Inappropriate Medication Use Among Older Adults On-The-Rise in Outpatient Setting


Adults aged 80 years and older and those living in areas with worse economic conditions are more likely to receive potentially inappropriate medications in the outpatient setting, which may be associated with cognitive impairment.

Worldwide, the prevalence of potentially inappropriate medication (PIM) use was 36.7% among older adults in 2022, according to results from a systematic review and meta-analysis published in JAMA Network Open. Countries with worse economic conditions tend to have a higher prevalence of PIM misuse, as regulations and drug control may not be widely enforced.

Image credit: pikselstock -

Image credit: pikselstock -

“The opposite is true in countries with good economic conditions,” the study authors wrote in the article. “When economic conditions are better, the medical environment is usually better, and medical insurance is more perfect, which makes the rational use of drugs more strictly controlled.”

In a subgroup analysis of the prevalence of PIM use based on geographic region, Africa had the highest prevalence among older adults at 47.0%. The high prevalence trend was most observed in South America at 46.9%, Europe at 35.0%, North America at 29.0%, and Oceania at 23.6%.

PIM use is associated with adverse drug events, worse health-related quality of life, and increased visits to the emergency department. However, there are limited studies about PIM use among older adults in outpatient services—the primary medical services upon visiting the hospital—compared to inpatient services.

The current systematic review and meta-analysis aimed to estimate the overall prevalence of PIM use in older patients at outpatient services. Including data of nearly 371.2 million people across 94 studies 132 prevalence estimates in 17 countries.

Africa had the highest prevalence of PIM use among older adults. The medical conditions in Africa are considered below optimal—the regulations, insubstantial—which could explain the high prevalence.

Benzodiazepine, a type of depressant, was the most prescribed PIM for older adults in the outpatient setting. Despite the negative association with increased risk of cognitive impairment, falls, and fractures, benzodiazepines are prescribed to older adults, who often suffer from insomnia.

In the subgroup analysis, investigators also evaluated PIM use by World Bank status (country-level income), period, PIM criteria, location, study design, mean age or number of drugs, sex, population, and sample size. High-income countries had a lower prevalence of PIM use at 33.2%. Patients who take a higher number of drugs also have a pooled higher prevalence of PIM use (45.9%).

Investigators observed that patients aged 80 years and older were more likely to be given PIMs in the outpatient setting, arguably due to the likelihood of worse health outcomes and multimorbidity compared to younger adults. The investigators hypothesized that PIM use in the outpatient clinic has likely increased significantly during the past 20 years because older adults are more susceptible to age-related diseases and chronic conditions.

Study limitations noted were the exclusion of low-income countries, which could reduce the accuracy of prevalence in these geographical regions. In addition, some countries only provided few studies, and there are no studies on the long-term health outcomes of PIM use.

PIM use among older adults is cause for concern. The study authors concluded, “the high prevalence of PIM use highlights the global need for health care reforms and improvements in drug safety in outpatient settings.”


Tian F, Chen Z, Zeng Y, et al. Prevalence of Use of Potentially Inappropriate Medications Among Older Adults Worldwide. JAMA Netw Open. 2023;6(8):e2326910. doi:10.1001/jamanetworkopen.2023.26910

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