The global rise in the elderly population—from 9% in 1990 to 12% in 2013—is projected to reach 21% by2050, with India’s proportion of adults aged 60 and above expected to increase from 8% in 2010 to 19% by 2050.^[1] Aging leads to reduced physical and cognitive function and a higher burden of chronic diseases.^[2] In India, lifestyle-related non-communicable diseasesaffectnearlyoneinfourpeople,andstrokeremainsamajorhealthchallenge,ranking as the world’s third leading cause of death in 2021, with national incidence rates of 105–152 per 100,000 and wide regional variation.^[3,4,5]

Older adults commonly experience multiple chronic conditions that often require several medications, increasing the likelihood of polypharmacy and heightening the risk of receiving potentially inappropriate medications (PIMs).^[6,7] PIMs are defined as drugs where the risk outweighsthebenefitwhensaferalternativesexist,andtheiruseisespeciallycommoninolder adults with multimorbidity.^[8]The resulting negative impact on health systems—through avoidablehospitalisations,increasedmedicationburden,andrisingmorbidityandmortality— makes PIM use a significant global concern.^[9]

TheBeersCriteria, first introduced in 1991 byDr. MarkBeers,identifymedications that may pose risks to older adults due to age-related physiological changes, with the American Geriatrics Society releasing its seventh update in 2023 and fourth under its stewardship since 2011.^[10]

Althoughseveralstudieshaveassessedpotentiallyinappropriatemedication(PIM)useinolder adults using previous versions of the criteria, research utilizing the 2023 update remains limited, particularly among post-stroke populations. To date, no study has specifically evaluated PIM prescribing in elderly post-stroke patients based on the 2023 Beers Criteria. Therefore, this study aims to determine the prevalence and types of PIMs in this group using the latest Beers framework

StudyDesign andPopulation

This cross-sectional, questionnaire-based observational study was conducted in the Geriatric Outpatient Department (OPD) of a tertiary care government hospital over two months (February–March 2025). Ethical approval was obtained (Acad./IEC/2025/616). Patients of either sex, aged 60 years or older, with a history of one or more episodes of stroke (either ischemicorhaemorrhagic)occurringmorethansixmonthsprior,wereincludedafterproviding writteninformedconsent.Individualswhowererecentlydiagnosedwithstroke,terminallyill, or had permanent disabilities were excluded.

SampleSize

Thesamplesizeof100wascalculatedusingCochran’sformula,incorporatinganadditional 5% to compensate for possible non-responses. The calculation assumed a 6% stroke prevalence among Geriatric OPD attendees based on prior studies, with a 95% confidence level and 5% margin of error.[11]

Data Collection

Patients who met the inclusion criteria were recruited through convenience sampling during their visit to the Geriatric OPD. The study was explained in the participants’ native language to ensure comprehension, and participation was voluntary with the option to withdraw at any time.Writteninformedconsentwasobtainedfromalleligibleindividuals.Datawerecollected through in-person interviews conducted by the trained lead investigator using a predesigned, structured questionnaire-based case record form over a two-month period. The form captured demographicdetails,medicalhistory,currentillness,andallprescribedmedications,including drug name, dose, frequency and route. The total number of medications was recorded to identifypolypharmacy,commonlydefinedastheconcurrentuseoffiveormoredrugs.[6]The duration since the initiation of stroke treatment was also documented.

Study Tools

Thequestionnairewasdevelopedafteranextensivereviewofrelevantliteratureandvalidated by faculty from the Departments of Pharmacology and Medicine. Each interview took approximately8–10minutes,duringwhichcurrentprescriptionswererecordedandscreened.

for PIMs based on the American Geriatric Society (AGS) Beers Criteria 2023. Although the Beers Criteria primarily target adults aged 65 years and above, their purpose is to identify inappropriate prescribing in older adults; therefore, this study included individuals aged 60 yearsorolder,consistentwithUnitedNations(UN)andnationalguidelinesaswellasprevious research.[12,13,14]

The2023updatedAGSBeersCriteria categorize PIMsintofive groups.[10]

1. PIMsareto beavoidedregardless ofdiagnosisordisease.
2. PIMstobeavoidedinspecificdiseasesorsyndromes(drug–diseaseordrug– syndrome Interactions).
3. PIMsthatshouldbeusedwithcaution.
4. PIMsinvolvingpotentiallyinappropriate drug-drug interactions.
5. PIMsaretobeavoidedorusedatreduceddosesinpatientswithreducedkidney function.

Prescriptions were assessed for PIMs under the first four categories, while the renal dose- adjustment category was excluded due to the lack of recent laboratory reports in most OPD patients. In cases where two prescribed drugs formed a potentially inappropriate drug–drug interaction, they were counted as a single PIM.

