Potentially inappropriate medicines for older people: consensus-based lists

SUMMARY

Older people, especially with multimorbidity and polypharmacy, are at higher risk of adverse medication outcomes compared with younger adults.

To guide safer prescribing for older people, several lists of ‘potentially inappropriate medicines’ (PIMs lists) have been developed. Prominent PIMs lists include the Beers Criteria (USA) and the Screening Tool of Older People’s Prescriptions (STOPP) (Europe). A new Australian PIMs list was published in 2024.

PIMs are medicines for which there is evidence or consensus expert opinion that the potential risks usually outweigh the clinical benefits in a specific patient cohort.

The Australian PIMs list outlines medicines that should be avoided in all older people, and medicines that should be avoided in certain clinical contexts. It also provides guidance on potentially safer alternatives to the listed medicines.

Importantly, medicines included in PIMs lists are not always inappropriate. There may be clinical scenarios where a PIM is appropriate for an individual patient (hence the term potentially inappropriate). Prescribing decisions should always be individualised, considering the patient’s clinical status and goals of care.

 

Introduction

As the global population ages, the incidence of multimorbidity, currently estimated to be 61.9% in people aged 65 years and over, will continue to rise.¹ Therefore, it is unsurprising that polypharmacy – the concurrent use of multiple medications – is also on the rise. Although polypharmacy is not always inappropriate, it is associated with a higher risk of falls, cognitive impairment, hospitalisation and all-cause death in older individuals.^2-4 Adverse drug reactions account for 20% of unplanned hospital admissions, the majority of which may be preventable.^5,6

Prescribing for older adults, especially those with multimorbidity, polypharmacy or frailty, is challenging. Age-related physiological changes, such as reduced liver and kidney function, and changes to body composition contribute to alterations in the pharmacokinetics and pharmacodynamics of medicines. Older people are at greater risk of medication-related harm and require dose adjustments and more frequent monitoring. There is a need to judiciously prescribe for the older person and regularly review their medication regimen in the context of the person’s individual goals of care.

 

Inappropriate prescribing

Inappropriate prescribing can be defined as prescribing where the risks outweigh clinical benefits or the treatment is not cost-effective, especially when safer or more cost-effective therapeutic alternatives are available.^7,8

A key concept related to inappropriate prescribing is ‘potentially’ inappropriate medicines (PIMs) – medicines where the risk of adverse events may outweigh the clinical benefits in certain clinical scenarios or populations.^9,10

PIM use (identified using explicit criteria such as those discussed below) is common in older people, affecting almost 1 in 2 older people, and up to 4 in 5 people living in aged-care homes.^8,10 Use of PIMs is associated with increased risk of adverse drug events, drug interactions, poorer quality of life, hospitalisation and mortality.^10-13 Despite these risks, the rate of PIM prescription remains high in the older adult population.

 

Identifying inappropriate prescribing

Evaluation of prescribing for an older person, for example in a clinical medication review, is complex. It usually relies on clinical judgement to determine the appropriateness of each medication (sometimes referred to as implicit review). Implicit review has an important role in medication rationalisation, but may not detect all clinically relevant PIMs. Implicit review is also associated with poor inter-rater reliability and therefore, when used in research or quality improvement activities, the findings may not be generalisable.

Another approach for evaluating prescribing is to use predefined explicit criteria, sometimes referred to as PIMs lists; these are widely used in research and quality improvement but may also be a helpful tool in clinical practice and clinician training. Implicit and explicit approaches can be used in combination.^14,15

PIMs lists

PIMs lists are typically developed using the Delphi method (a technique used to reach consensus among content experts through a series of questionnaires). PIMs lists can play an important role in prescribing and deprescribing processes by providing clinicians with consensus-based guidance on medicines to avoid or to consider for deprescribing in an older patient.

Of the various published PIMs lists, the US-based Beers Criteria is the most widely cited. First published in 1991 targeting older people living in nursing homes, the criteria have since expanded to include older people in all settings. The seventh and most recent update to the Beers Criteria was published in 2023.¹⁶ Several commonly prescribed drug classes such as nonselective nonselective nonsteroidal anti-inflammatory drugs, alpha-1 receptor antagonists and anticholinergic drugs feature in the criteria.

Since the introduction of the Beers Criteria, locally relevant PIMs lists have been developed in other countries to account for variations in drug availability and regional prescribing patterns. Another prominent PIMs list is the European-based Screening Tool of Older People’s Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START). The STOPP criteria aim to identify PIMs, while the START criteria identify medications commonly omitted where no contraindication exists.¹⁷ More recently, extensions of the STOPP criteria, such as the STOPPFrail and STOPPCog criteria, have been developed to assist prescribers in deprescribing in frail and cognitively impaired populations.^18,19

An Australian PIMs list

International PIMs lists include medicines that may not be available in Australia. Therefore, Wang et al. developed an Australian PIMs list in 2024. As well as listing PIMs in Australia, this list includes recommendations for potentially safer alternatives to the PIMs.²⁰ The Australian PIMs list was developed using the Delphi technique to reach consensus across an expert panel comprising subject matter experts in geriatric medicine, general medicine, pharmacy and clinical pharmacology. Panel members were asked to agree or disagree that a particular drug poses a greater risk to older adults than to the general population, and if there were circumstances that would increase the risk to an older person. Additionally, if a drug was considered to pose a greater risk, panel members were asked to consider if there were medications or therapies that were safer alternatives. A total of 130 locally relevant drugs or drug classes were considered by the panel, with 19 ultimately identified as potentially inappropriate (Table 1).

