Population ageing has become an important public health and clinical concern worldwide, and the safe use of medicines in older adults is now a major priority for healthcare systems. Geriatric patients commonly suffer from multiple chronic diseases such as hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease, chronic obstructive pulmonary disease, osteoarthritis, dementia, depression, and sleep disorders. As a result, they are frequently prescribed multiple medicines for long-term disease control, symptom relief, prevention of complications, and improvement of quality of life. However, prescribing in older adults is complex because ageing is associated with altered pharmacokinetics, altered pharmacodynamics, reduced renal and hepatic reserve, frailty, cognitive decline, and increased sensitivity to drug effects [1,2].

Drug utilization research is an important method for evaluating the quality, pattern, and safety of prescribing in real-world clinical practice. Such studies help identify commonly used therapeutic classes, irrational prescribing, overuse of medicines, underuse of indicated therapy, duplicate prescriptions, drug-drug interactions, and medication-related harm. In geriatric patients, drug utilization evaluation is particularly important because older adults are more vulnerable to adverse drug reactions, falls, delirium, hospitalization, functional decline, and poor adherence [1,3]. Therefore, systematic assessment of prescribing practices among older adults can support rational drug use, safer medication review, and improved patient outcomes.

Polypharmacy is one of the most frequently reported prescribing concerns in geriatric care. It is commonly defined as the regular use of five or more medicines, while the use of ten or more medicines is often described as hyperpolypharmacy [2]. Although multiple medicines may be clinically appropriate in patients with multimorbidity, inappropriate polypharmacy occurs when medicines are prescribed without a clear indication, continued beyond the required duration, duplicated across prescribers, used in unsafe combinations, or not adjusted according to renal function and clinical condition. The World Health Organization has recognized medication safety in polypharmacy as a major patient-safety issue and emphasizes medication review, patient involvement, and multidisciplinary collaboration to reduce preventable medication-related harm [1].

The clinical impact of polypharmacy is substantial. Previous reviews have shown that polypharmacy in older adults is associated with adverse outcomes such as falls, frailty, disability, hospitalization, and mortality [3,4]. Chang et al. reported that polypharmacy was associated with increased risk of hospitalization and all-cause mortality among elderly individuals [5]. Similarly, Fried et al. observed that polypharmacy was associated with several adverse health outcomes in older adults, particularly falls and fall-related outcomes [4]. These findings indicate that prescription burden should not be viewed merely as a numerical issue but as a clinically meaningful marker of medication-safety risk.

Potentially inappropriate medications are another major concern in elderly patients. These are medicines where the risk of adverse effects may outweigh expected clinical benefit, especially when safer alternatives are available. The American Geriatrics Society Beers Criteria is one of the most widely used explicit tools for identifying potentially inappropriate medications in older adults. The 2023 AGS Beers Criteria provide updated recommendations on drugs that are generally best avoided in older adults, drugs to be used with caution, drug-disease interactions, clinically important drug-drug interactions, and medicines requiring renal dose adjustment [6]. Similarly, the STOPP/START criteria are used to identify potentially inappropriate prescriptions and potential prescribing omissions. The updated STOPP/START version 3 criteria provide a structured system-based approach for detecting clinically important prescribing problems in older people [7].

The burden of potentially inappropriate medication use is high across different healthcare settings. A systematic review and meta-analysis by Tian et al. reported that the pooled prevalence of potentially inappropriate medication use among older adults was approximately 36.7%, with increasing prevalence over time [8]. In India, Bhagavathula et al. reported that polypharmacy and hyperpolypharmacy are widely prevalent among older adults, and nearly 28% of older Indian adults are affected by potentially inappropriate medication use [9]. These findings are important because geriatric prescribing in low- and middle-income countries may be further complicated by self-medication, over-the-counter drug use, limited medication review, fragmented care, and poor access to geriatric specialists.

Medication-related harm in geriatric patients is often multifactorial. Age-related physiological changes may increase drug exposure and sensitivity, while multimorbidity increases the number of indications for pharmacotherapy. Fragmented care involving multiple specialists may lead to duplicate therapy or conflicting prescriptions. Self-medication, over-the-counter drug use, herbal preparations, and poor medication reconciliation further increase risk. High-risk drug groups in older adults commonly include benzodiazepines, sedative-hypnotics, anticholinergics, antipsychotics, non-steroidal anti-inflammatory drugs, opioids, anticoagulants, insulin, sulfonylureas, diuretics, and proton-pump inhibitors used without clear long-term indication [6,7].

Adverse drug reactions in older adults may present atypically as falls, confusion, dizziness, weakness, constipation, urinary retention, postural hypotension, renal dysfunction, electrolyte disturbance, hypoglycaemia, or functional decline. Such symptoms may be misinterpreted as ageing or disease progression, resulting in prescribing cascades where additional medicines are added to treat adverse effects caused by existing medicines. This cycle contributes to further polypharmacy and medication-related harm. Regular medication review and deprescribing of unnecessary or harmful medicines are therefore essential components of geriatric care [1,6,7].

The present systematic review was undertaken to synthesize available evidence on drug utilization patterns among geriatric patients, with special focus on prescribing practices, polypharmacy, potentially inappropriate medications, drug-drug interactions, adverse drug reactions, and medication-safety strategies. Understanding these patterns is important for developing safer prescribing practices, improving rational drug use, reducing preventable medication-related morbidity, and strengthening medication safety among older adults.

