ORIGINAL ARTICLE: EPIDEMIOLOGY,CLINICAL PRACTICE AND HEALTH

Prescribing of potentially inappropriate medications amongthe elderly population in an ambulatory care setting in aSaudi military hospital: Trend and costggi_951 616..621

Hussain A Al-Omar,1,2 Mohammed S Al-Sultan1,2 and Hisham S Abu-Auda1

1Department of Clinical Pharmacy, 2Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia

Aim: To explore the prevalence of potentially inappropriate medication (PIM) use in the elderly, to identify thetrends and the patterns of prescribing such medication, and to calculate the associated direct medication cost of suchpractice in a Saudi hospital.

Methods: This was a retrospective cross-sectional study of patients who were aged 65 years or older on at least onePIM. The source of our data was outpatient pharmacy prescription records at Riyadh Military Hospital (RMH) for2002, 2003 and 2004. Beers’ explicit criteria for PIM was used to identify these medications.

Results: A total of 20 521 PIM were identified. The prevalence of PIM for 2002, 2003 and 2004 was 2.5%, 2.3% and2.1%, respectively. A total of 43.6% of the patients had filled a prescription of one PIM, 18% filled two PIM and38.4% filled three or more PIM. Digoxin accounted for 23.7% of these PIM. The most commonly prescribedmedications were cardiovascular medications at 26.7%. The total direct cost that was associated with inappropriateprescribing was 518 314 Saudi Riyals (US$138 217) during the study period.

Conclusion: PIM prescribing in RMH was less compared with what was published in the literature in othercountries. It was unclear whether these results reflect the level of elderly healthcare services provided to RMH patientsor because of underreporting. Drug utilization review programs, medical education, recruiting physicians and clinicalpharmacists who are specialized in geriatrics, finding safer medications or integration of computer software to detectsuch medications during prescriptions entry can improve the medical services provided to the elderly. GeriatrGerontol Int 2013; 13: 616–621.

Keywords: cost, drug utilization, elderly, potentially inappropriate medications, Saudi Arabia.

Introduction

Elderly people represent a large segment of the worldpopulation; the word “elderly” or “geriatrics” refers topersons who are aged 65 years or older. Demographi-cally, the relative size of the elderly population aged 65years and older is projected to increase rapidly in devel-oped countries; this increase can influence healthcarespending, retirement policies, use of long-term care ser-vices, workforce composition and income.1

In Saudi Arabia, the estimated number of elderlypeople in the year 2000 was 626 431, which represents3% of the total population; whereas for the year 2007,

they were 675 915, which represents 2.8% of thegeneral population.2

As this population increases, an ever-greater needexists to improve the health, quality of life and promotethe appropriate use of medications among the elderly.

Potentially inappropriate medications (PIM) aremedications in which the risks of use outweigh thebenefits.3 Inappropriate medication use in the elderlyhas been associated with a substantial number ofadverse drug reactions (ADR), worsening physical func-tion and excessive healthcare utilization. Nearly 5% ofall hospital admissions for the elderly are believed to berelated to ADR.4 Other studies reported a rate as highas 17% in elderly persons. In addition, up to 140 000deaths per year might be a result of ADR in this groupof the population.5 According to many publishedstudies, PIM have been estimated to affect approxi-mately 4.8–45.6% of the elderly population, and the useof such medications can be considered a challengebecause of varied and incomplete clinical information

Accepted for publication 16 August 2012.

Correspondence: Mr Hussain A Al-Omar MSc, ClinicalPharmacy Department, College of Pharmacy, King SaudUniversity, Riyadh, 11451, Saudi Arabia. Email:halomar@ksu.edu.sa

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Geriatr Gerontol Int 2013; 13: 616–621

616 � © 2012 Japan Geriatrics Societydoi: 10.1111/j.1447-0594.2012.00951.x

about the safety of the use of such medications in theelderly.

Elderly patients are at high risk of developing ADRbecause they often have complex drug regimens, age-related physiological changes, and alteration in drugpharmacokinetics and pharmacodynamics. PIM can becategorized into the following: (i) PIM; (ii) potentiallyinappropriate duration; (iii) potentially inappropriatedosage; and (iv) potentially inappropriate drug–druginteraction.6 These medications either lack the efficacyor pose an unnecessary high risk to the elderly whileother safer alternatives are available.

