Jurnal Ilmu Farmasi dan Farmasi Klinik
(Journal of Pharmaceutical Science and Clinical Pharmacy)
ISSN 1693-7899 (print) - 2716-3814 (online)
DOI: 10.31942/jiffk.v21i1.9529

Identification of Potentially Inappropriate Medications
(PIMs) Based on Beers 2023 in Geriatric Type-2 Diabetes
Outpatients
Novi Setyowati, Pradhani Dhaneswari *, Tetty Retno Puspitasari
Pharmacy Study Program, Sekolah Tinggi Ilmu Kesehatan Bantul, Bantul, Special Region of Yogyakarta,
Indonesia

ABSTRACT: Geriatric patients with type-2 diabetes mellitus are particularly vulnerable to the use of
potentially inappropriate medication (PIM) due to the complexity of their therapeutic regimens, agerelated physiological changes, and the presence of multiple comorbidities. The pharmacological
management of diabetes often involves medications that carry a higher risk of adverse effects or drug
interactions in older adults, contributing to polypharmacy and increasing the likelihood of PIMs. The
Beers Criteria is a widely used tool to identify medications that may be inappropriate for the elderly.
This study aimed to look at the types of medications used, how often potentially inappropriate
medications (PIMs) were prescribed, and how patient characteristics related to PIM prescriptions
among older outpatients with type-2 diabetes at Panjatan 1 Primary Health Centre in Gunungkidul
Regency, Special Region of Yogyakarta, Indonesia. This was a descriptive observational study using
retrospective data from patient prescriptions that met the inclusion and exclusion criteria during
June–July 2024. The data were analysed using descriptive statistics and the Spearman correlation
test to assess the relationship between medication profiles and PIM occurrences. The results showed
a PIM prevalence of 85.4% (35 out of 41 patients), with the most common PIM category being
category 1 (89.8%). The most frequently identified PIM was glimepiride (67.4%). A strong
correlation was found between the number of medications prescribed and the occurrence of PIMs (p
< 0.001, r = 0.711) and a weak correlation with fasting blood glucose levels (p = 0.040, r = -0.265).
The high incidence of PIMs among geriatric patients with type-2 diabetes mellitus highlights the need
for optimised pharmacotherapy to minimise adverse effects. Regular evaluation of prescribing
practices using the Beers Criteria can enhance medication safety in this population.
Keywords: Beers Criteria; Geriatrics; PIM; T2DM

*Corresponding author:

Name
: Pradhani Dhaneswari
Email
: dhanes.020192@gmail.com
Address : Sekolah Tinggi Ilmu Kesehatan Bantul, Bantul, Special Region of Yogyakarta, Indonesia

63
Submitted: 21-03-2025 ; Received in Revised Form: 19-04-2025; Accepted: 24-05-2025

Setyowati et al.