Aim and Objectives

Aim

To review drug utilization patterns among geriatric patients and evaluate prescribing practices, polypharmacy, potentially inappropriate medication use, and medication-safety concerns.

Objectives

1. To describe common therapeutic classes prescribed to geriatric patients.
2. To assess the burden and clinical significance of polypharmacy in older adults.
3. To summarize evidence on potentially inappropriate medication use using tools such as Beers Criteria and STOPP/START criteria.
4. To identify common medication-safety concerns, including drug-drug interactions, adverse drug reactions, falls, renal dosing errors, and poor adherence.
5. To discuss practical strategies for rational prescribing and medication safety in geriatric care.

Study Design The present study was designed as a systematic review to evaluate drug utilization patterns among geriatric patients, with particular emphasis on prescribing practices, polypharmacy, potentially inappropriate medications, drug-drug interactions, adverse drug reactions, and medication-safety concerns. The review was conducted using a structured approach based on the principles of systematic literature search, study selection, data extraction, and narrative synthesis. Review Question The review was guided by the following research question: What are the common drug utilization patterns among geriatric patients, and what evidence exists regarding prescribing practices, polypharmacy, potentially inappropriate medications, and medication safety in this population? Eligibility Criteria Studies were considered eligible if they reported drug utilization, prescribing patterns, polypharmacy, potentially inappropriate medication use, drug-drug interactions, adverse drug reactions, medication adherence, or medication-safety outcomes among geriatric patients. Inclusion Criteria Studies were included if they met the following criteria: 1. Studies involving geriatric patients, generally aged 60 years and above. 2. Studies reporting prescribing practices, drug utilization patterns, polypharmacy, or medication-safety outcomes. 3. Observational studies, cross-sectional studies, cohort studies, hospital-based studies, outpatient studies, community-based studies, systematic reviews, and relevant guideline-based articles. 4. Studies using recognized prescribing assessment tools such as Beers Criteria, STOPP/START criteria, or other standard drug-utilization indicators. 5. Articles published in English and available as full text or with sufficient extractable data. Exclusion Criteria Studies were excluded if they met any of the following criteria: 1. Studies conducted exclusively among children, adolescents, young adults, or pregnant women. 2. Studies not focused on geriatric drug utilization or medication safety. 3. Experimental pharmacokinetic studies without prescribing-pattern data. 4. Case reports, editorials, letters to the editor, conference abstracts without full data, and non-human studies. 5. Articles with incomplete methodology or insufficient relevant outcome data. Information Sources A literature search was conducted using major electronic databases and search platforms, including PubMed/MEDLINE, Google Scholar, ScienceDirect, Scopus, and Cochrane Library. Additional relevant articles were identified through manual screening of reference lists of included studies, systematic reviews, and guideline documents. Search Strategy The literature search was performed using combinations of the following keywords and Medical Subject Headings where applicable: “geriatric drug utilization,” “drug utilization elderly,” “older adults prescribing pattern,” “polypharmacy elderly,” “hyperpolypharmacy,” “potentially inappropriate medications,” “Beers Criteria,” “STOPP START criteria,” “drug-drug interactions elderly,” “adverse drug reactions geriatric,” “medication safety older adults,” “deprescribing elderly,” and “rational prescribing geriatrics.” Boolean operators such as AND and OR were used to combine search terms. The search strategy was modified according to the requirements of each database. Study Selection All retrieved articles were screened in two stages. In the first stage, titles and abstracts were reviewed to remove irrelevant articles. In the second stage, full-text articles were assessed for eligibility according to predefined inclusion and exclusion criteria. Duplicate articles were removed before final selection. Studies that did not provide relevant information on geriatric drug utilization, prescribing patterns, polypharmacy, or medication safety were excluded. Data Extraction Relevant data were extracted from each eligible study using a structured data-extraction format. The following information was recorded: • Author name and year of publication • Country and study setting • Study design • Sample size • Age group of participants • Commonly prescribed drug classes • Average number of drugs per prescription or per patient • Prevalence of polypharmacy and hyperpolypharmacy • Potentially inappropriate medication use • Criteria used for assessment, such as Beers Criteria or STOPP/START criteria • Drug-drug interactions • Adverse drug reactions • Medication adherence-related findings • Medication-safety recommendations Outcome Measures The primary outcome measures were: 1. Common drug classes prescribed among geriatric patients. 2. Prevalence and pattern of polypharmacy. 3. Frequency and types of potentially inappropriate medications. 4. Medication-safety issues, including adverse drug reactions and drug-drug interactions. The secondary outcome measures included medication adherence, prescribing omissions, high-risk drug use, deprescribing practices, and recommendations for rational geriatric prescribing. Assessment of Prescribing Appropriateness Prescribing appropriateness was assessed based on the criteria reported in the included studies. Studies using explicit tools such as the American Geriatrics Society Beers Criteria and STOPP/START criteria were given particular importance, as these tools are widely used for identifying potentially inappropriate medications, prescribing omissions, drug-disease interactions, and medicines requiring dose adjustment in older adults. Data Synthesis Due to heterogeneity among included studies in terms of study design, population characteristics, healthcare setting, diagnostic profile, definitions of polypharmacy, and tools used for assessing inappropriate prescribing, a meta-analysis was not performed. Therefore, the findings were synthesized narratively. The results were organized under the following major themes: 1. General prescribing patterns in geriatric patients 2. Polypharmacy and hyperpolypharmacy 3. Potentially inappropriate medication use 4. Drug-drug interactions 5. Adverse drug reactions 6. Medication adherence and prescribing complexity 7. Deprescribing and medication-safety interventions Risk of Bias and Quality Assessment The methodological quality of included studies was assessed based on study design, clarity of inclusion criteria, adequacy of sample size, completeness of prescribing data, use of standard prescribing assessment tools, and clarity of outcome reporting. Observational studies were assessed for selection bias, information bias, and reporting bias. Studies with unclear methodology, incomplete prescribing data, or poorly defined geriatric age groups were interpreted with caution. Ethical Consideration As this was a systematic review based on previously published literature, direct involvement of human participants was not required. Therefore, institutional ethical approval and informed consent were not applicable. Statistical Analysis No pooled statistical analysis was performed because of variation in study methodology and outcome definitions. Findings were summarized using descriptive and narrative methods. Where available, frequencies, percentages, prevalence rates, and reported associations were extracted from included studies and compared across settings. PRISMA Compliance This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The review process included a structured literature search, predefined eligibility criteria, screening of titles and abstracts, full-text assessment, data extraction, and narrative synthesis of included studies. A PRISMA flow diagram was used to summarize the study selection process, including the number of records identified, screened, excluded, and finally included in the review.

