Widespread and potentially inappropriate prescribing (PIP) for older adults with atrial fibrillation (AF) has been identified in a retrospective outpatient study, highlighting the need for optimisation strategies.
Published in the International Journal of Pharmacy Practice, the study at Tallaght University Hospital and Trinity College Dublin evaluated the appropriateness of prescribing in older adults with AF attending a specialist multidisciplinary outpatient clinic. It aimed to characterise polypharmacy, quantify PIP, and identify patient-level factors associated with prescribing issues.
The cohort comprised 168 patients aged over 65 years (median age 74 years; 59.4% male) who attended the clinic over a one-year period in 2022. Patients had substantial multimorbidity, with a median of six comorbidities, and were prescribed a median of six medications.
Polypharmacy was highly prevalent, affecting 74.4% of patients, including 53.0% with minor polypharmacy consisting of five to nine medicines, and 21.4% with major polypharmacy of over nine medicines.
These figures reinforce the expectation that AF populations seen in secondary care are frequently complex, requiring careful medication reconciliation and prioritisation.
Polypharmacy and PIP in older AF patients
Using STOPP/START version 2 criteria, the authors found that 75.6% of patients had at least one instance of PIP. Potentially inappropriate medications (PIMs) were identified in 60.1% of patients, while potential prescribing omissions (PPOs) occurred in 46.4%.
The most frequent issue was prescribing without an evidence-based indication, affecting 51.2% of patients. Inappropriate dosing of direct oral anticoagulants (DOACs) was observed in 11.6% of cases.
Regression analyses demonstrated that increasing medication count was independently associated with PIMs, while a higher number of comorbidities was associated with PPOs.
The study also underscored the complexity of medication management in older AF populations by revealing common patterns in prescribing issues. These included inappropriate use of sedatives and hypnotics, cardiovascular medication-related concerns, and omissions of bone-protective therapies such as vitamin D and calcium in at-risk individuals.
Targeted interventions and prescribing optimisation
The authors noted that the retrospective design restricted analysis to available medical record data, and as only patients attending the clinic were included, there was the potential for selection bias. Additionally, the use of an earlier version of STOPP/START criteria may have underestimated the true prevalence of PIP.
Nevertheless, they concluded that polypharmacy and inappropriate prescribing were widespread in older adults with AF and emphasised the need for targeted interventions.
The authors suggested that multidisciplinary AF clinics could provide an effective setting for holistic medication review. And they also recommended that future research should look to develop and validate interventions aimed at reducing PIP and address both excess prescribing and omissions in this high-risk population.
Reference
Doherty I et al. Potentially inappropriate prescribing and polypharmacy in older adults with atrial fibrillation: a retrospective observational study. Int J Pharm Pract. 2026;00:1–9.
