered as potentially inappropriate among older adults was 70.11% and the most commonly prescribed PIM were proton pump inhibitors (PPIs) (52.99%). The proportion of medications to be used with caution was 19.55%, and the most frequently prescribed medication to be used with caution was diuretics (91.43%).

Table 3 Categorization of PIMS

According to the AGS Beers Criteria 2023, 342 of 420 participants had PIMs (81.43%).

Of these, 35.41% were administered one PIM, 26.48% were administered two PIMs, and 17.32% were administered three PIMs. However, four (1.25%) and five (0.97%) PIMs were uncommon. The proportion of people who were prescribed PIMs according to age group is shown in Figure 1.

Figure 1 Proportion of older patients receiving PIMS.

Among the 716 PIMs, the most commonly prescribed medications were PPIs (37.15%), followed by aspirin (19.27%) and diuretics (17.88%) (Figure 2).

Figure 2 Commonly prescribed PIMs.

Multivariate logistic regression was used to assess the influence of age, gender, number of medications and comorbidities on PIMs (Table 4). Gender and comorbidity did not influence PIMs, but age and number of medications significantly influenced the likelihood of PIMs.

Table 4 Logistic Regression Analysis Among Explanatory Variables and PIMs

Discussion

This study assessed the prevalence of PIMs in the Tabuk population aged ≥65 years. Our study findings showed that most participants were in the age group of 65–69 years (32.38%), had one or two disease conditions (60%), hypertension (72.38%) and diabetes (49.52%) as common comorbidities, and were prescribed five to nine medications (77.62%) and 81.43% of the older patients were prescribed a PIM. The medications prescribed depend on the number of diseases; hence, multiple comorbidities compel the physicians to prescribe multiple medications.²² Our study found that one-third of the older persons had three to four comorbidities, which explains the prescription of more medications. In our study, nearly three-quarters of the study population had hypertension, and almost half of the study population had diabetes mellitus. Several studies have reported a positive association between PIMs and cardiovascular diseases and diabetes.^23,24

PIMs were commonly found among older persons in our study, which showed that 35.41% were prescribed one PIM and the prevalence of PIM was found to be 81.43%. A higher prevalence rate has also been observed in other studies. A study conducted in China reported 93.8% of PIM prevalence²⁵ and a Portuguese study reported the prevalence of PIMs to be 92%.²⁶ However, a study conducted in Riyadh, Saudi Arabia, reported that the prevalence of PIM in older adults was 57.2%, 63.6% and 60.4% in 2017, 2018 and 2019, respectively. They also reported an increase in the prevalence of PIMs from 2017 to 2019.²⁷ Different studies conducted in different settings reported the existence of PIMs – 53.1% in Kuwait,²⁸ 76% in Qatar²⁹ and 62.5% in Jordan.³⁰ The increased prevalence of PIMs in our older population could be related to the prescribing patterns of prescribers and difference in study setting and population. There may be limited awareness about PIMs and the tools used to assess PIMs, and the physicians’ attitude of not making changes in the prescription prescribed by other physicians.³¹ Moreover, we used 2023 Beers criteria, which was a modified version of Beers criteria 2019. The modifications made in 2023 Beers criteria would also be a reason for this increasing prevalence of PIMs. For instance, aspirin was moved from “Medications to be used with caution” to “Medications considered as potentially inappropriate” on the basis of new evidence. In Saudi Arabia, most interns do not receive training in geriatric medicine.³² Moreover, 87% of residents reported that they did not wish to take geriatric medicine as their career in their future.³² These factors warrant further research to assess the local guidelines regarding medication prescribing in older persons. Studies have demonstrated that medication reviews resulted in a decrease in the prevalence of PIMs in older adults.^33,34 The outcomes of pharmacist interventions have not yet been studied in Saudi Arabia. In addition, we included an older population prescribed at least 5 medications, which could be one of the reasons for the increased prevalence of PIMs.

