The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence

To provide an updated review of the literature on the extent of and risk factors for inappropriate prescribing in the elderly.

A comprehensive review of the most recent publications in English assessing inappropriate prescriptions for elderly patients in the United States using the 1997 version of the Beers explicit criteria. The reviewed articles were obtained via an electronic search of the MEDLINE database for articles published between 1997 and 2001 and a manual search through major journals for articles referenced in those located through MEDLINE. Search terms were Beers, explicit criteria, inappropriate drug use, prescribing, prescriptions, medication use, elderly, and health outcomes.

Using the updated explicit criteria, a total of 11 empirical studies were identified, all of which were conducted using observational surveys or claims databases. The reported prevalence of elderly patients using at least one inappropriately prescribed drug ranged from a high of 40% for a population of nursing home patients to 21.3% for community-dwelling patients over age 65. Propoxyphene, amitriptyline, long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam, flurazepam), and dipyridamole are among the most commonly occurring inappropriate prescriptions. With a few exceptions, the most significant patient-related predictors of inappropriate prescribing include polypharmacy, poor health status, and female sex. Other potential risk factors include prescribing location, ethnicity, age, and referral status. Limited evidence was found of increased health care utilization and poorer quality of life resulting from inappropriate drug use in the elderly in Medicare health maintenance organization and emergency department settings.

The prevalence of inappropriate prescribing remains alarmingly high for the elderly in general and for nursing home residents in particular. This review identified some attributes of the elderly groups most vulnerable to inappropriate prescribing. Future research should document more evidence regarding the adverse impact of inappropriate prescribing on total health care costs and patient health outcomes.