PIM were studied and evaluated by many experts andspecialists in geriatrics, pharmacology and medicine.Different explicit criteria were developed and publishedin the literature. The first well-known and most fre-quently used validated explicit criteria are known asBeers criteria. They were first published in 1991,updated in 1997, and finally revised and published in2003.7 Beers’ group consists of 13 recognized experts ingeriatrics pharmacology who developed a validated con-sensus and provided explicit criteria for defining inap-propriate use of medications. The experts identifiedmedications that should not be prescribed for theelderly or medications for which dose, frequency orduration of use should not be exceeded. They alsodescribed medications that should be avoided inpatients known to have various medical conditions.Beers’ categorized the criteria into two lists of medica-tions; one is independent of diagnosis or condition,whereas the second depends on diagnosis or condition.7

The second explicit criteria are known as Canadiancriteria or McLeod’s criteria. They were developed by apanel of experts in 1997 in Canada, where they initiallycategorized inappropriate practices in prescription ofmedications for elderly into three types: (i) prescriptionof medications that are generally contraindicated in theelderly because of an unacceptable risk–benefit ratio; (ii)prescription of medications that can cause drug–druginteractions; and (iii) prescription of medications thatcan cause drug–disease interactions.8 Improved Pre-scribing in the Elderly Tool (IPET) is a tool published in2000 as an attempt to update McLeod’s criteria. Itincludes a shortlist of most that most PIM that areprescribed routinely in clinical practice.9

Many studies have been published to explore andidentify the pattern of prescribing PIM in elderlypatients in different countries.

There is no doubt that the expenditure on prescribedmedications is significantly higher among the elderlycompared with their younger counterparts, whetherthey are receiving PIM or not.

Because the knowledge about healthcare services pro-vided to the elderly in Saudi Arabia was not comprehen-sively explored, the present study was carried out toidentify the prevalence of PIM prescribing in Saudi

elderly patients in one of Riyadh’s hospitals. In addition,trends, patterns and the cost of such prescribing in Saudielderly patients in that hospital were also identified.

Methods

This was a retrospective cross-sectional study that uti-lized the outpatient pharmacy prescriptions data forRiyadh Military Hospital (RMH), a tertiary care hospitallocated in Riyadh, Saudi Arabia. RMH provides servicesfor Ministry of Defense employees, and all healthcareservices expenses provided by RMH are covered by theSaudi Government. A study proposal was sent to theRMH Ethical and Research Committee for revision andapproval. After the Ethical and Research Committee hadapproved the study, we retrieved patients’ data for years2002, 2003 and 2004. Retrieved information includedpatient hospital number, age, sex, medication name,medication code, dose, duration, frequency, physicianname, physician department and medications unit cost.Data were re-coded, new variables were created and thetotal cost of medications was calculated. Only directcost of PIM was calculated by multiplying the unitcost of each medication by the quantity dispensed perprescription.

Beers’ explicit criteria published in 2003 were used asexplicit criteria to identify PIM. As the diagnosis is dif-ficult to be obtained and in most of the times is irrel-evant, we only included criteria that are independent ofdiagnosis or condition.

Data were coded and analyzed by SPSS version 14.0.for Windows (SPSS, Chicago, IL, USA).

Data normality was checked by the Kolmogorov–Smirnov test. Pearson’s c2-test was used for categoricalvariables, and t-test was used for non- categorical vari-ables. Results were considered statistically significant ifP < 0.05. A linear model was developed to estimate theprojected number of filled PIM until 2010.

Results

The mean age of the present study population was74.02 1 7.46 years (Table 1). The prevalence of PIM was

Table 1 Demographic data

Variable n (%)

Mean age 74.02 1 7.46 years65–69 years 6 575 (32)70–74 years 5 580 (27.2)375 years 8 366 (40.8)

SexMale 11 079 (54)Female 9 442 (46)

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higher in men than women (54% vs 46%) with nostatistical difference between the two sexes, and it washighest among patients who were aged 75 years andolder (40.8%; P < 0.05; Table 1).