Statistical Analysis

Data were entered in Microsoft Excel 11.0, and chi-square tests were used to evaluate associationsbetweenPIMoccurrenceandvariablessuchasage(60–75vs.≥76years),gender, multimorbidity, polypharmacy, and stroke type. A p-value <0.05 was considered statistically significant. StatisticalanalysiswasdoneusingSPSSversion21.0 (IBM Corp.,Armonk, NY), and PIM prevalence was determined according to the 2023 Beers Criteria

Demographiccharacteristicsoftheparticipants

Atotalof100patientswereenrolled,including75menand25women.Themeanagewas

67.58 ± 6.78 years (range 60–85). No significant age difference was observed between male and female participants (p=0.115). Most patients (84%) were aged 60–75 years, while 16% were above 75 years as shown in Table 1.

ComorbidCharacteristicsof theParticipants

Most participants had multimorbidity, with 86% reporting one or more comorbidities besides stroke, and 14% having stroke as the only condition (Table 1). Hypertension was the most prevalentcomorbidity(74%),followedbydiabetes(24%),coronaryarterydisease(11%),and thyroid disorders (7%). Overall, 58% had one comorbidity, 33% had two, and 9% had more thantwo.Nosignificantdifferenceincomorbiditydistributionwasobservedbetweenmenand women (p=0.9613).

PolypharmacyAmongParticipants

A total of 737 medications were prescribed, with an average of 7.37 ± 2.50 drugs per prescription. The number of drugs did not differ significantly between men and women. However,polypharmacyshowedastrongassociationwithPIMuse(p=0.0004),indicatingthat theriskofreceivingaPIMincreasedwithahighermedicationcount(Table1).Thenumberof drugs per prescription ranged from 3 to 15. Commonly prescribed medications included Aspirin(88%),Atorvastatin(74%),Clopidogrel(53%),Pantoprazole(47%),Amlodipine

(38%), Losartan (33%), and Telmisartan (26%). Overall, 89% of participants experienced polypharmacy (Table 1), with 12% receiving more than ten medications, and one patient receiving 15 drugs.

Table 1: Demographic and Clinical Characteristics of Participants and the Prevalence of Potentially Inappropriate Medications (n=100).

PotentiallyInappropriateMedicationsin theStudyPopulation

Ofthe737medicationsprescribed,130wereidentifiedasPIMs,with76%ofpatientsreceiving atleastonePIMaccordingtothe2023AGSBeersCriteria(Figure1).Therewasnosignificant differenceinPIMprescribingbetweenmalesandfemales,noranyassociationwithageor multimorbidity (Table 1). The number of PIMs per prescription ranged from one to six: 44% had one PIM, 22% had two, 4% had three, another 4% had five, and 1% received six PIMs.

Figure 1: Proportion of Prescriptions Containing at Least One Potentially Inappropriate Medication (PIM) (n=100).

ThemostcommonPIMclasswasprotonpumpinhibitors(53%),followedbydiuretics(22%). Other frequently prescribed PIMs included hypoglycemic agents (13%) and antidepressants (10%).AcompleteclassificationofallPIMsacrosstheBeerscategoriesisprovidedinTable

2. All identified PIMs carried a strong recommendation level under the AGS Beers 2023 guidelines.

Table2:PotentiallyInappropriateMedications(PIMs) Identified Accordingto BeersCriteria and Their Frequency among Participants (n=76).

Comparison of the total number of PIM prescriptions with the distribution of medications acrosseachBeerscategory,assessingindividualdrug–druginteractionmedicationsseparately is shown in figure 2.

Figure 2: Comparison of Potentially Inappropriate Medication (PIM) Prescriptions and theNumber of Drugs within Each Beers Criteria Category (n=76).

*Thesumof'n'valuesexceedsthetotalnumberofparticipantswithPIMs,assome participants had PIMs from multiple categories

The identification and assessment of potentially inappropriate medications (PIMs) in elderly post-stroke patients represents a crucial yet underexplored area. Older stroke survivors frequentlypresentwithcomplexmedicalneedsarisingfrommultimorbidity,polypharmacy, and functional impairments.[15]Despite this, there is limited data specifically examining the prevalence and clinical consequences of PIMs in this population. Therefore, evaluating PIMs in elderly post-stroke patients is essential not only to optimize pharmacological management but also to reduce preventable harm and improve treatment outcomes.

In our study, males predominated (75%), with a mean age of 67.58 ± 6.78 years, reflecting established epidemiological trends of higher stroke incidence among older men.[16]Although the age difference between genders was not statistically significant, the participants appeared comparatively younger than in similar studies, likelydue to India’s lower life expectancyand the intentional exclusion of terminally ill individuals or those with permanent disabilities.[17] Nevertheless, the mean age of participants is comparable to findings from other studies conducted in various regions of India.[18-21]

The high prevalence of multimorbidity (86%) highlights the complex clinical landscape frequently encountered in stroke survivors. Hypertension was the most common comorbidity (74%), followed by diabetes (24%) and coronary artery disease (11%), consistent with well- establishedassociations between these conditions and cerebrovascular events.[22]The absence of a statistically significant difference in comorbidity distribution between genders indicates that the burden of co-existing conditions is similar in both male and female stroke patients in this cohort.

