this cross - sectional study was conducted in the medicine outpatient department ( opd ) of a tertiary care hospital in south india , during the period of january 2015 to april 2016 . both male and female patients above the age of 60 years attending medicine opd of a tertiary care hospital were included in the study . data regarding patient 's demographics and their clinical history and drug history were obtained from the patient records maintained in the opd . we excluded vitamins and minerals , herbals , and other alternative medicines as it is difficult to analyze their appropriateness using the criteria , and we counted the remaining medications which the patient was receiving , and if five or more drugs were present , then it was considered as polypharmacy . medication appropriateness for each patient was analyzed separately based on their medical history and clinical findings by applying mai , beers criteria , stopp criteria , and start criteria [ table 1 ] . different tools to assess appropriateness of prescription in geriatric patients sample size was calculated based on expected proportion of people aged 60 years conceiving polypharmacy as 52% as per previous studies . taking 10% as relative precision at 90% power and confidence level of 95% , the sample size was found to be 355 . adding 20% as nonresponders , final sample size came to be 426 geriatric patients . continuous variables were analyzed using student t tests , and categorical variables were analyzed using chi - square test . continuous variables were analyzed using student t tests , and categorical variables were analyzed using chi - square test . a total of 426 patients were included in the study . among them , 216 ( 50.7% ) were males and 210 ( 49.3% ) were females . mean age of the patients was 71.6  6.4 years ( 61 - 91 years ) . around 144 ( 33.8% ) patients were receiving < 5 medications and 282 ( 66.19% ) patients were on five or more medications . mean number of medications used by patients was 4.84  1.945 ( range 110 ) . various demographic features related to distribution of gender and age are mentioned in table 2 . gender and age distribution among the geriatric patients in the study ( n=426 ) patients had various comorbidities such as diabetes mellitus ( dm ) , hypertension ( htn ) , ischemic heart disease ( ihd ) , chronic kidney disease , central nervous system diseases , dyslipidemia , liver , or joint diseases . there was a positive correlation between increasing comorbidity and polypharmacy ( r = 0.559 ) . there was an association between polypharmacy and all individual comorbidities except for liver disease and ihd / coronary heart disease , and it was statistically significant . the proportion of these comorbidities among the patients and the proportion based on age category have been mentioned in tables 3 and 4 . distribution of comorbidities among different age groups in geriatric patients and association between comorbidities and polypharmacy age group - wise distribution of elderly patients based on the number of comorbidities ( n=426 ) there was a positive correlation between the number of drugs prescribed and increasing number of comorbidities . table 5 depicts the distribution of patients based on the number of drugs they received . distribution of number of drugs prescribed among male and female geriatric patients in the study out of 426 prescriptions analyzed , 282 prescriptions had five or more than five medications , i.e. , polypharmacy was present in 282 prescriptions ( 66.2% ) . around 65.7% of males and 66.7% of females were receiving five or more than five medications . 45.3% of participants in the age group of 6069 years , 81.6% of 7079 years age group , and 46.7% of 8089 years age group were receiving five or more than five medications . the highest prevalence of polypharmacy was seen in 7079 years age group compared to the other two groups , and it was statistically significant . out of 426 patients , 36 patients ( 24 males and 12 females ) were receiving drugs which were to be avoided as per beers criteria [ tables 5 and 6 ] . thirty - nine patients ( thirty males and nine females ) were overprescribed as per mai . fifty - six patients ( 44 males and 12 females ) were underprescribed as per start criteria . proportion of patients receiving inappropriate prescriptions eighty - five out of 426 prescriptions ( 62 males and 23 females ) were inappropriate in accordance with beers criteria , stopp criteria , start criteria , and mai . there was a significant difference among males and females in all these parameters [ table 6 ] . our study aimed at evaluating the proportion of geriatric patients receiving polypharmacy in a tertiary care hospital . in our study , polypharmacy was defined as receiving five or more medications . our study showed 66.2% of the geriatric patients were receiving five or more medications , i.e. , two - thirds of the geriatric patients were labeled as taking five or more medications . in a study done by slabaugh et al . , the prevalence of polypharmacy was 39.4% , and proportion of polypharmacy was higher in the male gender and older individuals . the lower prevalence in the study done by slabaugh in italy could be due to larger sample size ( 8 , 87 , and 165 ) . there was no difference in the proportion of male and female geriatric patients , and there was also no difference in the proportion of polypharmacy among both the genders in our study . furthermore , the proportion of polypharmacy was higher in 7079 years age group ( 81.6% ) in our study similar to the one reported by dutta and prashad in his study . one of the important reasons for polypharmacy in geriatrics is because of the association of multiple comorbidities in them . htn ( 75.4% ) and dm ( 51.6% ) were seen in majority of geriatric population , being similar to the one seen in a study done by al ameri et al . the increased proportion of polypharmacy in 7079 years could be due to increased number of comorbidity seen in them . the assessed appropriateness of medications based on beers criteria , stopp criteria , start criteria , and mai . these criteria use an evidence - based approach to regularly update , thus making the criteria more relevant . all these criteria alert the physician and help in reducing the chance of prescribing inappropriate drugs . around 36 patients ( 8.45% ) were receiving inappropriate drugs to be avoided based on beers criteria . kumar et al . , in his study , reported inappropriate prescribing as per beers criteria in rural areas in karnataka as 45.41% and also reported analgesics , antidepressants , and vasodilators were the commonly prescribed potentially inappropriate medications . chung et al . , in his study , reported inappropriate prescribing in hospitalized patients using beers criteria as 27.8% . the inappropriate drugs prescribed in the present study population , according to beer 's criteria , were chlorpheniramine , promethazine , dicyclomine , digoxin , amitriptyline , and alprazolam . prescribing of inappropriate medications in the elderly is low in our study probably because of good knowledge , attitude , and practice among the treating physicians . overprescribing was assessed