The study identified a total of 20 521 prescribed PIMduring the study period, with a total direct cost of medi-cations of SR518 314 (US$138 217; Table 2). Just 35medications from Beers criteria were available in RMH.There were 6045 geriatrics patients who received at leastone PIM (Table 3). The majority of patients received atleast one PIM in their prescription (43.6%; Table 3).Based on risk, high-risk medications were more regu-larly prescribed than low-risk medications (57.2% vs42.8%; P < 0.05). Medications that are associated withside-effects in elderly patients were more commonlyprescribed than the others 49.6% (P < 0.05; Table 3).

Cardiovascular medications were the most frequentlyprescribed PIM (26.7%), followed by anti-arrhythmics(15.8%; Table 4). Digoxin was the most prescribedmedication (23.7%) of PIM (Fig. 1).

The present study identified that both Family andCommunity Medicine and Cardiology Departmentsprescribed PIM more frequently than other departments(31.2% and 16.8%, respectively; Table 4).

Most of RMH expenditure on inappropriate medica-tions was due to prescribing anti-arrhythmic agents(28%; Fig. 2). The cost of prescribing by departmentswas the highest among the Family and CommunityMedicine department (27.6%; Table 4).

Based on our linear model, the projected number offilled PIM until year 2010, assuming that all the factorsaffecting the pattern of prescribing will remain the same,was estimated to be 13 259 PIM for year 2010 (Fig. 3).

Discussion

A total of five studies from different countries; theUSA,10 Lebanon,11 Slovakia,12 Portugal13 and Taiwan14,

Table 2 Summary of the pattern and cost of potentially inappropriate medications

2002 2003 2004

Total no. prescriptions 1 161 565 1 590 105 2 105 106No. prescriptions 365 237 314 296 024 377 306No. prescriptions 365 of PIM 5 983 6 721 7 817Percentage of PIM 2.5% 2.3% 2.1%Total cost of prescriptions (SR†) 65 954 285 113 071 003 159 819 708Percentage of PIM costs of the total cost 0.32% 0.14% 0.1%†USD 1 equal to 3.75 Saudi Riyal (SR). PIM, potentially inappropriate medications.

Table 3 Details of potentially inappropriatemedications prescribed for elderly

Filled PIM/patients n (%)

1 PIM 2 635 (43.6)2 PIM 1 083 (18)3 or more PIM 2 327 (38.4)

Risk of PIM, n (%)High risk 11 737 (57.2)Low risk 8 784 (42.8)

Classification of PIM,n (%)Side-effects 10 170 (49.6)Dose 7 910 (38.5)Duration 2 436 (11.9)Lack of efficacy 5 (0.0)

PIM, potentially inappropriate medications.

Digoxin23.7%

Ferrous10.5%

Dipyridamole8.4%

Bisacodyl9.6%

Amitriptyline8.3%

Amiodarone7.4%

Chlorpheniramine7.1%

Other medications25.1%

Figure 1 Commonly prescribed potentially inappropriatemedications (PIM).

30%

25%

26.60%

20%

15%

10%

5%

0%

24.20%

16.70%

13.70%

3.70%

14.90%

Antiarrhythmics Plateletaggregation

inhibitors

Serotoninreuptakeinhibitors

Cardiovascularagents

Antidepressant,tricyclic

Others

Figure 2 Percentage of cost per pharmacological class.

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618 � © 2012 Japan Geriatrics Society

have been reviewed. The present study showed that theprevalence of PIM in RMH was lower than what wasreported in other studies. The average results by per-centage for one or more filled PIM prescription were21%, 59.6%, 20%, 38.5% and 10.1%, respectively.Reasons, such as the difference between Saudi elderlypatients’ life expectancy compared with other countries,lack of unified medical file, flexibility of eligibility criteriato seek medical care from different hospitals for thesame patient, availability of just 35 medications in RMHformulary that are considered to be PIM according tothe Beers criteria, and inappropriate age recording anddocumentation, might explain the low average of PIMprescription in RMH compared with other countries. Incontrast, RMH might be providing a good healthcareservice to the elderly patients compared with other hos-

pitals included in the other studies. In addition, theavailability of safer alternative medications other thanthose listed in Beers criteria in RMH might possiblyimprove the quality of the services provided for theelderly patients.

