Prevalence, Factors and Cost Comparison due to Potentially Inappropriate Medications (PIMs) of Elderly Outpatients in a State Hospital in Malaysia.


  • Wei Chern Ang Clinical Research Centre, Hospital Tuanku Fauziah, Ministry of Health Malaysia, Jalan Tun Abdul Razak, 01000 Kangar, Perlis, Malaysia
  • Nur Syafiqah Zulkepli Department of Pharmacy, Hospital Tuanku Fauziah, Ministry of Health Malaysia, Jalan Tun Abdul Razak, 01000 Kangar, Perlis, Malaysia
  • Nur Safinaz Mukhtar University Health Centre, Universiti Utara Malaysia, 06010 Sintok, Kedah, Malaysia
  • Nur Atikah Zulkefli Department of Pharmacy, Hospital Tuanku Fauziah, Ministry of Health Malaysia, Jalan Tun Abdul Razak, 01000 Kangar, Perlis, Malaysia



Potentially inappropriate medication, cost, elderly, outpatient, patient safety


Introduction: Malaysia will be a full aging nation by 2030. The elderly (aged >65 years old) population often has multiple comorbidities, which increases the risk of polypharmacy and potentially inappropriate medications (PIMs). This study aims to investigate the prevalence, factors associated with PIMs among elderly outpatients, and its burden of direct pharmacotherapy cost to the Ministry of Health Malaysia.

Materials and method:  A cross-sectional study involving clinic prescriptions among the elderly with more than one-month prescribing duration received from a tertiary hospital specialist clinic pharmacy from March to April 2017. Patient identifiers were screened using the Pharmacy Information System (PhIS) by including prescriptions from other clinics while excluding multiple visits and duplicate prescriptions. Patients were categorised as PIM group and non-PIM groups using Beers Criteria 2015. Logistic regression analysis was conducted to examine the factors associated with PIMs. The median monthly prescription cost was compared between PIM and non-PIM groups by Mann-Whitney test.

Results: Among 472 patients, 39.4% of patients had at least one PIM while 60.6% of patients did not receive any PIM. The number of medications prescribed was an independent risk factor contributing to PIMs (OR:2.04; 95% CI:1.40, 2.97). The median monthly prescription cost for the PIM group was MYR 29.50 (?USD 7.53) which was not statistically significant (p=0.735) compared with the non-PIM group which was MYR 28.50 (USD 7.28). 

Conclusion: PIM was frequently prescribed in our setting with the number of medications as the only factor. However, the prescribing of PIM did not add nor reduce the direct cost of pharmacotherapy.


Abd Mutalib, Z. A., Ismail, M. F., & Miskiman, N. (2020). Spatial Analysis: Ageing Population of Multi-ethnic in Rural Area, Malaysia. Proceedings of the 2020 Asia–Pacific Statistics Week, Bangkok, Thailand. Retrieved from

Abdulah, R., Insani, W. N., Destiani, D. P., Rohmaniasari, N., Mohenathas, N. D., & Barliana, M. I. (2018). Polypharmacy leads to increased prevalence of potentially inappropriate medication in the Indonesian geriatric population visiting primary care facilities. Therapeutics and Clinical Risk Management, 14, 1591-1597. doi: 10.2147/TCRM.S170475

Akazawa, M., Imai, H., Igarashi, A., & Tsutani, K. (2010). Potentially inappropriate medication use in elderly Japanese patients.American Journal of Geriatric Pharmacotherapy,8(2), 146–160. doi: 10.1016/j.amjopharm.2010.03.005

Department of Statistics Malaysia. (2017). Current population estimates, Malaysia, 2016–2017. Putrajaya: Malaysia.

Fick, D. M., Semla, T. P., Steinman, M., Beizer, J., Brandt, N,Dombrowski,R., ... Flanagan, N.(2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.Journal of the American Geriatrics Society,67(4), 674-694.

Gallagher, P., Barry, P., & O'Mahony, D. (2007). Inappropriate prescribing in the elderly. Journal of Clinical Pharmacy and Therapeutics,32(2), 113-121.

Galli, T. B., Reis, W. C., & Andrzejevski, V. M. (2016). Potentially inappropriate prescribing and the risk of adverse drug reactions in critically ill older adults. Pharmacy Practice (Granada),14(4), 818.

Hairi, N. N., Bulgiba, A., Cumming, R. G., Naganathan, V., & Mudla, I. (2010). Prevalence and correlates of physical disability and functional limitation among community dwelling older people in rural Malaysia, a middle income country. BMC Public Health, 10(1), 492.

Hefner, G., Stieffenhofer, V., Gabriel, S., Palmer, G., Müller, K.-M., Röschke, J., & Hiemke, C. (2015). Side effects related to potentially inappropriate medications in elderly psychiatric patients under everyday pharmacotherapy. European Journal of Clinical Pharmacology, 71(2), 165-172.

Heider, D., Matschinger, H., Meid, A. D., Quinzler, R., Adler, J.-B., Günster, C., . . . König, H.-H. (2017). Health service use, costs, and adverse events associated with potentially inappropriate medication in old age in Germany: retrospective matched cohort study. Drugs & Aging, 34(4), 289-301.