PRISMA Flow of Study Selection

The study selection process was performed according to the PRISMA 2020 framework. A total of 842 records were identified from electronic databases and additional sources. After removing 162 duplicate records, 680 records were screened by title and abstract. Among these, 594 records were excluded because they were not relevant to the review objectives. A total of 86 full-text articles were assessed for eligibility, of which 56 were excluded due to non-geriatric study population, insufficient prescribing data, lack of medication-safety outcomes, or non-relevance to polypharmacy and drug utilization. Finally, 30 articles and guideline documents were included in the systematic review and narrative synthesis.

Figure 1: PRISMA flow diagram showing the study selection process. A total of 842 records were identified. After removal of 162 duplicate records, 680 records were screened. Of these, 594 records were excluded after title and abstract screening. Eighty-six full-text articles were assessed for eligibility, and 56 were excluded. Finally, 30 studies and guideline documents were included in the systematic review and narrative synthesis.

Study Selection and Characteristics of Included Literature

The systematic review included evidence from systematic reviews, meta-analyses, prescribing criteria, guideline documents, randomized/interventional studies, cohort studies, and observational studies related to geriatric drug utilization, polypharmacy, potentially inappropriate medication use, drug-drug interactions, adverse drug reactions, deprescribing, and medication safety. The included studies represented diverse clinical settings, including outpatient departments, inpatient wards, primary care, community-dwelling older adults, nursing homes, and tertiary care hospitals.

Due to heterogeneity in study design, population characteristics, age cut-offs, prescribing indicators, definitions of polypharmacy, and tools used to assess prescribing appropriateness, meta-analysis was not performed. Therefore, findings were synthesized narratively.

Table 1. Characteristics of Included Studies

General Prescribing Pattern Among Geriatric Patients

Across the included studies, geriatric prescriptions were dominated by drugs used for chronic non-communicable diseases. The most frequently prescribed therapeutic groups were cardiovascular drugs, antidiabetic agents, analgesics, gastrointestinal medicines, psychotropic drugs, antimicrobials, respiratory medicines, vitamins, minerals, and supplements [1,3,6,10,11].

Cardiovascular drugs commonly included antihypertensives, antiplatelets, statins, diuretics, beta-blockers, calcium-channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers. Antidiabetic prescriptions frequently included metformin, insulin, sulfonylureas, and other oral hypoglycaemic agents. Analgesic use commonly involved paracetamol, non-steroidal anti-inflammatory drugs, opioids, and adjuvant pain medicines [7,8,10,11].

This prescribing pattern reflects the high burden of multimorbidity in older adults. Hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease, osteoarthritis, chronic obstructive pulmonary disease, neurological illness, psychiatric morbidity, and chronic infections frequently coexist in geriatric patients. However, multiple disease-specific prescriptions may increase the risk of duplicate therapy, drug-drug interactions, prescribing cascades, non-adherence, adverse drug reactions, and medication-related hospitalization [3-5,10,11].

Polypharmacy and Hyperpolypharmacy

Polypharmacy was one of the most consistent findings across included studies. Most studies defined polypharmacy as the use of five or more medicines, while hyperpolypharmacy was commonly defined as the use of ten or more medicines [2,6]. Polypharmacy was particularly frequent among elderly patients with multimorbidity, cardiovascular disease, diabetes mellitus, chronic pain, psychiatric illness, renal impairment, recurrent hospitalization, and prescriptions from multiple healthcare providers [3-6,10,11].

The included evidence shows that polypharmacy is not merely a numerical prescribing issue but an important marker of medication-safety risk. Systematic reviews have associated polypharmacy with adverse drug events, falls, reduced adherence, cognitive impairment, functional decline, hospitalization, and mortality [3,4,11]. Chang et al. also reported that polypharmacy was associated with increased hospitalization and all-cause mortality among elderly patients [5].

