Prescribing In Older Adults Research Articles

Prevalence of potentially inappropriate medication in hospitalized elderly patients by using explicit criteria

Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. The aim of this study was to determine the prevalence and type of PIM in polypharmacy elderly patients on admission and discharge and the factors associated with their prescription. Just as the applicability of various explicit criteria selected from the literature and adapted to our area. We performed a cross-sectional study for 12 months (March 2010-February 2011) on 179 polypharmacy elderly patients admitted to an Internal Medicine Department. We created a list of 50 PIM using a Delphi approach based on previous published criteria (Beers, Stopp, BMC and Priscus). Through patient interviews, review of medical records and discharge reconciliation report, we identified the prevalence of PIM in the patients. We also analyzed the relationship between different factors and the prescription of PIM. The prevalence of patients with PIM on admission and discharge were 71% and 48%, respectively. Out of the 50 selected PIM, 27 and 26 were detected on admission and discharge, respectively (55.5% and 57.69% included on STOPP criteria). We detected two factors associated with PIM prescription at discharge: severe-total dependence (OR = 1.8) and prescription of more than 11 drugs (OR = 2). PIM prevalence in our population is very high (70%), especially at hospital admission. These findings support the need for measures aimed at improving the quality of prescriptions, especially on dependent patients with polypharmacy.

Prescription Drug Use Among Older Adults in Italy: A Country-Wide Perspective

In Italy, prescription drug costs represent approximately 17% of total public health expenditures. Older adults commonly use multiple drugs and, for this reason, this population is responsible for a large portion of drug-related costs. In 2012, public expenditure for pharmaceuticals in primary care exceeded 11 billion Euros (approximately 15.2 billion US $), and older adults aged 65 or older accounted for more than 60% of these costs. Recently, increased attention has been focused on studies aimed at monitoring drug use and evaluating the appropriateness of drug prescribing in older adults. In this article, we examined studies that assessed these issues in different settings at a national level. Specifically, results of surveys of prescription drug use in primary care (OsMED), hospital (GIFA, CRIME, and REPOSI) and long-term care (ULISSE and SHELTER) settings are reviewed. Overall, these studies showed that the quality of drug prescribing in older patients is far from optimal. This leads to an increased risk of negative health outcomes and increased health care costs. Data from these studies are valuable, not only to monitor drug use, but also to target interventions aimed at improving the quality of prescribing. Translating the findings of clinical research and monitoring programs will be challenging, but it will lead to quantifiable improvements in the quality of drug prescribing at a national level.

Educational needs, practice patterns and quality indicators to improve geriatric pharmacy care

As the population ages and pressure increases to reduce adverse drug reactions and drug-related hospitalizations in the elderly, there will be a growing demand for pharmacists to competently take on shared responsibility for effective and safe prescribing in older adults. A cross-sectional postal survey was distributed to 3927 hospital and community pharmacists across Québec about their educational needs and practice patterns in geriatric care. Perceptions of different quality performance indicators were sought. Modifiable factors associated with higher performance were determined using univariate logistic regression. Seven hundred six pharmacists (18%) completed the survey. Less than 50% were aware of the prevalence of polypharmacy, inappropriate prescribing, drug-related hospitalizations or falls in the geriatric population. Forty-one percent of community pharmacists and 74% of hospital pharmacists acknowledged familiarity with the Beers criteria of drugs to avoid in the elderly. The likelihood of screening for inappropriate prescriptions was 2.96 (95% confidence interval = 1.97-4.47) among pharmacists familiar with the Beers criteria and 2.24 (95% confidence interval = 1.50-3.34) among those who received continuing geriatric education in the workplace. On average, pharmacists reported having time to conduct detailed medication reviews in 30% of their older patients. The 2 quality indicators of geriatric care that were ranked most pertinent were being able to track the number of patients requiring hospitalization for drug-related problems and monitoring rates of inappropriate prescriptions. Ninety-six percent of respondents desired continuing education about geriatric care. Exposure to continuing education in geriatric pharmacotherapy in the workplace is the most consistent determinant of professional performance to improve drug outcomes in the elderly.

The Medication Appropriateness Index at 20: Where It Started, Where It Has Been, and Where It May Be Going

Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.