The majority of RMH geriatrics prescriptions includeat least one PIM 43.4% compared with 80.3%, 22.4%,18%, 70% and 10.1%, as reported in the USA,10 Leba-non,11 Slovakia,12 Portugal13 and Taiwan,14 respectively.This variation between the different studies might berelated to physicians’ educational background, presenceor absence of geriatrics specialties, number of availablemedications from Beers criteria in different hospitals, orfactors such as patients’ socioeconomic status andaccess to healthcare for older adults.

The high prevalence of common chronic diseases,age-related risk factors and non-age-related risk factorsamong Saudi men compared with Saudi women canexplain the increased prevalence of PIM prescribing inmen compared with women in RMH.

In comparison with the reviewed studies, most of PIMin RHM resulted from cardiovascular medications(Table 4). This pattern can be justified by the higherprevalence of cardiovascular diseases compared withother diseases among the Saudi population as a result ofthe Saudi population’s lifestyle, high cardiovascular riskfactors and socioeconomic status.

High-risk medications were more regularly pre-scribed in RMH than low-risk medications. High-riskmedications are usually prescribed for diseases and

Table 4 Summary of potentially inappropriate medications during studyperiod

n (%) Cost (SR) (%)

By departmentFamily and Community Medicine 6 410 (31.2) 143 274.4 (27.6)Cardiology 3 447 (16.8) 110 758.6 (21.4)Residency Training Program 2 350 (11.5) 58 426.62 (11.3)Medicine 1 913 (9.3) 55 886.12 (10.8)Nephrology 1 192 (5.8) 42 510.59 (8.2)Neurology 956 (4.7) 23 353.25 (4.5)Other departments 4 252 (20.7) 84 100.86 (16.3)Total 20 520 100 518 310.5 100By pharmacological classesCardiovascular agents 5 489 (26.7) 71 231 (13.7)Anti-arrhythmics 3 244 (15.8) 137 929 (26.6)Iron supplements 2 153 (10.5) 7 285 (1.4)Laxative, stimulants 1 960 (9.6) 9 481 (1.8)Antidepressant, tricyclic 1 850 (9) 22 043 (4.3)Antihistamines 1 640 (8) 4 515 (0.9)Benzodiazepine, short acting 895 (4.4) 10 028 (1.9)NSAIDs 767 (3.7) 10 135 (2.0)Other classes 2 523 (12.3) 245 663.5 (47.4)

NSAIDs, non-steroidal anti-inflammatory drugs; SR, Saudi Riyal.

Figure 3 Projection of potentially inappropriatemedications (PIM) until 2010 based on prescribing patternsobserved in the hospital.

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© 2012 Japan Geriatrics Society � 619

conditions with high prevalence in elderly patients, suchas cardiovascular diseases and psychiatric disorders.

The present study showed that medications that areassociated with side-effects in older adults were morecommonly prescribed compared with other medica-tions. First, because medications with side-effects aremainly prescribed for high-prevalence diseases inelderly patients. Second, most of the medications thatare associated with side-effects are old generation medi-cations, even though safer medications are present, buteither they are not available in the RMH formulary orphysicians are not aware of them.

The present results show that The Family and Com-munity Medicine Department prescribed PIM morefrequently, and the cost of prescribing by them washigher than other departments. This is because thenumber of patients who visit the department is higherthan the number of other patients visiting other depart-ments. Furthermore, these high results could be a resultof the usual practice of the medication refill process bythe department.

Bodenheimer has raised three main explanations forthe increase in pharmaceutical expenditures as observedamong USA elderly. These factors include: (i) increasedutilization of prescription medications; (ii) increasedprices for existing prescription medications; and (iii)substitution of newer, higher priced medications forolder, less expensive medications.15

The expenditures on prescribed medications amongthe elderly in three large countries (USA, Canada andJapan) were found to be greater than before. In the USA,for example, the expenditure among the elderly on pre-scribed medications was estimated to be $324,16 $500–700, $827 and $1378 for the years 1989, 1991, 1997 and2000, respectively, with a growth of 130%.,17–19 In 2001,a retrospective cohort study was carried out in the USAto determine the relationship between PIM prescribingand healthcare expenditure, and estimate the annualincremental healthcare expenditures related to PIM usein the community-dwelling elderly population. Resultsshowed that the average individual healthcare expendi-ture in 2001 was $9292 for elderly who were exposed toPIM versus $6643 for unexposed elderly with an esti-mate of a $749 increment in healthcare expenditures asa result of PIM use. The total annual healthcare expen-ditures for community-dwelling elderly for 2001 were$7.2 billion.20