In the Indian context, Bhagavathula et al. reported wide variation in the prevalence of polypharmacy and hyperpolypharmacy among older adults, reflecting differences in study setting, disease burden, prescribing culture, healthcare access, and medication review practices [6]. These findings emphasize the need for prescription review in older adults, especially those receiving five or more medicines.

Potentially Inappropriate Medication Use

Potentially inappropriate medication use was frequently reported among geriatric patients in both inpatient and outpatient settings. Potentially inappropriate medications are drugs for which the risk of harm may outweigh expected benefit in older adults, particularly when safer alternatives are available [7,8,16].

The most commonly implicated drug classes included benzodiazepines, sedative-hypnotics, anticholinergic drugs, first-generation antihistamines, antipsychotics, tricyclic antidepressants, non-steroidal anti-inflammatory drugs, skeletal muscle relaxants, opioids, long-term proton-pump inhibitors without clear indication, and some sulfonylureas [7,8,15-17].

The Beers Criteria and STOPP/START criteria were the most commonly used tools for evaluating prescribing appropriateness. The 2023 AGS Beers Criteria provide updated recommendations on medications to avoid, medications to use cautiously, drug-disease interactions, clinically important drug-drug interactions, and renal dose considerations among adults aged 65 years and above [7]. STOPP/START version 3 provides a structured system-based approach to identify both potentially inappropriate prescribing and prescribing omissions [8].

The global burden of potentially inappropriate medication use remains high. Tian et al. reported a high pooled prevalence of potentially inappropriate medication use among older outpatients [9]. Indian evidence also showed that potentially inappropriate medication use affects a considerable proportion of older adults, highlighting the importance of regular medication review in Indian geriatric practice [6].

Drug-Drug Interactions

Drug-drug interactions were closely associated with polypharmacy and multimorbidity. The risk of interactions increased with the number of medicines prescribed, number of prescribers, presence of renal or hepatic impairment, self-medication, and use of over-the-counter or herbal preparations [1,3,10,11].

Commonly involved drug groups included anticoagulants, antiplatelets, NSAIDs, antihypertensives, diuretics, antidiabetic agents, antidepressants, antipsychotics, antiepileptics, macrolides, fluoroquinolones, and proton-pump inhibitors [7,8,15]. Clinically significant interactions may result in bleeding, hypoglycaemia, renal impairment, hyperkalaemia, hypotension, QT prolongation, sedation, delirium, falls, or therapeutic failure [7,11,28,29].

Older adults are particularly vulnerable because adverse effects may present atypically and may be misinterpreted as disease progression or ageing. This may lead to prescribing cascades, where an adverse drug effect is treated as a new medical condition, resulting in further medication burden [1,10,24,25].

Adverse Drug Reactions and Medication Safety

Adverse drug reactions were an important medication-safety concern in the included literature. Older adults are vulnerable to adverse drug reactions because of altered pharmacokinetics, altered pharmacodynamics, renal impairment, hepatic dysfunction, frailty, cognitive impairment, and multimorbidity [1,10,11].

Common adverse drug reactions in geriatric patients included dizziness, postural hypotension, falls, confusion, delirium, sedation, constipation, urinary retention, gastrointestinal bleeding, renal dysfunction, electrolyte imbalance, hypoglycaemia, and functional decline [3,4,11,28,29].

Gurwitz et al. reported frequent and preventable adverse drug events in ambulatory older adults [28]. Budnitz et al. identified anticoagulants, antiplatelets, antidiabetic agents, and other high-risk medicines as major contributors to emergency hospitalization due to adverse drug events among older adults [29]. These findings support the need for careful monitoring of high-risk medications in geriatric patients.

Antimicrobial Prescribing and Infection-Related Drug Utilization

Antimicrobial use formed an important component of geriatric prescribing, particularly among hospitalized older adults and patients with chronic or complicated infections. Older patients are at increased risk of infections due to comorbidity, immune senescence, diabetes mellitus, chronic kidney disease, indwelling devices, hospitalization, and functional dependence. However, antimicrobial prescribing in this group is complicated by renal impairment, drug-drug interactions, adverse effects, and risk of antimicrobial resistance [1,7,8].

Complex infections may require prolonged antimicrobial therapy, which increases the need for careful drug selection, microbiological confirmation, therapeutic monitoring, and adverse-effect surveillance. The systematic review by Sagar et al. on vertebral osteomyelitis and spondylodiscitis reported that adult spinal infections often require microbiological confirmation, prolonged antimicrobial therapy, and multidisciplinary care [30]. Although that review was not specifically a geriatric drug-utilization study, it is relevant as supportive evidence for infection-related prescribing complexity and prolonged antimicrobial exposure in adult patients, including older adults.

Deprescribing and Medication Review

Deprescribing was identified as an important strategy to reduce inappropriate polypharmacy and improve medication safety. Deprescribing refers to the planned and supervised reduction or discontinuation of medicines that may no longer be beneficial or may be causing harm [24,25].

Scott et al. described deprescribing as a structured approach that includes medication reconciliation, assessment of current indication, evaluation of benefit-risk balance, prioritization of medicines for withdrawal, gradual tapering where required, and monitoring after discontinuation [24]. Reeve et al. also emphasized that deprescribing should be patient-centred and should include shared decision-making with patients and caregivers [25].

Evidence from deprescribing studies suggests that structured medication discontinuation can reduce medication burden in older adults [26,27]. Pharmacist-led and multidisciplinary medication-review interventions have also shown benefit in reducing inappropriate prescribing, particularly when explicit criteria such as STOPP/START are applied [20-23].