High Prevalence of Poor Quality Drug Prescribing in Older Individuals: A Nationwide Report From the Italian Medicines Agency (AIFA)

Poor quality of drug prescribing in older persons is often associated with increased drug-related adverse events, hospitalization, and mortality. The present study describes a set of prescribing quality indicators developed by the Geriatrics Working Group of the Italian Medicines Agency (AIFA) and estimates their prevalence in the entire elderly (≥ 65 years) population in Italy. We performed a cross-sectional study using 2011 data from the OsMed (Osservatorio dei Medicinali) database, which comprises all prescribed drugs that are reimbursed by the Italian National Healthcare System. Yearly prevalence of drug prescribing quality indicators in the Italian older population (n = 12,301,537) was determined. Overall, 13 quality indicators addressing polypharmacy, adherence to treatment of chronic diseases, prescribing cascade, undertreatment, drug-drug interactions, and drugs to be avoided were identified. Polypharmacy was common, with more than 1.3 million individuals taking greater than or equal to 10 drugs (11.3% of the study population). The prevalence of low adherence and undertreatment was also elevated and increased with advancing age, with highest prevalence occurring in individuals aged 85 years and older. Prevalence was less than 3% for quality indicators assessing the prescribing cascade, drug-drug interactions, and drugs to be avoided. These results confirm the high frequency of suboptimal drug prescribing in older adults, using a database that covers the whole Italian population. In general, this descriptive study may help in prioritizing strategies aimed at improving the quality of prescribing in elderly population.

Inappropriate Use of Psychotropic Drugs in Older Individuals: Implications for Practice

Frailty at old age and institutionalization in nursing homes are often associated with multiple chronic diseases (multimorbidity) requiring multiple medications (polypharmacy). Among these chronic conditions, mental health problems (e.g., dementia, depression and insomnia) are common. Psychotropic drugs are frequently used as a treatment approach for these conditions, and the prevalence of their use is high among community-dwelling older adults, but even higher in nursing homes. Furthermore, within the problem of polypharmacy and inappropriate prescribing, psychotropic drugs (defined in this article as antipsychotics, benzodiazepines and antidepressants) constitute a significant proportion. The use of psychotropics in older adults remains controversial given the risk of adverse effects, in contrast to the limited effectiveness. Guidelines advise a thorough risk–benefit analysis before the initiation of psychotropics, in addition to time-limited use and discontinuation. In the future, serious efforts should be undertaken to tackle the burden of inappropriate psychotropic prescribing in older adults by incorporating a multidisciplinary approach and by offering credible alternatives.

Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact

Potentially inappropriate prescribing (PIP) has significant clinical, humanistic and economic impacts. Identifying PIP in older adults may reduce their burden of adverse drug events. Tools with explicit criteria are being developed to screen for PIP in this population. These tools vary in their ability to identify PIP in specific care settings and jurisdictions due to such factors as local prescribing practices and formularies. One promising set of screening tools are the STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) and START (Screening Tool of Alert doctors to the Right Treatment) criteria. We conducted a systematic review of research studies that describe the application of the STOPP/START criteria and examined the evidence of the impact of STOPP/START on clinical, humanistic and economic outcomes in older adults. We performed a systematic review of studies from relevant biomedical databases and grey literature sources published from January 2007 to January 2012. We searched citation and reference lists and contacted content experts to identify additional studies. Two authors independently selected studies using a predefined protocol. We did not restrict selection to particular study designs; however, non-English studies were excluded during the selection process. Independent extraction of articles by two authors used predefined data fields. For randomized controlled trials and observational studies comparing STOPP/START to other explicit criteria, we assessed risk of bias using an adapted tool. We included 13 studies: a single randomized controlled trial and 12 observational studies. We performed a descriptive analysis as heterogeneity of study populations, interventions and study design precluded meta-analysis. All observational studies reported the prevalence of PIP; however, the application of the criteria was not consistent across all studies. Seven of the observational studies compared STOPP/START with other explicit criteria. The STOPP/START criteria were reported to be more sensitive than the more-frequently-cited Beers criteria in six studies, but less sensitive than a set of criteria developed in Australia. The STOPP criteria identified more medications associated with adverse drug events than the 2002 version of the Beers criteria. Patients with PIP, as identified by STOPP, had an 85% increased risk of adverse drug events in one study (OR = 1·85, 95% CI: 1·51-2·26; P < 0·001). There was limited evidence that the application of STOPP/START criteria optimized prescribing. Research involving the application of STOPP/START on the impact on the quality of life was not found. The direct costs of PIP were documented in three studies from Ireland, but more extensive analyses on the economic impact or studies from other jurisdictions were not found. The STOPP/START criteria have been used to review the medication profiles of community-dwelling, acute care and long-term care older patients in Europe, Asia and North America. Observational studies have reported the prevalence and predictors of PIP. The STOPP/START criteria appear to be more sensitive than the 2002 version of the Beers criteria. Limited evidence was found related to the clinical and economic impact of the STOPP/START criteria.

