How Inappropriate Prescribing Harms Older Adults and What Science Is Doing About It
Imagine opening your elderly parent's medicine cabinet to find a collection of dozens of prescription bottles. While each medication was originally prescribed for a legitimate reason, together they create a complex web of potential interactions and side effects. This scenario plays out in millions of households worldwide as older adults with multiple health conditions often find themselves taking numerous medications—a practice known as polypharmacy.
Research shows that nearly 1 in 2 older people receive potentially inappropriate medicines, with the number rising to 4 in 5 among those in aged-care homes 1 .
The problem isn't just the number of medications, but whether each one is truly appropriate for an aging body. Potentially inappropriate medications (PIMs) are drugs whose risks often outweigh their benefits in older adults, yet they continue to be prescribed at alarming rates.
The consequences are far from theoretical: adverse drug reactions account for 20% of unplanned hospital admissions in older adults, the majority of which may be preventable 1 . As our global population ages, addressing this silent epidemic of inappropriate prescribing has become one of the most pressing challenges in modern healthcare.
The term "potentially inappropriate medications" (PIMs) refers to drugs that carry more risks than benefits for older adults, particularly when safer alternatives exist 1 . The key word is "potentially"—there might be specific circumstances where these medications are appropriate, but they require extra caution.
Aging bodies process medications differently. Reduced liver and kidney function can slow drug metabolism and elimination, while changes in body composition alter how medications are distributed 1 . A dose that was once safe can become dangerous as we age.
Polypharmacy—generally defined as taking multiple medications concurrently—isn't always bad. When carefully tailored to an individual's needs, it can be "appropriate polypharmacy." The trouble begins with "inappropriate polypharmacy," which occurs when medications are prescribed without evidence-based indications, cause unacceptable side effects, or don't align with a patient's goals and preferences 8 .
The statistics are staggering: studies indicate that over 40% of adults aged over 65 take five or more medications daily, and around 12% are on ten or more .
To guide safer prescribing, experts have developed several PIMs lists. The most prominent include the American Geriatrics Society Beers Criteria and the European Screening Tool of Older People's Prescriptions (STOPP) 1 . In 2024, Australia joined this effort with its own Australian PIMs list, developed by experts in geriatric medicine, general medicine, pharmacy, and clinical pharmacology 1 .
These tools help identify medications that warrant extra scrutiny. The table below highlights some commonly prescribed medications considered potentially inappropriate for many older adults:
| Drug Class | Examples | Primary Concerns |
|---|---|---|
| Long-acting benzodiazepines | Clonazepam, flunitrazepam | Increased risk of falls, confusion, memory issues |
| First-generation antipsychotics | Haloperidol, chlorpromazine | Sedation, falls, Parkinson-like symptoms |
| Nonsteroidal anti-inflammatory drugs (NSAIDs) | Ibuprofen, diclofenac, naproxen | Kidney impairment, high blood pressure, stomach bleeding |
| Certain antidepressants | Amitriptyline, dosulepin | Anticholinergic effects (confusion, constipation, dry mouth) |
| Sulfonylureas | Glibenclamide, glimepiride | Prolonged hypoglycemia in older adults |
| Genitourinary anticholinergics | Oxybutynin | Cognitive impairment, sedation |
One particularly insidious driver of inappropriate prescribing is the "prescribing cascade"—when a drug side effect is misinterpreted as a new medical condition, leading to prescription of yet another medication .
An older adult takes amlodipine for high blood pressure
Develops ankle swelling as a side effect of the medication
Swelling is misinterpreted as a new medical condition rather than a medication side effect
A diuretic is prescribed to treat the swelling
Now the patient faces potential side effects from both medications, plus the burden of an additional pill .
| Initial Drug | Adverse Effect | Inappropriately Prescribed New Drug |
|---|---|---|
| Amlodipine | Leg swelling | Furosemide (diuretic) |
| NSAIDs (e.g., ibuprofen) | High blood pressure | Additional blood pressure medication |
| Cholinesterase inhibitors | Urinary incontinence | Anticholinergic bladder medication |
| Calcium channel blockers | Constipation | Laxatives |
| Antipsychotics | Restlessness, agitation | Additional psychiatric medications |
An international expert panel recently identified 65 potentially inappropriate prescribing cascades (PIPCs) . Recognizing these patterns represents a promising new frontier in deprescribing—the planned reduction of unnecessary medications.
With inappropriate prescribing identified as a significant problem, researchers have turned to evaluating potential solutions. A comprehensive 2025 systematic review and meta-analysis published in JAMA Network Open examined 118 randomized clinical trials involving 417,412 patients to determine whether interventions to reduce potentially inappropriate prescribing actually work 2 7 .
