International Journal of Clinical Pharmacy

, Volume 34, Issue 4, pp 596–603 | Cite as

Evaluation of potentially inappropriate medications among older residents of Malaysian nursing homes

  • Li Li Chen
  • Balamurugan TangiisuranEmail author
  • Asrul Akmal Shafie
  • Mohamed Azmi Ahmad Hassali
Research Article


Background: There is an increasing evidence of medicines related issues such as inappropriate prescribing among older people. Inappropriate prescribing is an important risk factor for adverse drug reactions and hospitalizations in the older people. Objective : To assess and characterize the prevalence of Potentially Inappropriate Medications (PIMs) in nursing home care in Malaysia as defined by Screening Tool of Older Peoples Prescriptions (STOPP) and Beers criteria. Setting : Four Nursing Homes situated in Penang, Malaysia. Methods : A multicenter and cross-sectional study was conducted over 2 months period at four large non-governmental organizations nursing homes in Penang, Malaysia. The study population included older residents (≥65 years old) taking at least one medication. Residents who had been diagnosed with dementia or taking anti dementia drugs, delirium, too frail or refused to give consent were excluded. Demographic, clinical data and concurrent medications were collected through direct interview and also by reviewing medical records. STOPP and Beers criteria were applied in the medical review to screen for PIMs. Main Outcome measure : Potentially Inappropriate Medication using STOPP and Beers criteria. Results : Two hundred eleven residents were included in the study with the median age of 77 (inter quartile range (IQR) 72–82) years. Median number of prescription medicines was 4 (IQR 1–14). STOPP identified less residents (50 residents, 23.7 %) being prescribed on PIMs compared with Beers criteria (69 residents, 32.7 %) (p < 0.001). There was a significant difference in the number of residents with PIMs detected by STOPP (23.7 %) and by Beers criteria (32.7 %), p < 0.001. The common identified PIMs by Beers criteria included nifedipine short acting, chlorpheniramine and diphenhydramine. The STOPP identified first generation antihistamines, duplication of drug classes, glibenclamide and anticholinergic agents. Higher number of medications (OR = 1.405 [1.193–1.654]; OR = 1.447 [1.215–1.723]) and longer stay at nursing home (OR = 1.132 [1.045–1.226]; OR = 1.133 [1.034–1.241]) were identified as predictors for both Beers and STOPP PIMs. Conclusion: Potentially inappropriate medications are highly prevalent among older residents living in the nursing homes and are associated with number of medications and longer nursing home stay. Further research is warranted to study the impact of PIMs towards health related outcomes in these elderly.


Beers criteria Malaysia Nursing home Older people Potentially inappropriate medications STOPP criteria 



The authors wish to thank the management of Penang Home for the infirm and age, Silver Jubilee old folks home, Wang Ching Yuan and Rumah Charis for the use of the nursing homes medical records. We wish to thank Dr Soo Borson, Professor in the University of Washington Department of Psychiatry and Behavioral Sciences, for granting the permission to use the Mini Cog tool.


The authors acknowledge Universiti Sains Malaysia for financing this project through Short Term Research Grant