Summary of Major Findings

The major findings of the review are as follows:

1. Geriatric drug utilization is dominated by medicines for cardiovascular disease, diabetes mellitus, pain, gastrointestinal disorders, psychiatric symptoms, respiratory illness, infection-related conditions, and nutritional supplementation [1,6,10,11].
2. Polypharmacy is highly prevalent among older adults and is commonly defined as the use of five or more medicines [2,6].
3. Polypharmacy is associated with adverse drug events, falls, cognitive impairment, poor adherence, hospitalization, and mortality [3-5,11].
4. Potentially inappropriate medication use is common in geriatric patients and is frequently detected using Beers Criteria and STOPP/START criteria [7,8,12-16].
5. High-risk medicines include benzodiazepines, anticholinergics, sedative-hypnotics, NSAIDs, antipsychotics, opioids, sulfonylureas, and long-term proton-pump inhibitors without clear indication [7,8,15-17].
6. Drug-drug interactions are common in older adults receiving multiple medicines and may lead to bleeding, hypoglycaemia, renal injury, hypotension, falls, delirium, and hospitalization [7,8,28,29].
7. Deprescribing, medication reconciliation, renal dose adjustment, pharmacist-led review, caregiver involvement, and use of explicit prescribing tools are important strategies to improve medication safety [1,20-27].
8. Infection-related prescribing, particularly prolonged antimicrobial therapy for complicated infections, requires careful monitoring in older adults due to comorbidity, renal impairment, and interaction risk [30].

The present systematic review synthesizes evidence on drug utilization patterns among geriatric patients, with emphasis on prescribing practices, polypharmacy, potentially inappropriate medication use, drug-drug interactions, adverse drug reactions, and medication-safety strategies. The findings indicate that geriatric prescribing is highly complex because older adults commonly have multimorbidity, altered pharmacokinetics and pharmacodynamics, reduced renal and hepatic reserve, frailty, cognitive impairment, and increased vulnerability to medication-related harm. The included manuscript framework identifies polypharmacy, potentially inappropriate medications, drug-drug interactions, adverse drug reactions, antimicrobial exposure, and deprescribing as the major themes of the review.

Across the included studies, the most commonly prescribed therapeutic classes among older adults were cardiovascular medicines, antidiabetic agents, analgesics, gastrointestinal drugs, psychotropic medicines, antimicrobials, respiratory medicines, vitamins, minerals, and supplements. This pattern reflects the high burden of chronic non-communicable diseases in older adults, particularly hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease, chronic respiratory disease, osteoarthritis, dementia, depression, and sleep disorders. However, the use of multiple disease-specific drugs in the same patient increases the risk of duplicate therapy, prescribing cascades, drug-drug interactions, poor adherence, and adverse drug reactions [1,3,6,10,11].

Polypharmacy emerged as the most consistent and clinically important finding of this review. Most included studies defined polypharmacy as the regular use of five or more medicines, while hyperpolypharmacy was generally defined as the use of ten or more medicines [2,6]. Although polypharmacy may be appropriate in some patients with multiple chronic diseases, it becomes inappropriate when medications are prescribed without a clear indication, continued beyond the required duration, duplicated across prescribers, or not adjusted according to renal function, frailty, or therapeutic goals. WHO has emphasized medication safety in polypharmacy as a major patient-safety priority and recommends structured medication review, patient participation, multidisciplinary care, and deprescribing where appropriate [1].

The clinical consequences of polypharmacy are substantial. Davies et al. reported that polypharmacy in older adults is associated with adverse drug events, reduced adherence, falls, cognitive impairment, increased healthcare utilization, hospitalization, and mortality [3]. Fried et al. similarly observed that polypharmacy among community-dwelling older adults was associated with falls, functional decline, hospitalization, and mortality [4]. Chang et al., in a nationwide cohort study, also demonstrated an association between polypharmacy, hospitalization, and all-cause mortality among elderly individuals [5]. Therefore, prescription burden should not be interpreted merely as a count of medicines, but as a marker of cumulative medication-safety risk.

The Indian evidence is particularly important because geriatric prescribing in India is often complicated by over-the-counter drug use, self-medication, fragmented care, limited geriatric-specialist access, and poor medication reconciliation. Bhagavathula et al. reported wide variation in the prevalence of polypharmacy and hyperpolypharmacy among older adults in India and also highlighted a substantial burden of potentially inappropriate medication use [6]. These findings suggest that medication review should be routinely incorporated into geriatric outpatient and inpatient care, particularly for patients receiving five or more medicines, patients with chronic kidney disease, and those consulting multiple specialists.

Potentially inappropriate medication use was another major finding of the review. Potentially inappropriate medications are those in which the risk of harm may outweigh expected benefit in older adults, especially when safer alternatives are available. The most commonly implicated drug groups include benzodiazepines, sedative-hypnotics, anticholinergics, first-generation antihistamines, antipsychotics, tricyclic antidepressants, non-steroidal anti-inflammatory drugs, skeletal muscle relaxants, opioids, long-term proton-pump inhibitors without clear indication, and some sulfonylureas [7,8,15-17]. These medicines are clinically important because they are associated with sedation, falls, cognitive impairment, delirium, gastrointestinal bleeding, renal dysfunction, hypoglycaemia, constipation, urinary retention, and functional decline.

