According to the United Nations, the number of older people in the world is projected to double and reach 2.1 billion by 2050 [1]. In Iran, the population over 60 years old in 2006 was about 7% and is estimated to reach about 22% in 2036 [3]. In old age, in addition to the increase in the burden of disease, the time of using health services, and health costs [4, 5], polypharmacy is common and can significantly increase the risk of side effects, drug interactions, medication errors, hospitalization and even death [8-10]. In many countries, the Beers criteria is used to estimate the prescription of Potentially Inappropriate Medications (PIMs) in the elderly [15]. The purpose of this study was to investigate the status of PIM prescription for the elderly according to Beers criteria in Tabriz, Iran.
 

This is a descriptive cross-sectional study. The number of samples was obtained 1421 using Cochran’s formula and considering a 95% confidence interval, Z (1-α / 2)=1.96, α=0.05, P=1-P=0.5, and d=0.026. For more accuracy, it was set to 1500. By referring to the social security and health insurance organizations of East Azarbaijan province, the prescriptions belonging to people aged 65 years and older who were prescribed by general physicians in Tabriz city in winter and spring 2019 were collected. First, the prescriptions were screened and if they belonged to the target group, they were separated. Finally, out of 16,842 prescriptions, 1500 were selected. Also, in order to achieve more generalizability of the results, the number of selected prescriptions from each physician was determined up to 10-15. In addition to general patient information (type of insurance, age and gender), the name of prescribed medications, drug group, number of items in each prescription, and the average number of prescription items were recorded. Then, according to the Beers criteria 2019, the name and number of prescribed PIMs were determined and if there were appropriate medications, their alternatives were suggested based on valid scientific sources [14, 28, 29]. Data were expressed as Mean±Standard Deviation (SD) and No. (%) and were analyzed in SPSS v. 21 software. First, the distribution of PIM prescription data was evaluated using Kolmogorov-Smirnov test and due to their abnormal distribution, Mann-Whitney U test was used for statistical analysis. Spearman correlation test was used to examine the relationship between patients’ age and PIM prescription. P< 0.05 was considered as the significance level.

Among 1500 prescriptions, 571(38.1%) was related to health insurance and 929(61.9%) for social security insurance; 876(58.4%) belonged to older women and 624(41.61%) belonged to older men and the Mean±SD age of all patients was 73.31±6.8 years. On average, 3.93±1.5 medications were prescribed for each participant; 4% contained one drug, 12.8% contained 2 drugs, 25.5% contained 3 drugs, 25.1% contained 4 drugs, 16.4% contained 5 drugs and 16.2% contained 6 and more drugs. Therefore, according to the definition of polypharmacy (using 5 drugs or more), there was polypharmacy in 32.6% of the studied prescriptions. Moreover, 809 prescriptions (53.9%) contained PIMs according to Beers criteria; 37.8% of prescriptions had one PIM, 13.1% two PIMs and 3% three or four PIMs. All prescribed PIMs were classified into 15 medication groups, which are listed in Table 1.



Among these groups, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) with a frequency of 45.6%, antihistamines (10.9%), benzodiazepines (10.6%), anti-diabetic drugs (8.9%), antispasmodics (5.1%), antidepressants (4.1%), antitussive drugs (3.7%) and gastrointestinal drugs (2.4%) were more common. Moreover, the most common prescribed PIMs were: Adult cold (14.5%), Diclofenac (10.4%), Glibenclamide (8.9%), Ketorolac (6.9%), Diphenhydramine (4.7%), Ibuprofen (4.3%), Clonazepam (3.8%), Indomethacin (3.7%), Alprazolam (3.4%), and Piroxicam (2.8%).
Using Mann-Whitney U test, comparison of the mean number of prescribed PIMs in each prescription did not show a statistically significant difference between those related to health insurance and social security (P=0.343). The relationship between age and PIM prescription was assessed using Spearman correlation test and the effect of gender on PIM prescription was evaluated using Mann-Whitney U test for which the P values were 0.312 and 0.660, respectively. Therefore, the variables of age, gender and type of insurance had no significant relationship with the frequency of PIM prescription.

According to the obtained data, about 54% of prescriptions issued by general physicians for the elderly in Tabriz in 2019 contained PIMs, and polypharmacy was observed in 32.6% of prescriptions. Due to the high polypharmacy and the rate of PIM prescriptions for the elderly in this study and previous similar studies conducted in Iran, which imposes high financial costs, drug side effects, increased hospitalization and even death, there is a need to develop and implement scientific criteria and guidelines for prescribing medications to the elderly, raising the awareness of general physicians and increasing the supervision of relevant authorities. Moreover, due to the increase in the aged population and the spread of chronic and non-communicable diseases, it is necessary to pay serious attention to the issue of geriatrics and pharmacotherapy of the elderly in medical universities and medical retraining courses. Furthermore, holding supplementary geriatric medicine courses to train employed general physicians can be helpful.

This study has an ethical approval (Code: IR.TBZMED.REC.1397.1033) obtained from the Research Ethics Committee of Tabriz University of Medical Sciences. All information on the prescriptions examined in this study was kept confidential.

This study was extracted from a Pharm D. dissertation of the second author at the Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz.

All authors contributed equally in preparing this article.

The authors declare no conflict of interest

The authors would like to thank the officials of the Health Insurance Organization and the Social Security Insurance Organization of East Azerbaijan Province for their cooperation.