1. Introduction
Aging is associated with an increased incidence of chronic diseases, multidrug therapy, and thus an increased risk of drug side effects and changes in quality of life. With the increase of the world’s aging proportion, the quality and safety of prescribing drugs has become a global health concern. A number of medications or certain doses of some medications can cause side effects in the elderly. Prescribing these medications is potentially inappropriate. One way to identify inappropriate prescriptions and increase the quality of care for the elderly is to recheck the prescribed medications using medication prescription tools by the treatment team, including nurses. One of these criteria is the STOPP (Screening Tool of Older Persons’ Prescriptions). Health-Related Quality Of Life (HRQOL) is an important indicator of a person’s health status when evaluating health interventions. This study aims to determine the prevalence of Potentially Inappropriate Medication (PIM) in the elderly based on STOPP criteria and assess their subsequent HRQOL.
2. Methods
In this descriptive-analytical study, participants were 783 older patients admitted to the internal medicine and surgery wards of three hospitals affiliated to Qom University of Medical Sciences in 2018 who were selected using a convenience sampling method. Inclusion criteria were age ≥65 years, passing of 48-72 hours after hospitalization, daily use of at least one medication, and the ability of to answer questions or having an informed companion. The study obtained an ethical approval from the Ethics Committee of Qom University of Medical Sciences (Code: IR.MUQ.REC.1393.25). Information was collected after obtaining informed consent from the patients and assuring them of the confidentiality of their information through interviews and referring to their medical records. The instruments used included the Charlson Comorbidity Index (CCI), the STOPP Version 2, and the 15D instrument of HRQOL. The CCI predicts 10-year survival in people with several diseases. The STOPP Version 2 contains 80 criteria under 13 categories. The 15D is self-report tool that assess breathing, mental function, speech, vision, mobility, usual activities, vitality, hearing, eating, elimination, sleeping, distress, discomfort and symptoms, sexual activity, and depression. Its score ranges from 0 to 1. The content validity of the tools was assessed using the opinions of 10 expert professors and their face validity was assessed using the opinions of 10 older people. Cronbach’s alpha value for assessing the scientific reliability of the 15D was obtained 0.92; for the STOPP, it was 0.95. Data were analyzed in SPSS v. 22 software using descriptive statistics, independent t-test and logistic regression analysis to identify the factors affecting the prevalence of PIM (as a dependent variable). The significance level was set at 0.05.
3. Results
The Mean±SD age of participates was 72.35±7.91 years. Most of them had age 65-75 years (68.33%), were women (52.75%) and illiterate (81.73%). Most of them (58.61%) were hospitalized in the internal wards of the hospital, due to cardiovascular diseases (25.03%), respiratory disorders (16.99%) and nervous system disorders (16.48%). The mean number of used medications by the elderly was 7.21±3.16 and 79.57% of them had multidrug use (taking ≥5 medications daily). The CCI score was 29.9% for four participants and 24.4% for five participants. The prevalence of PIM based on STOPP criteria was 46.10%. The most common PIMs was benzodiazepines (9.96%). The most common categories of PIMs were Drugs that adversely affect those prone to falls (13.79%), Duplicate Drug Class (12.39%), Central Nervous System and Psychotropics (5.36%) and endocrine system (4.85%). The Mean±SD of total HRQOL score was 0.85±0.12; where the lowest score was 0.70±0.24 for mobility and 0.79 ±0.24 for breathing, and the highest score was 0.95±0.11 for hearing.
The results showed that the total score of HRQOL and its domains (except for hearing, elimination and sexual activity) were significantly different between the two groups of elderly with and without PIM (P<0.05). Logistic regression analysis results showed that the elderly with no PIM had better overall HRQOL scores than the elderly with PIM. If the HRQOL score increases by 1 unit, the likelihood of prescribing PIM for the elderly decreases by 99.91% (95%CI: 0.030-0.307, OR= 0.096). Those who took ≥5 medications daily were eight times more likely to use PIM than those who took <5 medications daily (95%CI: 4.780-14.966, OR =8.46). Moreover, those with a CCI score of 3-4 were two times more likely to use PIM than those with a CCI score of 1-2 (95%CI: 1.36-3.17, OR =2.079) (Table 1).


4. Discussion and Conclusion
PIM use is a common health problem among the elderly in Iran and is associated with HRQOL, multidrug use and CCI. Given the high prevalence of PIM in the elderly and the constant changes in their health status, continuous evaluation of the list of medications used by them for finding PIM should be defined as one of the important nursing measures. One of the reasons for the high prevalence of PIM is the lack of awareness of the treatment team about medication therapy of the elderly, and the tools used to screen PIM prescriptions for the elderly are inappropriate. It is necessary to introduce STOPP criteria in the training programs of the treatment team. One of the limitations of the study was the lack of electronic prescriptions and appropriate software for reviewing prescribed drugs for the elderly and extracting PIM online. It is recommended to design appropriate software for this purpose and to conduct national studies in order to electronize prescriptions for the elderly.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information. They were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.



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