INTRODUCTION
The global increase in the elderly population has brought attention to the unique
challenges in managing pharmacotherapy among geriatric patients, particularly those with
chronic diseases such as type-2 diabetes mellitus (T2DM). Epidemiological studies have
shown a high prevalence and rising incidence of T2DM among the elderly worldwide,
driven by factors such as increased life expectancy, obesity, and sedentary lifestyles
(Barman et al., 2023; Nasution et al., 2021). The development and progression of T2DM in
this population are influenced by both intrinsic factors (e.g., age, genetics) and extrinsic
factors (e.g., lifestyle, environment), with socio-demographic characteristics such as
education and income further impacting treatment utilisation (Barman et al., 2023; Bellary
et al., 2021; Corriere et al., 2013; Nasution et al., 2021). These multifactorial influences
contribute to the complexity of medication regimens, making elderly individuals more
susceptible to drug-related problems (Fauziah et al., 2020; Prasetyo, 2019). As a result,
there is a substantially increased risk of polypharmacy and the administration of
potentially inappropriate medications (PIMs), which can lead to adverse health outcomes
and reduced quality of life.
PIMs are drugs where the potential risks outweigh the clinical benefits, particularly
when safer alternatives are available. Their use is associated with adverse drug reactions,
drug interactions, hospital admissions, increased morbidity, and mortality in elderly
patients (Tian et al., 2023; Yakaryılmaz & Öztürk, 2017). Several studies have
demonstrated a high prevalence of PIMs among geriatric patients in both inpatient and
outpatient settings. One of the most widely accepted tools for identifying PIMs is the Beers
Criteria developed by the American Geriatrics Society, which is periodically updated to
reflect current clinical evidence (Sharma et al., 2020).
Despite existing studies on PIM prevalence, there remains a lack of recent research
focusing specifically on geriatric outpatients with T2DM in primary care settings in
Indonesia, particularly using the updated 2023 Beers Criteria. Given the high prevalence of
diabetes mellitus in the Special Region of Yogyakarta—surpassing the national average
(Badan Kebijakan Pembangunan Kesehatan (BKPK), 2023)—and the potential for adverse
outcomes due to PIM use in elderly diabetic patients, this issue represents a significant
concern in clinical pharmacy practice. Other studies have also evaluated the applicability
of the Beers Criteria in the management of patients with diabetes mellitus. For example, a
study conducted in Turkey demonstrated that poorly controlled diabetic patients were
prescribed a higher number of medications, had more comorbidities, and exhibited
increased risks according to the Beers Criteria, in comparison to those with well-controlled
diabetes (Atak Tel et al., 2023). This suggests a significant correlation between the use of
PIMs and poor glycemic control. Similarly, research in Indonesia revealed a high prevalence
of PIMs among hospitalised elderly diabetic patients, with polypharmacy and multiple
comorbidities identified as key contributing factors (Dhafin & Putri, 2024). These findings
highlight the critical need for regular medication reviews using tools such as the Beers
Criteria to optimise pharmacotherapy and improve medication safety in elderly diabetic
populations.
This study aims to address this gap by evaluating the prevalence and pattern of PIM
use among geriatric outpatients with T2DM at a primary healthcare center, using the 2023
Beers Criteria as a reference. By identifying factors associated with PIMs in this population,
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the findings are expected to inform safer prescribing practices and contribute to the
optimisation of pharmacotherapy in geriatric care.
METHODS
This study employed a retrospective, descriptive observational design using patient
medical record data from geriatric outpatients with type-2 diabetes mellitus at Panjatan 1
Primary Health Center during the period of January to March 2024. The study aimed to
identify the use of potentially inappropriate medications (PIMs) based on the 2023 Beers
Criteria. This study received ethical approval from the Research Ethics Committee of
Universitas Ahmad Dahlan with approval number 022407086.
The study was conducted at Panjatan 1 Primary Health Center, located in
Gunungkidul Regency, Special Region of Yogyakarta, from June to July 2024. The target
population included all geriatric outpatients diagnosed with type-2 diabetes mellitus in
2023–2024. A purposive sampling method was employed based on predetermined
inclusion criteria.
Inclusion criteria included geriatric patients (≥65 years old), complete medical
record data, outpatient status, and a confirmed diagnosis of type-2 diabetes mellitus.
Exclusion criteria were incomplete records concerning patient identity, diagnosis, drug use,
and fasting blood glucose levels.
Data analysis
Data collection involved reviewing electronic medical records (EMRs) and recording
them into a data collection sheet. Descriptive statistics were used to analyse the prevalence
of PIMs. Statistical analysis was performed using IBM SPSS version 29. Normality was
tested using the Kolmogorov-Smirnov test. The Spearman correlation test was applied to
examine the relationship between patient characteristics (age, number of comorbidities,
fasting blood glucose, and number of medications) and PIM occurrence.
RESULT AND DISCUSSION
This study evaluated 60 geriatric outpatients with type 2 diabetes mellitus (T2DM) at
Panjatan 1 Primary Health Centre. The demographic profile was predominantly female
(68.3%) and within the age group of 65–74 years (78%), which aligns with the typical
ageing population seen in primary care settings. Most patients were prescribed three to
four medications, with a minority exhibiting polypharmacy. Hypertension was the most
common comorbidity, and some patients had two or more additional chronic conditions.
Furthermore, 73,2% of patients had fasting blood glucose (FBG) levels exceeding 126
mg/dL, indicating suboptimal glycemic control. A detailed description of the study
population is available in Table 1.
Using the 2023 Beers Criteria, this study found that 85,4% of participants received at
least one potentially inappropriate medication (PIM) (Table 2). This high prevalence of
PIMs among elderly patients with T2DM is consistent with previous studies highlighting
the widespread use of inappropriate medications in older adults, particularly those with
multiple comorbidities (Febriyanti et al., 2023; Permana S et al., 2024). PIMs are strongly
associated with adverse drug reactions (ADRs), which significantly increase hospitalization
and mortality risks in geriatric patients (Q. Chen & Zhang, 2021). A systematic review by
Xing et al. (2019) indicated that PIM use is associated with a 44% higher risk of ADRs and
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Setyowati et al.