In Canada, expenditures on prescribed medicationsamong elderly were found to have increased by 317%from 1981 to 1988.21

In Japan, elderly patients consume more medicationsthan non-elderly patients, where spending was esti-mated to be $130 per older adult in 1991.22

Jano and Aparasu reviewed 235 published articles,and they found 18 studies that examine the impact oroutcomes of Beers criteria for PIM in older adults.23

Costs were measured in three studies, one studyfocused on costs of pharmaceutical services;24 anotherstudy looked at the cost of provider, facility, prescriptionand total costs;25 and the third study measured the totalannual healthcare and prescription expenditures.26 Inone study, PIM use increased the healthcare costs,24

whereas another study found no such association.None of the reviewed studies calculated the cost of

PIM and measured the prevalence at the same time. Inthe present study, we calculated the direct cost of PIMfor 2002, 2003 and 2004. The percentage cost for PIMwas 0.32%, 0.14% and 0.1% for 2002, 2003 and 2004,respectively, of the total cost of medications prescribedfor the elderly.

In general, the cost of healthcare associated with thecare of the older population can be expected to increaseannually. Pharmaceutical care represents a major com-ponent of any healthcare system that is associated withhigh cost, because of advances in technology andincreased use of such medications. However, such costsshould be utilized effectively in the elderly population todecrease disabilities and improve the quality of life. Useof evidence-based medicine in diagnosis and treatmentin the elderly population can assure maximum benefitfrom available medications with less inappropriateprescribing.27

Prescribing PIM in the elderly is often attributed tothe lack of geriatrics training in medicine and pharmacyprograms. Implementation of Drug Utilization Reviews(DUR) can effectively overcome the prescribing of PIMproblem in older adults. DUR are designed to sendwarnings to pharmacists and physicians when PIM areprescribed. The warnings provide an opportunity toeducate both pharmacists and physicians through a dis-cussion about the safety and effectiveness of a targetedmedication before it is dispensed.28

Further research is required to assess the impact ofDUR on improving the quality of care among elderlypeople in Saudi Arabia. Such research should be aimedto evaluate the outcomes of DUR and estimate the levelof PIM awareness among pharmacists and physicians todecrease the number of PIM prescribed as much aspossible.

The present study had several strengths and limita-tions. One of the strengths was the large number ofpatients’ prescriptions included in the study. However,as discussed previously, there was still some underre-porting of patient medications prescribing because ofthe easy accessibility to different Saudi hospitals.Another strength was the ability to identify the sourcesof PIM in RMH, which assisted us to improve medi-cation prescriptions in the elderly by providing educa-tion for the medical staff at RMH. Limitations of thepresent study were the limited number of variables anddata that prevented us from applying further statisticalanalysis, such as logistic regression, to identify what

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the factors associated with prescribing PIM in olderadults are. Additionally, the results of the present studycannot be generalized to the Saudi geriatric population,because the study included only one outpatient phar-macy hospital in Saudi Arabia, which limited the studyoutcome.

The present study is the first to compare the preva-lence of PIM in a Saudi Arabian outpatient hospital withother countries and to assess the direct medication costof such practice. Prescribing PIM in RMH was lesscompared with other relevant studies in other countriesthat were published in the literature. It was unclearwhether these results reflect the level of elderly health-care services provided to RMH patients or because ofunderreporting. Drug utilization review programs,medical education, recruiting physicians and clinicalpharmacists who are specialized in geriatrics, findingsafer medications or integration of computer software todetect such medications during prescription entry canimprove the medical services provided for older adults.

Acknowledgments

We thank Dr Ali Al-Metwazi and Pharmacist MajedAl-Ameel at Riyadh Military Hospital for their valuableassistance in granting permission, retrieving and usingRMH pharmacy data.

Disclosure statement

None of the authors received financial support or haverelationships that may pose a conflict of interest.

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