Table 1 Summary of the Australian consensus list of potentially inappropriate medicines (PIMs) for older people [NB1]²⁰

Drug class	Potentially inappropriate medicines (PIMs) [NB1]
alpha-adrenoreceptor antagonists	prazosin
antiemetics, dopamine-blocking	chlorpromazine prochlorperazine
antihypertensives, centrally acting	methyldopa
antipsychotics, 1st generation (‘typical’)	chlorpromazine flupenthixol haloperidol periciazine trifluoperazine thioridazine zuclopenthixol
antipsychotics, 2nd generation (‘atypical’)	olanzapine
benzodiazepines, long-acting	clonazepam flunitrazepam
benzodiazepines, medium-acting	bromazepam lorazepam
benzodiazepines, short-acting	alprazolam
genitourinary anticholinergics	oxybutynin
NSAIDs	diclofenac indometacin ibuprofen ketoprofen ketorolac meloxicam piroxicam
opioids	codeine dextropropoxyphene fentanyl hydromorphone pethidine
opioid agonists–SNRIs	tramadol
oral anticoagulants, direct thrombin inhibitors	dabigatran
oral anticoagulants, factor Xa inhibitors	rivaroxaban
sedating antihistamines	promethazine
sulfonylureas	glibenclamide glimepiride
tricyclic antidepressants	doxepin dosulepin (dothiepin)
NSAIDs = nonsteroidal anti-inflammatory drugs; SNRIs = serotonin and norepinephrine reuptake inhibitors NB1: PIMs are medicines that should be avoided in older people if there are equally or more effective but lower risk treatments available.20 Refer to Wang et al’s paper20 for further detail.

The Australian PIMs list is presented similarly to the Beers Criteria, in 2 ways – by drug name or class, and by specific clinical scenario. Suggested alternatives to the listed PIMs are provided.²⁰ An example of a listing by drug name or class is sulfonylureas. The longer acting sulfonylureas (glibenclamide and glimepiride) are listed as potentially inappropriate for all older people, due to increased risk of hypoglycaemia. As a class, all sulfonylureas (short- and long-acting) are listed as potentially inappropriate in older people when used with other glucose-lowering medications or in people who are frail or have irregular diet or renal impairment. As alternatives, the Australian PIMs list suggests prescribing metformin or other oral hypoglycaemic drugs. An example by specific clinical condition is when reviewing an individual with constipation. The PIMs list recommends avoiding tricyclic antidepressants and the opioids codeine and hydromorphone. As alternatives for pain management, the PIMs list suggests that prescribers consider physiotherapy, paracetamol, or opioids with lower risk of toxicity, such as oxycodone or buprenorphine.²⁰

The 2 presentation methods enhance the utility of the PIMs list. Practically, when conducting medication reviews, prescribers can refer to the PIMs list for guidance on medicines to avoid in the presence of specific conditions, such as cognitive impairment, rather than searching for a specific drug class. This approach allows for a more targeted and context-specific assessment of PIMs.

Of note, the Australian PIMs list does not include an evaluation of the quality of evidence and strength of recommendation as featured in the Beers Criteria.

Application of PIMs lists

PIMs lists may be used as decision-support tools for optimising medication safety when prescribing for older people. They can be used during medication review, and may guide decisions to deprescribe. PIMs lists may also be used at transitions of care to reduce the prescription of PIMs and thereby reduce the risk of adverse drug effects. Integration of PIMs lists in electronic medical records has been shown to be effective in reducing PIM prescription rates in hospitals in the USA and Canada.²¹

As there is a scarcity of high-quality studies on the use of medicines in frail, multimorbid older people, PIMs lists provide a practical and expert-guided resource for clinicians reviewing medication regimens. PIMs lists developed using the Delphi method represent current expert opinion, based on current evidence, and reduce the risk of bias. To improve clinical applicability, some lists, including the Beers Criteria and the Australian PIMs list, highlight reasons why a PIM may be inappropriate, such as prazosin and the risk of hypotension or falls.²⁰

Limitation of PIMs lists

It is important to note that medications included in PIMs lists are not always inappropriate. There may be situations where no suitable alternative exists due to individual patient factors and a PIM may be the most appropriate treatment option (hence the term ‘potentially’ inappropriate). Clinical judgement is always required when determining whether to proceed with prescribing (or deprescribing) a PIM.

Similarly, suggested alternatives in the Australian PIMs list may not be appropriate for every patient, or they may not be well supported by robust clinical trial evidence (e.g. melatonin as a benzodiazepine substitute for insomnia). Ultimately PIMs lists serve as a support tool to prompt review and additional monitoring for adverse effects.

Impact of PIMs lists on clinical outcomes

Although the use of PIMs has been associated with poorer outcomes in older people, there remains limited published evidence that application of PIMs lists improves patient outcomes. This may, in part, be attributable to the reliance on clinical judgement when rationalising medications and the use of PIMs lists. Notably, PIMs lists can improve prescribing practices by promoting the identification and avoidance of PIMs. For example, application of the STOPP and START criteria in a randomised control trial was shown to reduce unnecessary polypharmacy, incorrect dosing and drug–drug interactions.²² Deprescribing PIMs in community-dwelling older adults has been shown to reduce mortality, albeit modestly.²³ More studies investigating the potential clinical benefit of applying PIMs lists to prescribing are required.

 

Conclusion

With the increasing prevalence of chronic disease and multimorbidity in our ageing population, it has never been more important to choose medicines wisely. Locally relevant PIMs lists are a valuable resource for prescribers to complement their clinical judgement. Further studies are needed to evaluate the clinical impact of PIMs lists on patient outcomes.

This article was finalised on 16 June 2025.

Conflicts of interest: none declared

This article is peer reviewed.

 

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