Fewer medications per patient with interventions
Randomized clinical trials analyzed
Patients included in the analysis
The findings were both encouraging and sobering. The interventions successfully reduced the number of medications prescribed—by approximately 0.5 fewer medications per patient on average. Perhaps most importantly, these reductions didn't cause harm; there were no significant increases in adverse drug reactions, hospitalizations, or mortality 2 7 .
However, the interventions also didn't substantially improve most clinical outcomes measured. The table below summarizes the key findings:
| Outcome Measure | Impact of Interventions | Statistical Findings |
|---|---|---|
| Number of medications | Significant reduction | SMD: -0.25 (equivalent to ~0.5 fewer medications) |
| Adverse drug reactions | No substantial difference | RR: 0.92 (95% CI: 0.58-1.46) |
| Hospitalizations | No substantial difference | RR: 0.95 (95% CI: 0.89-1.02) |
| Mortality | No substantial difference | RR: 0.94 (95% CI: 0.85-1.04) |
| Quality of life | No substantial difference | SMD: 0.09 (95% CI: -0.04 to 0.23) |
| Injurious falls | No substantial difference | SMD: 0.01 (95% CI: -0.12 to 0.14) |
SMD = Standardized Mean Difference; RR = Risk Ratio; CI = Confidence Interval
These results suggest that we can safely reduce medication burdens, but we need better strategies to translate these reductions into measurable improvements in quality of life and clinical outcomes 2 7 .
Sometimes, the problem isn't that prescribers don't know what's appropriate—it's that they don't act on that knowledge. This disconnect, called the "know-do gap," was brilliantly exposed in a 2025 study of antibiotic prescribing for childhood diarrhea in India 5 .
Researchers combined provider knowledge assessments with over 2,000 anonymous standardized patient visits to determine why antibiotics were inappropriately prescribed for childhood diarrhea when most cases are viral 5 . The results were striking: while 50% of providers knew antibiotics were inappropriate (the "know gap"), among those with correct knowledge, 62% still prescribed antibiotics in practice (the "know-do gap") 5 .
The researchers conducted randomized experiments to understand this behavior and found that the know-do gap stemmed primarily from providers' mistaken belief that patients wanted antibiotics. When patients expressed preference for the correct treatment (oral rehydration salts), inappropriate antibiotic prescribing dropped significantly 5 . Financial incentives and medication availability had much smaller effects.
The evidence points to several promising strategies for reducing inappropriate prescribing:
Comprehensive, structured medication reviews—especially those involving multiple healthcare providers—can identify inappropriate medications and opportunities for deprescribing 6 .
Interdepartmental collaborative medication reviews bring together diverse expertise to optimize medication regimens, particularly for hospitalized older adults 6 .
Integrating PIMs lists into electronic health records can alert prescribers to potentially problematic medications 1 .
Correcting mistaken beliefs about patient preferences can significantly impact prescribing behavior 5 .
| Tool/Concept | Function | Application |
|---|---|---|
| Beers Criteria | Evidence-based list of PIMs to avoid in older adults | Helps identify high-risk medications during prescribing and medication review |
| STOPP/START Criteria | Screening tool to identify potentially inappropriate prescriptions (STOPP) and potential prescribing omissions (START) | Systematic assessment of medication appropriateness |
| Medication Appropriateness Index (MAI) | Judgement-based instrument for assessing prescribing quality | Evaluates appropriate indication, effectiveness, dosage, and directions |
| Potentially Inappropriate Prescribing Cascades (PIPCs) | Identifies patterns where new medications are inappropriately prescribed to treat side effects of existing ones | Helps target deprescribing opportunities |
| Structured Medication Review | Comprehensive evaluation of all medications | 7-step approach promoted by Scottish guidelines to ensure person-centered care 8 |
Based on the Scottish Polypharmacy Guidance 8
The challenge of inappropriate prescribing in older adults is complex, but not insurmountable. Evidence confirms that we can safely reduce medication burdens, even if we're still learning how to best translate these reductions into improved quality of life.
The path forward requires a shift from automatically continuing medications to regularly questioning their ongoing appropriateness. It demands that we address not just knowledge gaps but the "know-do gaps" that prevent best practices from reaching patients. Most importantly, it calls for partnerships between patients, families, and healthcare providers to ensure that medication decisions align with personal values and goals.
As one editorial aptly noted, "Tackling prescribing cascades and medical optimization in general requires curiosity, compassion, and the courage to pause and question what we easily add but rarely take away" . In cultivating these qualities, we can transform our approach to medications in later life—from merely adding prescriptions to thoughtfully optimizing well-being.