Systematic review of anticholinergic risk scales in older adults.

Anticholinergic drugs are often involved in explicit criteria for inappropriate prescribing in older adults. Several scales were developed for screening of anticholinergic drugs and estimation of the anticholinergic burden. However, variation exists in scale development, in the selection of anticholinergic drugs, and the evaluation of their anticholinergic load. This study aims to systematically review existing anticholinergic risk scales, and to develop a uniform list of anticholinergic drugs differentiating for anticholinergic potency. We performed a systematic search in MEDLINE. Studies were included if provided (1) a finite list of anticholinergic drugs; (2) a grading score of anticholinergic potency and, (3) a validation in a clinical or experimental setting. We listed anticholinergic drugs for which there was agreement in the different scales. In case of discrepancies between scores we used a reputed reference source (Martindale: The Complete Drug Reference®) to take a final decision about the anticholinergic activity of the drug. We included seven risk scales, and evaluated 225 different drugs. Hundred drugs were listed as having clinically relevant anticholinergic properties (47 high potency and 53 low potency), to be included in screening software for anticholinergic burden. Considerable variation exists among anticholinergic risk scales, in terms of selection of specific drugs, as well as of grading of anticholinergic potency. Our selection of 100 drugs with clinically relevant anticholinergic properties needs to be supplemented with validated information on dosing and route of administration for a full estimation of the anticholinergic burden in poly-medicated older adults.

High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level

BackgroundHigh risk prescribing can compromise independent wellbeing and quality of life in older adults. The aims of this project are to determine the prevalence, risk factors, clinical consequences, and costs of high risk prescribing, and to assess the impact of interventions on high risk prescribing in older people.MethodsThe proposed project will utilise data from the 45 and Up Study, a large scale cohort of 267,153 men and women aged 45 and over recruited during 2006–2009 from the state of New South Wales, Australia linked to a range of administrative health datasets. High risk prescribing will be assessed using three indicators: polypharmacy (use of five or more medicines); Beers Criteria (an explicit measure of potentially inappropriate medication use); and Drug Burden Index (a pharmacologic dose-dependent measure of cumulative exposure to anticholinergic and sedative medicines). Individual risk factors from the 45 and Up Study questionnaire, and health system characteristics from health datasets that are associated with the likelihood of high risk prescribing will be identified. The main outcome measures will include hospitalisation (first admission to hospital, total days in hospital, cause-specific hospitalisation); admission to institutionalised care; all-cause mortality, and, where possible, cause-specific mortality. Economic costs to the health care system and implications of high risk prescribing will be also investigated. In addition, changes in high risk prescribing will be evaluated in relation to certain routine medicines-related interventions. The statistical analysis will be conducted using standard pharmaco-epidemiological methods including descriptive analysis, univariate and multivariate regression analysis, controlling for relevant confounding factors, using a number of different approaches.DiscussionThe availability of large-scale data is useful to identify opportunities for improving prescribing, and health in older adults. The size of the 45 and Up Study, along with linkage to health databases provides an important opportunity to investigate the relationship between high risk prescribing and adverse outcomes in a real-world population of older adults.

Updated 2012 Beers Criteria: What’s Noteworthy and Cautionary?