Polypharmacy was also highly prevalent (89%), with an average of 7.37 ± 2.50 medications perprescriptionandarangeofupto15drugs.Similarfindingswerereportedinanotherstudy, wherethemaximumnumberofdrugsperprescriptionwas17.[23]Thisdegreeofpolypharmacy raises concerns about adverse drug events, drug-drug interactions, reduced medication adherence, and poorer clinical outcomes, particularly in the elderly due to age-related physiological changes and potential frailty.[24] Moreover, polypharmacy was significantly associatedwiththeuseofpotentiallyinappropriatemedications(PIMs)(p=0.0004).Themost frequently prescribed drugs – Aspirin (88%), Atorvastatin (74%), Clopidogrel (53%), Pantoprazole (47%), Amlodipine (38%), Losartan (33%), and Telmisartan (26%) – reflect standard careforsecondarystrokepreventionandmanagementofcardiovascularriskfactors.

[25] Nonetheless, the high number of medications necessitates careful evaluation for appropriateness and potential interactions.

The prevalence of potentially inappropriate medications (PIMs) was notably high, with 76% ofparticipantsreceivingatleastoneaccordingtothe2023AGSBeerscriteria.[14,26]Matsumoto et al. reported 65.4% PIMs in a stroke study (n = 234), highlighting the vulnerability of this population.[27] In our study, 17.6% (n = 130) of all prescribed drugs were PIMs, similar to Anand et al.[14]

Most PIMs (71%) fell under Criterion 1 of the Beers criteria. Proton pump inhibitors (53%) werethemostcommon,reflectinggastroprotectioninantiplateletusers,butlong-termusemay causeClostridiumdifficileinfection,fractures,andvitaminB12deficiency.[14,28]Anti-diabetic drugs such as Glimepiride and short-actinginsulin(13%) pose hypoglycemia risk, suggesting safer alternatives. Non-steroidal Antiinflammatory drugs (NSAIDs) (11%), including diclofenac and naproxen, increase gastrointestinal bleeding risk, especially when combined with antiplatelet or anticoagulant therapy.

Beers Criteria Category 2 identifies medications potentially inappropriate for patients with certaindiseases,astheymayworsentheconditionorincreaseadverseoutcomes.Inourstudy, 4% of participants had such drug-disease interactions. For example, aspirin and diltiazem in heart failure patients may exacerbate fluid retention, clonazepam can impair cognition and increase confusion, and the combination of fluoxetine and oxcarbazepine may heighten fall risk.

Criterion 3, the “to be used with caution” category, accounted for 23% of PIM prescriptions, with diuretics (hydrochlorothiazide, torsemide, furosemide) being the most frequent (18%), consistent with Zhang et al.[29] Diuretics pose risks in the elderly, including electrolyte imbalance, dehydration, and falls. Antidepressants such as fluoxetine and amitriptyline (6%) were also notable, reflectingthe need for careful use due to risks like hyponatremia, sedation, and fall susceptibility.

Drug-druginteractionswerenotable,particularlytheconcomitantuseoftworenin-angiotensin system (RAS) inhibitors (3%), which increases hyperkalemia risk in chronic kidney disease patients, consistent with another Indian study.[1]Similarly, prescribing three or more CNS- actingdrugsinasinglepatientraisesconcernsforadditivesedation,cognitiveimpairment,and falls.[30]

All identified PIMs carried a strong recommendation according to the 2023 AGS Beers Criteria,underscoringtheirclinicalsignificance. Thesefindingshighlight thehighprevalence of polypharmacy and PIMs in elderly stroke patients, emphasizing the need for interventions to optimize medication management. Strategies include regular medication review, clinician education on Beers Criteria and PIM risks, use of decision-support tools like STRIP and real- time EHR alerts, and a collaborative interprofessional approach involving physicians, pharmacists, nurses, and clinical pharmacologists.[31-33] Such measures aim to enhance prescribingpractices,minimizePIMuse,andimprovemedicationsafetyandoutcomesinolder adults.

Limitations:

Thesingle-centredesignandmodestsamplesizemaylimitthegeneralizabilityofourfindings. Additionally,thecross-sectionaldesigncapturesmedicationuseatasingletimepointanddoes not reflect changes in prescribing over the disease course. Future longitudinal, multi-centre studiesareneededtovalidatetheseresultsandassesstheimpactofPIMsonclinicaloutcomes in stroke survivors.

Strength:

Toourknowledge, this is thefirst Indianstudyusingthe2023 Beers Criteriato identifyPIMs in elderly post-stroke patients. Medication data were collected directly from patients, minimizingerrorsfromrecallorincompleterecordsandreducingbiasfromduplicatecounting of the same drug under different names or formulations

Prescription of potentially inappropriate medicines is alarmingly high among post-stroke elderly patients. Multimorbidity and polypharmacy are found to be high among elderly patients, possibly increasing the risk of PIM prescriptions. These findings demonstrate the clinical utilityof the 2023 AGS Beers Criteria in identifying inappropriate prescribing. There isanurgentneedtoincreaseawarenessamongprescribersregardingPIMsandassociatedrisks topromotesafeandeffectivemedicationmanagement.Routinemedicationreviewandrational prescribing strategies are essential to enhance medication safety in this vulnerable group

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