a 27% increase in hospital admissions (Xing et al., 2019). Similarly, Floroff et al. (2014)
observed that a greater PIM burden was associated with longer ICU stays and delayed
recovery in critically ill elderly patients (Floroff et al., 2014). A meta-analysis revealed that
PIM users had 52% higher odds of hospital admissions and 72% higher odds of emergency
department visits compared to non-PIM users (Weeda et al., 2020).
Table 1. Baseline Characteristics of Geriatric Patients with Type-2 Diabetes Mellitus (n = 41)
Characteristic
N (%)
Age group (years)
65-74
32 (78.0)
75-90
9 (22.0)
Sex
Female
28 (68.3)
Male
13 (31.7)
Number of medications
1-2 medications
7 (17.1)
3-4 medications
26 (63.4)
≥5 medications (polypharmacy)
8 (19.5)
Comorbidities
1 comorbidities
30 (73.2)
≥2 comorbidities
11 (26.8)
Fasting Blood Glucose (FBG)
≤126 mg/dL
11 (26.8)
>126 mg/dL
30 (73.2)

Table 2. Prevalence of Potentially Inappropriate Medications (PIMs) Among Geriatric Patients with
Type-2 Diabetes Mellitus (n = 41)
Characteristic
N
Percentage (%)
Patient with ≥1 PIM
35
85.4
Patients without PIM
6
14.6
Total patients included
41
100.0

The majority of PIMs identified in this study were classified as Category 1 (89,8%),
indicating drugs that should generally be avoided in older adults due to an unfavorable riskbenefit profile (Table 3). Glimepiride, a long-acting sulfonylurea, was the most frequently
identified PIM, accounting for 67,4% of all PIM prescriptions (Table 4). The American
Geriatrics Society recommends avoiding such agents in favor of safer alternatives like
short-acting sulfonylureas (e.g., glipizide) due to the increased risk of prolonged
hypoglycemia associated with agents like glimepiride (Terauchi et al., 2017). The high use
of glimepiride in this study may reflect a lack of prescriber awareness or limited access to
appropriate alternatives. Other medications identified as PIMs included first-generation
antihistamines (chlorpheniramine), and NSAIDs (diclofenac and ibuprofen). T hese drug
classes are frequently associated with adverse outcomes in elderly populations, including
anticholinergic burden, gastrointestinal toxicity, and electrolyte imbalances (American
Geriatrics Society, 2023; Yakaryılmaz & Öztürk, 2017). These findings are consistent with
previous studies conducted in primary care settings, which reported similar patterns of
PIM use, particularly the frequent prescription of long-acting sulfonylureas and first66
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generation antihistamines as the most commonly identified potentially inappropriate
medications among the elderly population (Lina & Nuringtyas, 2023; Putra et al., 2024).
Table 3. Distribution of Potentially Inappropriate Medications (PIMs) According to Beers Criteria
2023
Beers Category
Number of PIMs
Percentage (%)
Category 1
44
89.8
Category 2
Category 3
4
8.2
Category 4
1
2.0
Category 5
Not assessed
Total
49
100.0
* Percentage calculated based on the total number of PIM prescriptions (n = 49). One patient may have received more
than one PIM. Category 5 could not be evaluated due to incomplete medical records and missing renal function data

Table 4. List of Medications Identified as Potentially Inappropriate Medications (PIMs) Based on
Beers Criteria 2023
Drug Name
Therapeutic
Beers
Identified Risk(s) Frequenc Percentage
Class
Category
y (n)
(%)
Glimepiride
Sulfonylurea Category 1 Risk of prolonged
33
67.4
hypoglycemia
Glibenclamide
Sulfonylurea Category 1 Risk of prolonged
1
2.0
hypoglycemia
Chlorpheniramine
FirstCategory 1 Anticholinergic
4
8.2
(CTM)
generation
effects, sedation,
antihistamin
cognitive
e
impairment
Diclofenac
NSAID
Category 1 GI bleeding,
4
8.2
nephrotoxicity,
cardiovascular
risk
Ibuprofen
NSAID
Category 1 GI bleeding, renal
2
4.1
impairment
Hydrochlorothiazid Thiazide
Category 3 Risk of
3
6.1
e
diuretic
hyponatremia,
hypokalemia
Furosemide
Loop
Category 3 Electrolyte
1
2.0
diuretic
imbalance, volume
depletion
Candesartan +
ARB +
Category 4 Increased risk of
1
2.0
Spironolactone
Diuretic
hyperkalemia
(drug–drug
interaction)
Total
49
100.0
*GI: gastrointestinal, NSAID: Non-Steroidal Anti-Inflammatory Drug. Percentage calculated based on the total
number of PIM prescriptions (n = 49). One patient may have received more than one PIM.