The Beers Criteria for potentially inappropriate medication use in older adults, originally published in 1991, have gone through several iterations.1 The initial publication focused exclusively on nursing home residents, providing a list of medications where the potential for harm exceeded the potential for beneficial effects. The criteria have arguably been influential in providing guidance for appropriateness of prescribing decisions in the elderly, especially for physicians and pharmacists practicing in long term care. In 1997 and again in 2003, the criteria were updated by a consensus panel of experts in geriatric pharmacotherapy who expanded the scope of the criteria and made it applicable for all adults aged 65 and older no matter where they reside and receive care.2,3 For more than a decade now, the Beers Criteria have been used as a clinical reference for informed decision making regarding prescribing in older adults. They have been used in several studies to predict health outcomes associated with potentially inappropriate medication (PIM) use in the elderly with variable andmixed results.4,5 The Beers Criteria also inform quality measures for several organizations and agencies, such as the National Committee for Quality Assurance, the Pharmacy Quality Alliance, the Centers for Medicare and Medicaid Services, and Medicare Part D. These bodies have relied on the criteria when developing quality measures addressing the pharmacological management of older adults.6 In 1999 and then again in 2006, the Centers for Medicare and Medicaid Services adopted some of the medications in the “Beers list” as quality indicator measures for assessing medication use in long term care facilities. The Beers Criteria have recently been revised by the American Geriatrics Society (AGS); this 2012 update,7 including several other tools and resources for public and professional use, are published on the AGS Web site.8 The 2012 Beers Criteria significantly improve on the previous methodology used in the past versions by using Institute of Medicine standards for clinical practice guidelines and a robust evidence-based grading system. The methodology and the literaturebased review are well characterized in the AGS publication.7 The structure and categorization of medications in tables remains essentially the same as in previous versions, with the exception of another table of medications to be used with caution. In essence, 53 medications or medication classes comprise the final updated criteria, and they are divided into 3 categories: PIMs and classes to avoid in

Commentary on the New American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Recently, the American Geriatrics Society (AGS) Beers criteria were unveiled as a measure of potentially inappropriate medication use in older adults.1 We thought it would be timely and relevant to comment on this updated quality measure for medication use. Of note, a recent systematic review summarized the current literature on the more than a dozen measures of potentially inappropriate prescribing in older adults and reported that the Beers criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria were some of the most common measures used.2 With that in mind, in this commentary we discuss some of the history of the Beers criteria as well as briefly describe the process of updating the criteria, highlighting some of the key changes made. Then, we compare and contrast the new criteria with the STOPP criteria from Europe.3 Finally, we briefly comment on some future directions for the Beers criteria as an explicit measure of potentially inappropriate medication use in older adults.

Safe prescribing for the elderly

Prescribing for older adults is a complex and high-risk process. Age-related changes produce differences in the way lderly patients respond to and process medication. This article discusses age-related changes, common problems that increase risk for older adults, strategies for improving adherence, and models for safe and effective prescribing.

Geriatrics Medication Management Rounds: A Novel Approach to Teaching Rational Prescribing with the Use of the Medication Screening Questionnaire

Prescribing for older adults has become increasingly complex as treatment regimens have intensified, and the use of herbal and over-the-counter medications has increased. This article describes an educational intervention called Geriatrics Medication Management Rounds, which uses a new and comprehensive assessment tool called the Medication Screening Questionnaire (MSQ). This case-based interactive session is aimed at teaching trainees and postgraduate physicians and pharmacists to examine the pharmacology, potential drug and disease interactions, efficacy, adherence issues, and goals of care for a geriatric patient's medication regimen. Twenty-three sessions were held from January 2008 to January 2009, with 241 participants overall and an average of 10.4 participants per session. Of the 163 participants who completed an evaluation, all agreed or strongly agreed that the learning goals were clearly established, and 99% agreed or strongly agreed that the overall quality of the session was excellent. Participants described the sessions as excellent, interactive, informative, and educational. Teaching medication management through a case-based format with the MSQ is an effective format that is interactive and informative, as demonstrated by positive quantitative and qualitative evaluations. These sessions may be replicated in other settings and with other disciplines.