Hilmer, S. N. (2008). The dilemma of polypharmacy. Australian Prescriber, 31, 2-3.

Hill-Taylor, B., Sketris, I., Hayden, J., Byrne, S., O'sullivan, D., & Christie, R. (2013). 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.Journal of Clinical Pharmacy and Therapeutics,38(5), 360-372.

Jaafar S.N. K., Muttalib,K., Othman,N. H., & Healy,J.(2013).Malaysia health system review. Health Systems in Transition, 3(1). New Delhi: World Health Organization, Regional Office for the Western Pacific.

Kalisch, L. M., Caughey, G. E., Roughead, E. E., & Gilbert, A. L. (2011). The prescribing cascade. Australian Prescriber, 34,162-6.

Guzmán, J. M., Pawliczko, A., & Beales, S. (2018). Ageing in the twenty-first century: A celebration and a challenge.New York: United Nations Population Fund (UNFPA).

Lim, L. M., McStea, M., Chung, W. W., Azmi, N. N., Aziz, S. A. A., Alwi, S., ... Rajasuriar, R. (2017). Prevalence, risk factors and health outcomes associated with polypharmacy among urban community-dwelling olderadults in multi-ethnic Malaysia. PLoS One, 12(3), e0173466.

Lim, Y. J., Kim, H. Y., Choi, J., Lee, J. S., Ahn, A. L., Oh, E. J., . . . Kweon, H. J. (2016). Potentially Inappropriate Medications by Beers Criteria in Older Outpatients: Prevalence and Risk Factors. Korean Journal of Family Medicine, 37(6), 329-333. doi: 10.4082/kjfm.2016.37.6.329

Mortazavi, S. S., Shati, M., Keshtkar, A., Malakouti, S. K., Bazargan, M., & Assari, S. (2016). Defining polypharmacy in the elderly: a systematic review protocol. BMJ Open, 6(3), e010989.

Nishtala, P. S., Bagge, M. L., Campbell, A. J., & Tordoff, J. M. (2014). Potentially inappropriate medicines in a cohort of community-dwelling older people in New Zealand. Geriatrics & Gerontology International, 14(1), 89-93. doi:10.1111/ggi.12059

O'mahony, D., O'sullivan, D., Byrne, S., O'connor, M. N., Ryan, C., & Gallagher, P. (2015). STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age and Ageing, 44(2), 213-218.

Oliveira, M. G., Amorim, W. W., Jesus, S. R., Heine, J. M., Coqueiro, H. L., & Passos, L. C. S. (2015). A comparison of the Beers and STOPP criteria for identifying the use of potentially inappropriate medications among elderly patients in primary care. Journal of Evaluation in Clinical Practice, 21(2), 320-325.

Page, A., Clifford, R., Potter, K., & Etherton-Beer, C. (2018). A concept analysis of deprescribing medications in older people.Journal of Pharmacy Practice and Research,48(2), 132-148.

Radcliff, S., Yue, J., Rocco, G., Aiello, S. E., Ickowicz, E., Hurd, Z., Samuel M.J. & Beers, M. H. (2015). American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society,63(11), 2227-2246.

Santos, A. P., da Silva, D. T., dos Santos Junior, G. A., Silvestre, C. C., Nunes, M. A., Lyra, D. P., Jr., & Antoniolli, A. R. (2015). Evaluation of the heterogeneity of studies estimating the association between risk factors and the use of potentially inappropriate drug therapy for the elderly: a systematic review with meta-analysis. European Journal of Clinical Pharmacology, 71(9), 1037-1050. doi: 10.1007/s00228-015-1891-2

Senik, S. (2006). A study of polypharmacy and its associated factors among elderly patients in Klinik Rawatan Keluarga Hospital Universiti Sains Malaysia in 2005.Malaysian Journal of Medical Sciences, 13(1): 79–96.

Shah, K. N., Joshi, H. M., Christian, R. P., Patel, K. P., & Malhotra, S. D. (2016). Prevalence of potentially inappropriate medications and prescription cost analysis among older cardiac patients in an outpatient department of a tertiary care hospital in India. Journal of Basic and Clinical Pharmacy,7(4), 110-115. doi: 10.4103/0976-0105.189434

Xing, X. X., Zhu, C., Liang, H. Y., Wang, K., Chu, Y. Q., Zhao, L. B., Jiang, D. C., ... Yan, S. Y. (2019). Associations between potentially inappropriate medications and adverse health outcomes in the elderly: a systematic review and meta-analysis.Annals of Pharmacotherapy,53(10),1005–1019.doi: 10.1177/1060028019853069




How to Cite

Ang, W. C., Zulkepli, N. S., Mukhtar, N. S., & Zulkefli, N. A. (2021). Prevalence, Factors and Cost Comparison due to Potentially Inappropriate Medications (PIMs) of Elderly Outpatients in a State Hospital in Malaysia. Journal of Pharmacy, 1(1), 27–33.



Original Articles