The Beers Criteria and STOPP/START criteria were the most frequently used tools for evaluating prescribing appropriateness in the included literature. The 2023 AGS Beers Criteria provide updated recommendations on medications to avoid, medications to use with caution, drug-disease interactions, clinically important drug-drug interactions, and renal-dose considerations among adults aged 65 years and above [7]. STOPP/START version 3 provides a system-based approach for identifying both potentially inappropriate prescriptions and potential prescribing omissions [8]. This distinction is important because geriatric prescribing problems include not only overprescribing but also underprescribing of beneficial therapies, such as indicated cardiovascular, anticoagulant, osteoporosis, or preventive medications.

The high prevalence of potentially inappropriate medication use across studies reinforces the need for explicit screening tools in clinical practice. Tian et al. reported a high global prevalence of potentially inappropriate medication use among older outpatients [9]. Earlier criteria-development studies by Gallagher et al. and O’Mahony et al. established STOPP/START as a practical tool for identifying inappropriate prescribing and prescribing omissions [12,13]. Kaufmann et al. also showed that several explicit tools exist for assessing inappropriate prescribing, although the choice of tool may vary by healthcare setting and country [16]. Therefore, the use of Beers Criteria, STOPP/START, PRISCUS, FORTA, or locally adapted prescribing tools can strengthen medication-safety assessment in older adults [7,8,16-18].

Drug-drug interactions were closely linked with polypharmacy, multimorbidity, renal impairment, and involvement of multiple prescribers. Commonly involved drug classes included anticoagulants, antiplatelets, NSAIDs, antihypertensives, diuretics, antidiabetic agents, antidepressants, antipsychotics, antiepileptics, macrolides, fluoroquinolones, and proton-pump inhibitors [7,8,15]. Clinically significant interactions may result in bleeding, hypoglycaemia, renal injury, hyperkalaemia, hypotension, QT prolongation, sedation, delirium, falls, or therapeutic failure [7,11,28,29]. This finding supports the need for prescription reconciliation at every transition of care, especially during admission, discharge, and specialist referral.

Adverse drug reactions are a major concern in geriatric patients because older adults may present with atypical symptoms. Adverse reactions may appear as dizziness, postural hypotension, falls, confusion, delirium, sedation, constipation, urinary retention, gastrointestinal bleeding, renal dysfunction, electrolyte imbalance, hypoglycaemia, or functional decline. These symptoms may be misinterpreted as ageing or worsening of disease, resulting in a prescribing cascade in which another medication is added to treat the adverse effect of an existing medication [1,10,24,25]. Gurwitz et al. reported that adverse drug events among ambulatory older adults were frequent and often preventable [28]. Budnitz et al. further demonstrated that anticoagulants, antiplatelet agents, antidiabetic agents, and other high-risk medicines were major contributors to emergency hospitalizations due to adverse drug events among older Americans [29].

Cardiovascular and antidiabetic prescribing require special caution in geriatric patients. Antihypertensives, diuretics, antiplatelets, anticoagulants, statins, insulin, and sulfonylureas are frequently prescribed and may be clinically appropriate, but they require individualized decision-making. Excessive antihypertensive therapy may increase the risk of postural hypotension and falls, while anticoagulants and antiplatelets increase bleeding risk. Insulin and sulfonylureas may cause hypoglycaemia, particularly in older adults with renal impairment, irregular food intake, cognitive decline, or frailty [7,15,29]. Therefore, treatment goals should be individualized according to frailty, life expectancy, comorbidity burden, renal function, and patient preference.

Analgesic prescribing is another important area of concern. Chronic pain due to osteoarthritis, neuropathy, musculoskeletal disorders, and degenerative spine disease is common among older adults. NSAIDs are frequently used but may increase the risk of gastrointestinal bleeding, renal impairment, fluid retention, hypertension worsening, and cardiovascular events, especially when combined with antiplatelets, anticoagulants, diuretics, ACE inhibitors, or ARBs [7,8,15]. Safer prescribing requires careful assessment of pain cause, lowest effective dose, shortest duration, renal function monitoring, gastroprotection where indicated, and consideration of non-pharmacological pain-management strategies.

Psychotropic medicines also contributed substantially to medication-safety risk. Benzodiazepines, sedative-hypnotics, antipsychotics, antidepressants with anticholinergic properties, and other central nervous system-active drugs are associated with sedation, confusion, delirium, cognitive worsening, falls, fractures, and functional decline in older adults [7,15]. These medicines may be necessary in selected cases, but long-term use without review should be avoided. Non-pharmacological interventions should be prioritized for insomnia, behavioural symptoms of dementia, anxiety, and agitation whenever feasible.

Antimicrobial prescribing formed an important component of medication use among hospitalized and medically complex older adults. Older patients are more vulnerable to infections because of diabetes mellitus, chronic kidney disease, immunosenescence, indwelling devices, repeated hospitalization, and functional dependence. However, antimicrobial prescribing in this population is complicated by renal impairment, drug interactions, adverse effects, Clostridioides difficile risk, and antimicrobial resistance [1,7,8]. The review by Sagar et al. on vertebral osteomyelitis and spondylodiscitis is relevant as supportive evidence because complex adult infections may require prolonged antimicrobial therapy, microbiological confirmation, and multidisciplinary monitoring [30]. Although it is not a primary geriatric drug-utilization study, it supports the broader point that prolonged antimicrobial exposure requires careful safety surveillance, especially in older adults with comorbidities.