The cumulative exposure to anticholinergic and sedative medications has been
linked to cognitive decline in older adults (Akgün et al., 2022; Margolis et al., 2021). A
longitudinal cohort study in France found that higher Drug Burden Index (DBI) scores,
reflecting cumulative exposure to these medications, were associated with a decline in
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Mini-Mental State Examination (MMSE) scores (Dauphinot et al., 2014). This suggests that
cumulative drug burden may accelerate cognitive decline in elderly patients.
Moreover, the use of anticholinergic medications has been associated with an
increased risk of falls in the elderly. A study demonstrated that each additional
anticholinergic drug used by an older patient was associated with an increase in the odds
of experiencing a fall during hospitalization (Akgün et al., 2022; Machado-Duque et al.,
2018). This underscores the importance of minimizing anticholinergic burden to reduce
fall risk in this population.
Polypharmacy, defined as the concurrent use of five or more medications, has also
been linked to adverse outcomes in the elderly. A systematic review and meta-analysis
found that polypharmacy was associated with a significantly increased risk of cognitive
impairment in older adults (OR = 1.39, 95% CI: 1.23-1.58) (Yu et al., 2024). Additionally,
polypharmacy has been identified as a risk factor for delirium in critically ill older adults,
emphasizing the need for careful medication management in this population
Furthermore, cumulative exposure to anticholinergic medications has been linked to
an increased risk of dementia. A nested case-control study in the UK found that higher
cumulative exposure to anticholinergic drugs was associated with a greater risk of
developing dementia, particularly with anticholinergic antidepressants, antipsychotics,
and bladder antimuscarinic drugs (Coupland et al., 2019). These findings highlight the
critical need for regular medication reviews using tools such as the Beers Criteria to
optimize pharmacotherapy and improve medication safety in elderly populations.
Reducing the use of PIMs, particularly those with anticholinergic properties, and
minimizing polypharmacy are essential strategies to mitigate the risk of adverse outcomes
such as cognitive decline, falls, delirium, and dementia in older adults.
In addition to Category 1, this study identified several medications under Category 3
(drugs to be used with caution), hydrochlorothiazide and furosemide, which pose risks of
electrolyte imbalance. Category 4 PIMs (potentially harmful drug–drug interactions) were
identified in one case involving a combination of candesartan and spironolactone, which
increases the risk of hyperkalemia (American Geriatrics Society, 2023). Due to limitations
in available clinical data, Categories 2 (drugs to avoid in specific diseases or syndromes)
and 5 (drugs requiring renal dose adjustment) could not be fully evaluated. The absence of
renal function data, such as estimated glomerular filtration rate (eGFR) and clearance
creatinin (Clcr), remains a barrier to the complete application of the Beers Criteria in
primary care.
Category 1 medications should be prioritized for deprescribing efforts. Tools such as
the STOPP/START criteria can be used in conjunction with the Beers Criteria to identify
medications that should be discontinued or initiated. While deprescribing interventions
have shown potential in reducing PIM prevalence, their effect on long-term clinical
outcomes remains inconclusive due to a lack of robust evidence (Thillainadesan et al.,
2018). Meanwhile, medications under Categories 3 and 4 require careful monitoring, dose
adjustments, and enhanced patient education. These findings emphasize the urgent need
to strengthen the capacity of primary healthcare systems, including workforce training,
clinical decision support systems, and interprofessional collaboration, to ensure optimal
implementation of medication safety tools.
Pharmacists play a pivotal role in promoting safe medication use, particularly in
primary healthcare settings like community health centers. However, their involvement in
prescription review, patient counseling, and ADR monitoring remains suboptimal. Several
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studies have demonstrated that pharmacist-led interventions in geriatric care significantly
reduce ADRs and improve medication adherence (Ali et al., 2021; Lee et al., 2023).
Empowering pharmacists through expanded authority and structured clinical roles could
enhance medication safety and improve therapeutic outcomes in elderly patients.
This study also found a strong positive correlation between the number of
medications prescribed and the occurrence of PIMs (r = 0.711; p < 0.001) (Table 5),
supporting polypharmacy as a significant predictor of inappropriate prescribing. These
findings align with previous literature, including that of Putra et al. (2024), who observed
similar patterns in older adults with chronic conditions. Polypharmacy, commonly defined
as the use of five or more concurrent medications, has been associated with increased risks
of adverse drug events, drug–drug interactions, functional decline, and mortality in older
adults (Y.-Z. Chen et al., 2021; W.-H. Hsu et al., 2017, 2021; Huang et al., 2020; Lu et al.,
2015).
Table 5. Spearman Correlation Between PIM Occurrence and Clinical Variables
Variable
Correlation
P-value
Interpretation
Coefficient (r)
Number of medication
0.711
<0.001
Strong positive correlation
Fasting blood glucose
-0.265
0.040
Weak negative correlation
Age
0.013
0.934
Not significant
Number of
0.127
0.429
Not significant
comorbidities
*Spearman correlation test was used to examine the relationship between PIM occurrence and selected clinical
variables. A positive correlation coefficient (r) indicates that as one variable increases, the other tends to increase,
while a negative value indicates an inverse relationship. A p-value of < 0.05 was considered statistically significant.
Strong, moderate, or weak correlations were interpreted based on the absolute value of r (0,10 -<0,40 as weak, 0,40 <0,70 as moderate, 0,70 -<0,90 as strong, and 0,90-1,00 as very strong (Akoglu, 2018)).