Adverse Reactions/Medication Safety: Beyond the Beers Criteria: A Comparative Overview of Explicit Criteria

To provide a comparative overview of explicit criteria that have been developed since 2003 for inappropriate prescribing in older adults and to contrast these newer criteria with the most recent Beers criteria, published in 2003. MEDLINE and Google Scholar searches were performed from 2003 through July 2010. Within MEDLINE, MeSH terms included aged, drug prescriptions, medication errors, and polypharmacy. Free-text search terms included elderly, guideline adherence, inappropriate prescribing, and medications. Related articles, as identified by MEDLINE, were used as well. Free-text search was performed on Google Scholar, using "potentially inappropriate prescribing elderly." Additional articles were identified in reference lists of key articles. Studies were selected if they were published after the most recent revision of the Beers criteria in 2003 and addressed the development and application of explicit criteria for the elderly. We independently reviewed pertinent literature to extract key information. The first explicit criteria published were the Beers criteria, and most research regarding inappropriate medication use applied these criteria. Criteria developed subsequent to the Beers criteria include the French Consensus Panel list, STOPP (Screening Tool of Older Persons' Prescription) and START (Screening Tool to Alert doctors to Right Treatment), the Australian Prescribing Indicators tool, and the Norwegian General Practice Criteria. Newer criteria offer several improvements on the Beers criteria, namely drug-drug interactions, omission of potentially beneficial therapy, and more broadly applicable criteria across international borders. Although no criteria may ever be globally applicable, STOPP and START make significant advances. Regional drug availability, economic considerations, and clinical practice patterns impact criteria selection. Research to validate the several newer criteria in various practice settings and to explore the effect of adhering to the guidelines on patient outcomes is warranted. Data from such research will aid practitioners in identifying preferred criteria.

Inappropriate prescribing in the hospitalized elderly patient: Defining the problem, evaluation tools, and possible solutions

Potentially inappropriate medication (PIM) prescribing in older adults is quite prevalent and is associated with an increased risk for adverse drug events, morbidity, and utilization of health care resources. In the acute care setting, PIM prescribing can be even more problematic due to multiple physicians and specialists who may be prescribing for a single patient as well as difficulty with medication reconciliation at transitions and limitations imposed by hospital formularies. This article highlights critical issues surrounding PIM prescribing in the acute care setting such as risk factors, screening tools, and potential strategies to minimize this significant public health problem.

Rationalise prescribing and use simple remedies.

Prescribing for older adults requires greater skill levels and caution than prescribing for younger people. The prescriber must take into account age- related changes, possible concordance problems, greater risk of side effects and the effects of polypharmacy.

Use of computer decision support interventions to improve medication prescribing in older adults: A systematic review

Background: Older adults take multiple medications and are at high risk for adverse drug effects. Objective: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults. Methods: PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they described a CDS intervention intended to improve medication prescribing in adults aged ≥60 years. Studies were retained if they were observational or experimental in design and reported ≥1 process or clinical outcome measurement related to medication prescribing. In the main analysis, study characteristics and major outcome results were extracted. A combination of searches was performed using relevant medical subject headings: aged; drug therapy, computer-assisted; medication errors; medication errors/prevention and control; decision making, computer-assisted; decision support systems, clinical; and clinical pharmacy information systems. Results: After review of study abstracts, 10 articles met the eligibility criteria. Of those 10 studies testing CDS interventions, 8 showed at least modest improvements (median number needed to treat, 33) in prescribing, as measured by minimizing drugs to avoid, optimizing drug dosage, or more generally improving prescribing choices in older adults (according to each study's intervention protocols). Findings for the impact of CDS interventions on clinical outcomes were mixed and were reported for only 2 studies. Conclusions: Various types of CDS interventions may be effective in improving medication prescribing in older adults, but few studies reported clinical outcomes related to changes in medication prescribing. Data from this study should help to guide refinement and testing of future CDS interventions that specifically target older adult populations that are taking multiple medications.