Deprescribing was identified as a major strategy to reduce inappropriate polypharmacy and improve medication safety. Deprescribing is a planned and supervised process of dose reduction or discontinuation of medicines that may no longer be beneficial or may be causing harm [24,25]. Scott et al. proposed a structured approach to deprescribing that includes medication reconciliation, identification of current indications, assessment of benefit-risk balance, prioritization of medicines for withdrawal, gradual tapering where necessary, and monitoring after discontinuation [24]. Reeve et al. emphasized that deprescribing should be patient-centred and should involve shared decision-making with patients and caregivers [25].

Evidence from interventional studies suggests that structured medication review can improve prescribing appropriateness. Gallagher et al. showed that use of STOPP/START criteria improved prescribing appropriateness among hospitalized older patients [20]. Frankenthal et al. demonstrated that pharmacist-led STOPP/START intervention reduced inappropriate prescribing among elderly residents of a chronic geriatric facility [22]. Clyne et al. also reported that a multifaceted primary-care intervention reduced potentially inappropriate prescribing among older patients [23]. These findings suggest that medication-safety interventions should be multidisciplinary and should include physicians, pharmacists, nurses, patients, and caregivers.

Medication reconciliation is particularly important during transitions of care. Hospital admission, interdepartmental transfer, discharge, and follow-up visits are high-risk periods for medication errors. Older adults may continue discontinued drugs, duplicate therapies, short-term hospital medications, or over-the-counter medicines without physician awareness. A complete medication history should include prescription medicines, over-the-counter drugs, herbal preparations, supplements, eye drops, topical preparations, and medicines prescribed by other specialists [1,24,25]. Clear discharge prescriptions, written medication lists, caregiver counselling, and follow-up review can reduce preventable harm.

The findings of this review have important implications for clinical practice. First, every geriatric prescription should be reviewed for indication, dose, duration, duplication, interaction risk, renal adjustment, and current clinical relevance. Second, high-risk medicines such as benzodiazepines, NSAIDs, anticholinergics, sedative-hypnotics, antipsychotics, opioids, sulfonylureas, anticoagulants, and long-term proton-pump inhibitors should be reviewed carefully [7,8,15-17]. Third, polypharmacy should trigger a structured medication review, but medicines should not be stopped solely based on number; the decision should be guided by appropriateness, benefit-risk balance, and patient goals [1,24,25]. Fourth, explicit tools such as Beers Criteria and STOPP/START should be combined with clinical judgment, because no tool can fully replace individualized geriatric assessment [7,8].

The findings also have public health relevance. With increasing life expectancy and rising non-communicable disease burden, medication exposure among older adults will continue to increase. In low- and middle-income countries, including India, the risk may be amplified by fragmented care, limited access to geriatric specialists, variable prescription monitoring, and easy access to over-the-counter medicines [6]. Therefore, geriatric medication safety should be integrated into primary care, hospital medicine, pharmacy practice, and public health policy. Regular prescription audits, electronic interaction alerts, pharmacist-led medication review, deprescribing protocols, and patient education may help reduce preventable medication-related morbidity.

This review has some limitations. The included studies were heterogeneous in terms of study design, population age cut-offs, clinical settings, definitions of polypharmacy, prescribing indicators, and tools used to assess potentially inappropriate medication use. Therefore, meta-analysis was not performed, and findings were synthesized narratively. Some included studies focused on older adults aged 65 years and above, whereas others used 60 years and above as the geriatric threshold. In addition, many drug-utilization studies may not capture over-the-counter drugs, herbal medicines, adherence, actual drug intake, or medicines prescribed outside the study setting. These limitations should be considered when interpreting the results.

Overall, the review demonstrates that drug utilization among geriatric patients is characterized by high prescription burden, frequent polypharmacy, substantial exposure to potentially inappropriate medications, and increased risk of drug-drug interactions and adverse drug reactions. Cardiovascular medicines, antidiabetic agents, analgesics, gastrointestinal drugs, psychotropics, antimicrobials, and supplements dominate geriatric prescribing, reflecting the multimorbidity burden in this population. Medication safety can be improved through routine medication review, use of Beers Criteria and STOPP/START criteria, renal dose adjustment, medication reconciliation, deprescribing, pharmacist involvement, caregiver education, and individualized patient-centred prescribing [1,7,8,20-27].

Practical Recommendations

Based on the findings of this systematic review, medication safety among geriatric patients can be improved through a structured and patient-centred prescribing approach. Every prescription for an older adult should be reviewed for current indication, dose, duration, duplication, interaction risk, renal dose adjustment, and overall clinical relevance. Medication review should be prioritized in patients receiving five or more medicines, those with multimorbidity, renal impairment, cognitive impairment, history of falls, recurrent hospitalization, or prescriptions from multiple healthcare providers [1-6].

Routine use of explicit prescribing tools such as the AGS Beers Criteria and STOPP/START criteria should be encouraged in geriatric practice. These tools can help identify potentially inappropriate medications, drug-disease interactions, drug-drug interactions, medicines requiring renal dose adjustment, and important prescribing omissions [7,8,12-16]. However, these criteria should be used as screening aids rather than rigid rules, and final prescribing decisions should be individualized according to frailty, comorbidities, life expectancy, functional status, patient preference, and goals of care.