Conflicts of interest

Authors have no conflict of interest to declare


  1. 1.
    Gallagher P, O’Mahony D. Inappropriate prescribing in older people. Rev Clin Gerontol. 2008;18(01):65–76.CrossRefGoogle Scholar
  2. 2.
    Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? The Lancet. 2007;370(9582):173–84. doi: 10.1016/S0140-6736(07)61091-5.CrossRefGoogle Scholar
  3. 3.
    Schaefer M. Discussing basic principles for a coding system of drug-related problems: the case of PI-Doc®. Pharm World Sci. 2002;24(4):120–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Hanlon JT, Lindblad CI, Hajjar ER, McCarthy TC. Update on drug-related problems in the elderly. Am J Geriatr Pharmacother. 2003;1(1):38–43. doi: 10.1016/S1543-5946(03)80014-4.PubMedCrossRefGoogle Scholar
  5. 5.
    Fialová D, Topinková E, Gambassi G, Finne-Soveri H, Jónsson PV, Carpenter I, et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293(11):1348–58.PubMedCrossRefGoogle Scholar
  6. 6.
    Liu G, Christensen D. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc. 2002;42(6):847–57.CrossRefGoogle Scholar
  7. 7.
    Aparasu R, Mort J. Inappropriate prescribing for the elderly: beers criteria-based review. Ann pharmacother. 2000;34(3):338.PubMedCrossRefGoogle Scholar
  8. 8.
    Fiss T, Dreier A, Meinke C, van den Berg N, Ritter CA, Hoffmann W. Frequency of inappropriate drugs in primary care: analysis of a sample of immobile patients who received periodic home visits. Age Ageing. 2011;40(1):66.PubMedCrossRefGoogle Scholar
  9. 9.
    Gallagher P, O’Mahony D. STOPP (screening tool of older persons’ potentially inappropriate prescriptions) application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37:673–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Gallagher P, Lang PO, Cherubini A, Topinková E, Cruz-Jentoft A, Montero Errasquín B, et al. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol. 2011;67:1175–88.PubMedCrossRefGoogle Scholar
  11. 11.
    Conejos Miquel MD, Sánchez Cuervo M, Delgado Silveira E, Sevilla Machuca I, González-Blazquez S, Montero Errasquin B, et al. Potentially inappropriate drug prescription in older subjects across health care settings. Eur Geriatr Med. 2010;1(1):9–14. doi:  10.1016/j.eurger.2009.12.002].
  12. 12.
    Mamun K, Lien C, Goh-Tan C, Ang W. Polypharmacy and inappropriate medication use in Singapore nursing homes. Ann Acad Med Singap. 2004;33(1):49–52.PubMedGoogle Scholar
  13. 13.
    Harugeri A, Joseph J, Parthasarathi G, Ramesh M, Guido S. Potentially inappropriate medication use in elderly patients: a study of prevalence and predictors in two teaching hospitals. J Postgrad Med. 2010;56(3):186.PubMedCrossRefGoogle Scholar
  14. 14.
    Fick D, Cooper J, Wade W, Waller J, MacLean J, Beers M. Updating the beers criteria for potentially inappropriate medication use in older adults–results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–24.PubMedCrossRefGoogle Scholar
  15. 15.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (screening tool of older persons’ prescriptions) and START (screening tool to alert doctors to right treatment): consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.PubMedGoogle Scholar
  16. 16.
    Gallagher PF, Barry PJ, Ryan C, Hartigan I, O’Mahony D. Inappropriate prescribing in an acutely ill population of elderly patients as determined by Beers’ Criteria. Age & Ageing. [Article]. 2008;37(1):96–101.Google Scholar
  17. 17.
    O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, et al. STOPP & START criteria: a new approach to detecting potentially inappropriate prescribing in old age. Eur Geriatr Med. 2010;1(1):45–51.[doi:  10.1016/j.eurger.2010.01.007].Google Scholar
  18. 18.
    Ma H, Lum C, Dai L, Kwok C. Potentially inappropriate medication in elderly patients in outpatient clinics. Asian J Gerontol Geriatr. 2008;3(1):27–33.Google Scholar
  19. 19.
    Azoulay L, Zargarzadeh A, Salahshouri Z, Oraichi D, Bérard A. Inappropriate medication prescribing in community-dwelling elderly people living in Iran. Eur J Clin Pharmacol. 2005;61(12):913–9. doi: [ 10.1007/s00228-005-0036-4].
  20. 20.
    Sim OF. Ageing and Long-Term Care National Policies in the Asia-Pacific. Chan PDRPaACM, editor. Hong Kong: Ageing Research Network of the Asian Development Research Forum; 2002.Google Scholar
  21. 21.
    Shah A, Herbert R, Lewis S, Mahendra R, Platt J, Bhattacharyya B. Screening for depression among acutely ill geriatric inpatients with a short geriatric depression scale. Age Ageing. 1997 May 1, 1997;26(3):217–21.Google Scholar
  22. 22.
    Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int geriatr psychiatr. 2000;15(11):1021–7.CrossRefGoogle Scholar
  23. 23.
    Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970 March 20, 1970;10(1 Part 1):20–30.Google Scholar
  24. 24.
    Ryan C, O’Mahony D, Kennedy J, Weedle P, Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68(6):936–47.PubMedCrossRefGoogle Scholar
  25. 25.
    Chetty R, Gray A. Inappropriate prescribing in an elderly population: findings from a South African public sector survey. Int J Phar Pract. 2004;12(3):149–54.CrossRefGoogle Scholar
  26. 26.
    Beers M, Ouslander J, Rollingher I, Reuben D, Brooks J, Beck J. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825–32.PubMedCrossRefGoogle Scholar
  27. 27.
    Unit EP. The 9th Malaysia plan: 2006-2010. Putra Jaya, Malaysia: Prime Minister’s Department. 2006.Google Scholar
  28. 28.
    Hay JW, Leahy M. Cost and utilization impacts of oral antihistamines in the California medical program. Value in Health. 2005;8(4):506–16.PubMedCrossRefGoogle Scholar
  29. 29.
    Onder G, Landi F, Cesari M, Gambassi G, Carbonin P, Bernabei R. Inappropriate medication use among hospitalized older adults in Italy: results from the Italian group of pharmacoepidemiology in the Elderly. Eur J Clin Pharmacol. 2003;59(2):157–62. doi: [ 10.1007/s00228-003-0600-8].Google Scholar
  30. 30.
    Lang PO, Hasso Y, Dramé M, Vogt-Ferrier N, Prudent M, Gold G, et al. Potentially inappropriate prescribing including under-use amongst older patients with cognitive or psychiatric co-morbidities. Age and ageing. 2010 May 1, 2010;39(3):373–81.Google Scholar
  31. 31.
    Rancourt C, Moisan J, Baillargeon L, Verreault R, Laurin D, Gregoire J-P. Potentially inappropriate prescriptions for older patients in long-term care. BMC Geriatr. 2004;4(1):9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Li Li Chen
    • 1
  • Balamurugan Tangiisuran
    • 1
    Email author
  • Asrul Akmal Shafie
    • 1
  • Mohamed Azmi Ahmad Hassali
    • 1
  1. 1.Discipline of Clinical Pharmacy, School of Pharmaceutical SciencesUniversiti Sains MalaysiaMindenMalaysia

Personalised recommendations