SANDS: A service-oriented architecture for clinical decision support in a National Health Information Network

In this paper, we describe and evaluate a new distributed architecture for clinical decision support called SANDS (Service-oriented Architecture for NHIN Decision Support), which leverages current health information exchange efforts and is based on the principles of a service-oriented architecture. The architecture allows disparate clinical information systems and clinical decision support systems to be seamlessly integrated over a network according to a set of interfaces and protocols described in this paper. The architecture described is fully defined and developed, and six use cases have been developed and tested using a prototype electronic health record which links to one of the existing prototype National Health Information Networks (NHIN): drug interaction checking, syndromic surveillance, diagnostic decision support, inappropriate prescribing in older adults, information at the point of care and a simple personal health record. Some of these use cases utilize existing decision support systems, which are either commercially or freely available at present, and developed outside of the SANDS project, while other use cases are based on decision support systems developed specifically for the project. Open source code for many of these components is available, and an open source reference parser is also available for comparison and testing of other clinical information systems and clinical decision support systems that wish to implement the SANDS architecture. The SANDS architecture for decision support has several significant advantages over other architectures for clinical decision support. The most salient of these are: 1. Greater modularity than other architectures, allowing for work to be distributed. 2. The potential for creating and sustaining a commercial market for clinical decision support. 3. Reduced cost and risk of trying new decision support systems because of its ability to easily integrate a variety of decision support services, and to easily remove them, if desired, as well. 4. Significant freedom for developers of clinical decision support systems to choose the way they represent knowledge and internally implement their system, in comparison to other approaches which constrain such developers to a particular knowledge representation formalism. 5. Unification of the direction and agenda of decision support research and development with promising near-term efforts to improve interoperability of clinical systems.

&lt;b&gt;Cardiovascular Medication Prescribing in Older Adults with Psychiatric Disorders Research and Reports&lt;/b&gt;

To examine the appropriateness of cardiovascular (CV) medication prescribing of patients admitted to a geriatric psychiatry ward. Secondary aims included examining: 1) if differences in CV medication prescribing existed between admission and discharge and 2) if differences in CV medication prescribing existed between patients with and without dementia. Cross-sectional study. Inpatient geriatric psychiatry unit within a regional medical center. 197 patients admitted between June 2005 and May 2006. Changes in CV medication prescribing from admission to discharge. On admission, the percent of patients receiving appropriate CV medications for general CV prevention, atrial fibrillation, coronary-artery disease, and heart failure ranged from 33% to 56%. With the exception of the treatment of heart failure, no significant improvements in appropriate CV medication prescribing were noted at the time of discharge. No differences in CV medication prescribing were found between patients with and without dementia. Despite the known benefits of numerous CV medications in older adults, many patients admitted to a geriatric psychiatry ward were not prescribed optimal pharmacotherapeutic regimens on admission or had their medications changed by the time of discharge.

Inappropriate drug prescribing in older adults: the updated 2002 Beers criteria – a population‐based cohort study

In 1997, Beers and colleagues developed explicit criteria for potentially inappropriate drug prescribing in ambulatory older adults aged 65 years and over. Several studies have been performed to estimate the prevalence of inappropriate drug prescribing based on these criteria. In 2002, the criteria were updated. To examine the extent and trend of inappropriate drug prescribing to ambulatory older adults in the Netherlands between 1997 and 2001, according to the 1997 and the updated Beers criteria. Data were retrieved from the Integrated Primary Care Information (IPCI) project, a general practice research database with data from computer-based patient records of a group of 150 general practitioners in the Netherlands. All subjects aged 65 and over were included. Prescriptions were classified as inappropriate if they fulfilled the Beers criteria of prescriptions that generally should be avoided in older adults because of a high risk of adverse effects, while also considering dose and comorbidity. Between 1997 and 2001, the 1-year risk of receiving at least one inappropriate drug prescription for older adults ranged between 16.8% (95% CI: 16.3-17.3%) and 18.5% (18.3-18.7%) according to the 1997 criteria and between 19.1% (18.6-19.6%) and 20.0% (19.5-20.5%) according to the updated Beers criteria. According to the updated criteria, the most frequently prescribed inappropriate drugs were nitrofurantoin, long-acting benzodiazepines, amitriptyline, promethazine and cimetidine. Temazepam and zolpidem were mostly prescribed in supratherapeutic dose. Conventional NSAIDs in persons with a history of gastric/duodenal ulcer were the most frequently prescribed contra-indicated drugs. Prescribing potentially inappropriate prescriptions to ambulatory older people in the Netherlands is substantial. Compared with other studies using the 1997 Beers criteria, inappropriate prescribing to the elderly is lower than in the USA but similar to Finland. Despite a restrictive medication policy and a growing attention for medication surveillance in Europe, inappropriate drug prescribing is still a substantial problem.