According to our study, the proportion of medications considered as potentially inappropriate among older adults was 70.11% and the most commonly prescribed PIM were PPIs. Older adults generally expect the prescribers to prescribe them with PPIs and PPIs dramatically improve their quality of life.³⁵ The proportion of medications to be used with caution was 19.55%, and diuretics were the most frequently prescribed medications. Similar to our study results, another study reported that the prevalence of PIMs that should be avoided was 60.7%, with gastrointestinal drugs commonly prescribed, and the prevalence of PIMs that should be used with caution was 40.6%, with diuretics, antidepressants and antiplatelet drugs commonly prescribed.²⁹ Other studies also demonstrated that PPIs were the most common³⁶ and second most commonly prescribed PIM.³⁷ PPIs are most commonly used to treat ulcers and gastritis and are more frequently used in hospitalized patients to prevent stress ulcers.³⁸ Long-term use of PPIs results in renal toxicity or Clostridium difficile infection.³⁹ Pharmacists should intervene to improve the medication prescribing by reviewing the medication chart, assessing the appropriateness using different tools and discontinuing inappropriate medications.⁴⁰ The most common drug–drug interaction found in our study was alpha-1 blockers and loop diuretics, which was in accordance with another study that reported that loop diuretics-peripheral alpha-1 blockers were potentially inappropriate medication combinations.⁴¹ With regard to diuretics, PPIs and alpha-1 blockers, there were no differences between older Beers criteria and 2023 Beers criteria.

The current study found that gender and comorbidity did not influence PIMs, but age and number of medications significantly influenced the likelihood of PIMs. Similar results were obtained in another study, which reported that older populations with an increased number of diseases are more likely to be prescribed PIMs.²⁷ The number of medications dispensed is linked to the PIMs.⁴² An increased number of medications was found to be correlated with increased PIMs in older persons.^23,43,44 The older population visits multiple physicians for their multiple health disorders, which further increases the risk of PIMs.³¹ Similar to our study, other studies have reported that age influences PIMs.^45,46 A retrospective cohort study conducted in the United States reported mixed results regarding age and PIMs.⁴⁷ In contrast, another study reported that age does not influence PIMs.⁴⁸ This difference in results might be due to the different PIMs criteria used, study populations, and study settings. Moreover, depending on the clinical setting, such as ambulatory care, home care, hospitalization, non-critically ill brain injury patients, and critically ill brain injury patients, the prevalence of PIMs among older patients varies.⁴⁹

To improve patient outcomes and care delivery, an increasing number of healthcare systems, healthcare providers, and primary care teams are seeking the expertise of pharmacists. A critical aspect of ensuring sound pharmaceutical practice is the deliberate and informed use of the most up-to-date evidence when making decisions regarding patient care. To promote rational drug use in these contexts, pharmacists should regularly evaluate medication usage patterns and guideline adherence in hospitals by relying on the best available data.⁵⁰

PIMs in older adults lead to high treatment costs and reduced quality of life; hence, prescribers should prescribe them appropriately.⁵¹ Physicians should consider all the factors associated with PIMs. The duration of medication and dose adjustment based on liver or kidney function should be strictly monitored in older individuals.

The main strength of our study is that this is the first multicenter study conducted in Tabuk using the 2023 Beers Criteria guidelines. This study calls for action by authoritative bodies to reduce the high prevalence of PIMs among older adults and advocates for a nationwide examination of this issue. Notably, no published studies have assessed the prevalence of PIMs in Saudi Arabia using the revised Beers Criteria 2023. Our study is not without limitations. We could not generalize the results because of the small sample size and limited number of study centers. The retrospective, cross-sectional nature of the study does not provide evidence of an association between the dependent and independent variables. However, this study provides additional knowledge about PIMs in older persons in Tabuk based on the recent Beers Criteria.

Conclusion

Our results showed that PIMs are prevalent among older adults and are significantly associated with multiple medications. Age-related changes in older persons may increase the risk of PIM prescription. Frequent audits should be performed to assess PIMs, and clinicians should be informed of the same to avoid serious outcomes associated with PIMs. Intervention designed to reduce PIM need to be initiated.