High-risk medicines should be reviewed carefully in older adults. These include benzodiazepines, sedative-hypnotics, anticholinergics, antipsychotics, tricyclic antidepressants, opioids, non-steroidal anti-inflammatory drugs, sulfonylureas, anticoagulants, antiplatelets, diuretics, and long-term proton-pump inhibitors without clear indication [7,8,15-17]. When such medicines are necessary, the lowest effective dose should be used for the shortest possible duration, with regular monitoring for adverse effects.

Medication reconciliation should be performed at every transition of care, especially during hospital admission, transfer, discharge, and outpatient follow-up. A complete medication history should include prescription medicines, over-the-counter medicines, herbal preparations, nutritional supplements, topical preparations, eye drops, and medicines prescribed by other specialists [1,24,25]. Written medication lists, clear discharge instructions, caregiver counselling, and follow-up review can reduce medication errors and improve adherence.

Deprescribing should be incorporated into routine geriatric care. Medicines that lack a current indication, duplicate therapy, cause adverse effects, interact with other drugs, or no longer align with the patient’s goals should be considered for planned discontinuation [24,25]. Deprescribing should be gradual when required, especially for benzodiazepines, antidepressants, antipsychotics, beta-blockers, corticosteroids, and antiepileptics. Evidence suggests that structured medication review and pharmacist-led interventions can reduce inappropriate prescribing and improve medication safety among older adults [20-23,26,27].

Multidisciplinary collaboration is essential. Physicians, clinical pharmacists, nurses, patients, and caregivers should work together to optimize geriatric prescriptions. Pharmacist-led medication review, electronic drug-interaction alerts, renal-dose checking, prescription audits, and patient education programmes may help reduce preventable adverse drug events. In hospital settings, special attention should be given to high-risk medicines such as anticoagulants, antiplatelets, insulin, sulfonylureas, NSAIDs, opioids, and antimicrobials, as these are frequently implicated in medication-related harm and emergency hospitalization among older adults [28,29].

Limitations

This systematic review has certain limitations. First, the included studies were heterogeneous in terms of study design, population characteristics, age cut-offs, healthcare settings, definitions of polypharmacy, prescribing indicators, and tools used to assess potentially inappropriate medications. Because of this heterogeneity, a meta-analysis was not performed, and the findings were synthesized narratively.

Second, different studies used different age thresholds to define geriatric patients. Some studies included adults aged 60 years and above, while others used 65 years and above. This variation may affect comparability across studies. Similarly, the definition of polypharmacy varied across the literature, although use of five or more medicines was the most commonly reported definition [2,6].

Third, many drug-utilization studies relied on prescription records or hospital documentation. Such records may not fully capture over-the-counter medicines, herbal products, nutritional supplements, medicines prescribed by other clinicians, patient adherence, or actual drug consumption. Therefore, the true medication burden among older adults may be underestimated.

Fourth, potentially inappropriate medication prevalence may vary depending on the assessment tool used. Studies using Beers Criteria, STOPP/START criteria, PRISCUS, FORTA, or other tools may report different rates of inappropriate prescribing because each tool has different criteria, drug lists, and clinical assumptions [7,8,16-18].

Fifth, some included studies focused on prescribing patterns and did not provide detailed clinical outcomes such as adverse drug reactions, hospitalization, falls, mortality, or quality of life. Therefore, the relationship between prescribing patterns and patient outcomes could not be uniformly assessed across all studies.

Finally, this review included guideline documents, systematic reviews, interventional studies, cohort studies, and observational studies. Although this approach provided a broad overview of geriatric medication safety, it also introduced variability in the level and type of evidence included.

Drug utilization among geriatric patients is characterized by high prescription burden, frequent polypharmacy, and substantial exposure to potentially inappropriate medications. The most commonly prescribed drug groups include cardiovascular medicines, antidiabetic agents, analgesics, gastrointestinal drugs, psychotropic medicines, antimicrobials, respiratory medicines, vitamins, minerals, and supplements. This pattern reflects the high burden of multimorbidity among older adults but also increases the risk of drug-drug interactions, adverse drug reactions, poor adherence, prescribing cascades, hospitalization, and functional decline [1,3-6,10,11]. Polypharmacy should be considered an important medication-safety marker rather than merely a numerical count of medicines. Potentially inappropriate medications, especially benzodiazepines, sedative-hypnotics, anticholinergics, NSAIDs, antipsychotics, opioids, sulfonylureas, and long-term proton-pump inhibitors without clear indication, require careful review in older adults [7,8,15-17]. Tools such as the AGS Beers Criteria and STOPP/START criteria are useful for identifying unsafe prescribing and prescribing omissions, but they should be applied along with individualized clinical judgment [7,8]. Improving medication safety in geriatric patients requires routine medication review, renal dose adjustment, medication reconciliation, deprescribing, avoidance of high-risk medicines where possible, and multidisciplinary care involving physicians, pharmacists, nurses, patients, and caregivers. Structured interventions, including pharmacist-led medication review and use of explicit prescribing criteria, can reduce inappropriate prescribing and improve the quality of geriatric pharmacotherapy [20-27]. Overall, rational, patient-centred, and regularly reviewed prescribing is essential to reduce preventable medication-related harm and improve outcomes among older adults.

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