using mai , and 39 patients ( 9.1% ) were receiving overprescribed medications . under use of medications was assessed as per start criteria , and 56 ( 13.1% ) were underprescribed in our study . the potential prescribing omissions were lesser when compared to study conducted by lee et al . patients with potential prescribing omissions were receiving a lesser number of medications when compared to other patients . drugs belonging to the cardiovascular system ( antiplatelets and antihypertensives ) were the most common omissions . also reported cardiovascular drugs ( aspirin and statins ) as the most common prescribing omissions . most of the time , geriatric patients receive more medications than needed , and this gets the attention of researchers at the earliest , but a few of the prescribing omissions like that of cardiovascular drugs which significantly decrease morbidity and mortality can be pivotal and go unnoticed . this issue has to be addressed at the earliest , and the treating physician has to address , prioritize , and balance the use of medications in the elderly so that potential prescribing omissions and inappropriate prescribing can be avoided . our study aimed at seeing the proportion of inappropriate prescribing in the elderly , and we found that 85 patients ( 19.9% ) were receiving inappropriate medications . inappropriate prescribing was seen more in the males compared to female , and it was statistically significant too . lai et al . reported that 62.5% of the geriatric patients were receiving inappropriate medications and also reported the increased chance of receiving inappropriate medications was with female gender . the differences in patient characteristics , prescribing pattern , and assessment may be responsible for the variation seen in the prevalence of inappropriate prescriptions in various studies . a geographical variation among physicians ' awareness of regarding the existence of a list of inappropriate drugs for the elderly may have also led to these differences . the study was conducted among geriatric patients attending the opd in a tertiary care hospital which caters to large number of patients . apart from beers criteria , we also used stopp , start , and mai to assess the appropriateness of the prescribed medications . extrapolation of the findings to general population may be inappropriate as the study was based on the data from the tertiary care hospital . because of the limited duration of the study with cross - sectional design , impact of inappropriate prescription on patients could not assess . all the criteria used in this study were developed in the western countries , and the medications listed in these criteria may not have the same adverse effects in different populations of diverse ethnicity . physicians were not approached to find out their reasons for overprescribing and underprescribing due to time constraints . the assessment of overprescribing was based on a few questions from the mai which have not been validated independently . however , these questions found to have excellent intra- and inter - rater reliability as noted in the previous reports . the clinical and financial benefits from stringent application of stopp and start criteria in geriatrics are still not known . in future , large prospective randomized controlled trials are needed to find out if the stringent application of stopp and start criteria has appreciable benefits in terms of reduction of ades ( e.g. , falls ) , cost , hospitalization , and mortality . being a cross - sectional study , the effectiveness of the medications could not be assessed . the study was conducted among geriatric patients attending the opd in a tertiary care hospital which caters to large number of patients . apart from beers criteria , we also used stopp , start , and mai to assess the appropriateness of the prescribed medications . extrapolation of the findings to general population may be inappropriate as the study was based on the data from the tertiary care hospital . because of the limited duration of the study with cross - sectional design , impact of inappropriate prescription on patients could not assess . all the criteria used in this study were developed in the western countries , and the medications listed in these criteria may not have the same adverse effects in different populations of diverse ethnicity . physicians were not approached to find out their reasons for overprescribing and underprescribing due to time constraints . the assessment of overprescribing was based on a few questions from the mai which have not been validated independently . however , these questions found to have excellent intra- and inter - rater reliability as noted in the previous reports . the clinical and financial benefits from stringent application of stopp and start criteria in geriatrics are still not known . in future , large prospective randomized controlled trials are needed to find out if the stringent application of stopp and start criteria has appreciable benefits in terms of reduction of ades ( e.g. , falls ) , cost , hospitalization , and mortality . being a cross - sectional study , the effectiveness of the medications could not be assessed . a significant number of patients receive drugs which are to be avoided as per beer 's criteria , overprescribed as per mai , and underprescribed as per start criteria .
objectives : to assess the polypharmacy and appropriateness of prescriptions in geriatric patients in a tertiary care hospital.methods:an observational study was done in geriatric patients ( > 60 years ) of either gender . 
 the data collected from patients included : socio - demographic data such as age , gender , marital status , educational status , socioeconomic status , occupation , nutritional status , history of alcohol / smoking , exercise history , details of comorbid diseases , medication history , findings of clinical examination etc . in this study , 
 polypharmacy was considered as having 5 or more medications per prescription . 
 medication appropriateness for each patient was analysed separately based on their medical history and clinical findings by applying medication appropriateness index , screening tool to alert to right treatment ( start ) and beers criteria and stopp criteria.results:a total of 426 patients , 216 ( 50.7% ) were males and 210 ( 49.3% ) were females . 
 polypharmacy was present in 282 prescriptions ( 66.2% ) . 
 highest prevalence of polypharmacy was seen in 70 - 79 years age group compared to the other two groups and it was statistically significant . out of 426 patients , 36 patients were receiving drugs which were to be avoided as per beers criteria . among the total patients , 
 39 patients were overprescribed as per mai , 56 patients were under prescribed as per start criteria and 85 out of 426 prescriptions were inappropriate in accordance with beers criteria , stop criteria , start criteria and mai index.conclusion:around 66.19% patients were receiving polypharmacy . 
 significant number of patients were receiving drugs which are to be avoided as well as overprescribed and under prescribed . 
 inappropriate prescription was seen in a good number of patients .