Interestingly, a weak inverse correlation was found between PIM occurrence and
FBG levels (r = –0.265; p = 0.040) (Table 5), suggesting that inappropriate medications may
not contribute meaningfully to glycemic control. This may be attributed to reduced
treatment adherence resulting from complex regimens, undesirable side effects, or
inadequate patient education and clinical follow-up. A lack of understanding among
patients regarding the risks and benefits of prescribed medications may further
compromise treatment effectiveness. These observations highlight the importance of
adopting a person-centered approach in pharmacotherapy, where social, psychological,
and individual clinical contexts are considered in managing chronic diseases in older adults
(Kogan et al., 2016).
Contrary to previous reports (H.-F. Hsu et al., 2023; Wang et al., 2019), no significant
association was found between PIM occurrence and either patient age (r = 0.013; p = 0.934)
or number of comorbidities (r = 0.127; p = 0.429) in this study (Table 5). This discrepancy
may be explained by the homogeneity of the sample, as the majority of patients were within
the same age bracket (65–74 years), and by the standardized treatment protocols typically
employed in community health centers. Additionally, incomplete documentation regarding
comorbidity severity may have limited the analysis of these associations.

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CONCLUSION
At Panjatan 1 Community Health Centre, 85.4% of elderly type-2 diabetes patients
received outpatient therapy with potentially inappropriate medication (PIM). Most PIM
cases involved glimepiride, which is classified as Category 1 of the 2023 Beers Criteria and
should be avoided in older persons because to its poor risk–benefit ratio. There was a high
positive link between the number of medications prescribed and the occurrence of PIMs (r
= 0.711; p < 0.001), which confirms that polypharmacy is a major predictor of
inappropriate prescribing in this group. There was also a weak negative connection
between fasting blood glucose (FBG) levels and PIM occurrence (r = –0.265; p = 0.040). This
means that using the wrong drugs may not be very helpful for controlling blood sugar
levels.
Patient age and comorbidity did not significantly affect PIM occurrence. These
findings emphasise the significance of regular prescription reviews using proven screening
measures like the Beers Criteria to improve geriatric drug safety. They also emphasise the
importance of chemists in primary care to assist rational prescribing and improve
treatment outcomes for elderly patients..
ACKNOWLEDGMENT
The authors would like to express their sincere gratitude to the Gunungkidul District
Health Office and Panjatan 1 Primary Health Center, Gunungkidul Regency, Special Region
of Yogyakarta, for their valuable support and cooperation during the implementation of
this study. Their assistance in providing access to data and facilitating the research process
was essential to the successful completion of this work.
AUTHOR CONTRIBUTION
NS: design; definition of intellectual content; literature search; experimental studies; data
analysis; manuscript preparation.
PD: Concepts or ideas; design; definition of intellectual content; literature search;
experimental studies; data analysis; Manuscript editing; manuscript review.
TRP: Definition of intellectual content; literature search; Manuscript editing; manuscript
review.
ETHICS APPROVAL
This study received ethical approval from the Research Ethics Committee of Universitas
Ahmad Dahlan with approval number 022407086.
CONFLICT OF INTEREST
None to declare
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