Polypharmacy and inappropriate prescribing are associated with negative health outcomes in the elderly. Several prescribing tools have been developed to assess medication appropriateness. Explicit (criteria-based) tools often do not consider patients’ preferences and comorbidities and have little room for individualized clinical judgment.

A prospective observational study was conducted in 243 elderly patients admitted to the Geriatric Medicine service in a Singapore tertiary hospital over one month. We incorporated an implicit (judgment-based) tool developed by Scott et al into a mnemonic, ‘SI-R-E’, to assess medication appropriateness: S = symptoms (‘Have symptoms resolved?’), I = indication, R = risks and E = end of life.

Inappropriate prescribing was present in 27.6% of patients. The most common reason for the inappropriateness of medications was lack of valid indication (62.2%), followed by the high risk-benefit ratio (20.7%). The most common medications that lacked valid indication were supplements and proton pump inhibitors.

Polypharmacy was found in 93% of patients and was significantly associated with inappropriate prescribing (p = 0.047). Inappropriate prescribing and polypharmacy are highly prevalent in the hospitalized elderly. The ‘S-I-R-E’ mnemonic can be used as a memory aid and practical framework to guide appropriate prescribing in the elderly.

Iron, folic acid and vitamin B

Supplements, such as iron, folic acid, and vitamin B, was the most commonly prescribed class of drugs for which there was no valid indication or active symptoms. This high prevalence may be attributed to cultural and systemic factors.

Prescription orders are often made without documenting the indication of a specific medication. This gap in information becomes a systemic problem, which is perpetuated by an electronic prescription system that allows repeat prescriptions to be carried forward with a simple click of the mouse.

Hence, it is not uncommon for drugs to be repeated without a known indication. In addition, many physicians do not practice routine medication review when prescribing medications and often regard supplements as generally benign drugs.

While supplements may seem harmless as compared to other chronic disease medications, many can cause gastrointestinal side effects such as constipation. Moreover, they add to a patient’s pill burden, which can affect overall medication compliance and quality of life.

In conclusion, there is little doubt that inappropriate prescribing and polypharmacy in the hospitalized elderly are prevalent and can be reduced. Medication review and active deprescribing of inappropriate medications should be part of routine management for elderly patients.