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Evaluation & the Health Professions

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Potentially Inappropriate Medications in ª The Author(s) 2020
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Nursing Home Residents: A Comparison DOI: 10.1177/0163278719900653
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of Two Approaches

Marko Stojanović1 , Milica Vuković2, Milan Jovanović3,4, Srd̄an Dimitrijević4,

and Miroslav Radenković1

Abstract
There is currently limited information on the comparative effectiveness of the European Union(7)-potentially inappropriate
medication (EU(7)-PIM) list and the Beers criteria for screening PIMs, of which PIMs are a significant concern, in the geriatric
population of nursing home residents. This study aims to determine and compare the rates of PIMs detected with the Beers
criteria (five sections of which the first is a list of inappropriate medications in older adults) and the EU(7)-PIM list (based on the
first section of the Beers criteria). The study, conducted in Gerontology Center Belgrade (n ¼ 427), is retrospective and
observational. The EU(7)-PIM list detected 876 PIMs, while the first section of the Beers criteria detected 782 PIMs (1,803 with all
five sections). The majority of PIMs belong to psychotropic drugs (benzodiazepines being the most common). The EU(7)-PIM list
detected significantly more PIMs than the first section of the Beers criteria (2.03 + 1.63 vs. 1.83 + 1.27; p ¼ .0005). The number
of detected PIMs with both criteria correlates with age, the number of chronic illnesses, the number of medication prescribed, and
the comorbidity status. Ultimately, the EU(7)-PIM list detected more PIMs compared to the first section of the Beers criterion.

Keywords
EU(7)-PIM list, Beers criteria, geriatric population, nursing homes, potentially inappropriate medication

Expected to reach 22% of the global population by 2050 (Lunen-
feld, 2008), the geriatric population is on the rise (Lucchetti &
Lucchetti, 2017). Matching this increase, effort has also strength-
ened to examine the health problems of the elderly to mitigate
them. One such critical health issue facing the geriatric population
is the prescription of potentially inappropriate medications
(PIMs; Skaar & O’Connor, 2017; Vanderman et al., 2017).
While PIMs may be defined as the use of drugs that cause
significant potential to harm patient (Steinman & Fick, 2019),
PIMs in the elderly increase the risk of death (do Nascimento
et al., 2017). PIMs are a significant economic burden for a
country’s medical system (Guaraldo et al., 2011) because they
may also increase the rate of hospitalization (Guaraldo et al.,
2011), prolonging hospitalization, reducing quality of life, and
increasing risk of falling, fractures, and other disabilities.
Numerous criteria designed in particular to reduce the num-
ber of PIMs in the geriatric population are currently available.
Some are specifically used for the screening of PIMs. The
American Geriatrics Society’s (AGS, 2019) Beers criteria and
the European Union (7)-PIM (EU(7)-PIM) list (Renom-
Guiteras et al., 2015) have been specifically made for this
purpose. Other criteria, for instance, the screening tool of older
people’s prescriptions and screening tool to alert to right treat-
ment criteria (STOPP/START criteria) (O’Mahony et al.,
2015) and the GheOP3S tool (Tommelein et al., 2016), are for
the screening of both PIMs and potential prescribing omissions.
The EU(7)-PIM list is a European criterion initially
designed to analyze the prescription patterns of the PIMs of
those with dementia in several European countries (Renom-
Guiteras et al., 2015). The EU(7)-PIM list is based on several
previously existing PIM lists/criteria, including the Beers cri-
teria, which is the most frequently consulted system detailing
the safety of prescribing medications in older adults (Renom-
Guiteras et al., 2015; Steinman & Fick, 2019). Updated every
3 years, the structure of the Beers criteria significantly differs
from the EU(7)-PIM lists as the latter is simply a list detailing
the PIMs (Renom-Guiteras et al., 2015). The Beers criteria
consist of five sections (Steinman & Fick, 2019). The first
section is a list of medication that should be avoided in older
adults (AGS, 2019). Only, this section of the Beers criteria
resembles the EU(7)-PIM list.
1
Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty
of Medicine, University of Belgrade, Serbia
2
Faculty of Medicine, University of Belgrade, Serbia
3
Center for Endocrine Surgery, Clinical Center of Serbia, Belgrade, Serbia
4
Gerontology Center Belgrade, Serbia
Corresponding Author:
Marko Stojanović, Department of Pharmacology, Clinical Pharmacology and
Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotića 1,
PO Box 38, 11129 Belgrade, Serbia.
Email: marko.stojanovic@med.bg.ac.rs
2 Evaluation & the Health Professions XX(X)
While the abilities of both the EU(7)-PIM and the Beers
criteria to detect PIMs have been examined (Almeida et al.,
2018; Grina & Briedis, 2017), these investigations have been
limited to the previous update (AGS, 2015). Interestingly, the
comparison between these criteria has also never been con-
ducted among nursing home residents. Moreover, the rates of
PIM identification after using both the EU(7)-PIM list and
Beers criteria together have never been compared.
Taking into account the limited data on the ability of the
new Beers criteria to detect PIMs, the primary goal of this study
is to evaluate and to compare the ability of both the EU(7)-PIM
criteria and the most recent update of the Beers criteria (AGS,
2019) to detect PIMs. The secondary goal is to determine the
relationship between the PIMs prescribed and patient
demographics.
Material and Methods
Study Design and Population
As a retrospective observational study conducted in the Ger-
ontology Center Belgrade, the study included all service users
of the Gerontology Center of Belgrade (n ¼ 441). To be
included in this study, nursing home residents had to be older
than 65 years of age and to have been taking at least one
prescribed medication. Paper medical charts were analyzed,
paying particular attention to the list of the diagnosis and med-
ication prescribed. If there were any uncertainties on the paper
medical charts, the authors contacted the nursing home medical
doctors for clarification. To determine the comorbidity status,
the Medicines Comorbidity Index (MCI) for older people was
used (Narayan & Nishtala, 2017).
Screening for PIMs
To screen PIMs, both the EU(7)-PIM list and AGS’s (2019)
Beers criteria were applied. Two researchers (MV and MJ)
independently extracted the PIMs from the patients’ medical
charts. Since the benefit of prescribing PIMs outweighs the
harm that PIMs can cause in certain situations (Steinman &
Fick, 2019), three clinical pharmacologists (MS, SD, and MR),
who are more experienced in this field, reevaluated the correct-
ness of the decision to mark a prescribed medication as a PIM.
Statistical Analysis
The data were first collected in Microsoft Excel 2007® and
then transferred to GraphPad Prism (GraphPad Prism 5 Soft-
ware, San Diego, CA) for further statistical analysis. Data nor-
mality was tested using D’Agostino and the Pearson omnibus
normality test. To compare the PIM identification rates
between the EU(7)-PIM list and Beers criteria, the Wilcoxon
signed-rank test for nonparametric data was used. For the pur-
poses of this analysis, the results were expressed as the mean +
standard deviation. As to determine the statistical relationship
between the occurrence of inadequate prescription and age, the
number of medications prescribed, the number of diagnoses
and chronic diagnoses, and the MCI, a one-tailed bivariate
correlation was performed, where the Spearman’s r correlation
coefficient was calculated. The obtained values were consid-
ered to be significant if p values ⬎.05.
Ethics Statement
All procedures performed in this study followed the ethical
standards of the institutional and national research committees
involved, which are under the World Medical Association
Declaration of Helsinki. Approval was first granted by the local
research ethics committee (Medical Faculty, University of
Belgrade). All the data were assessed in an anonymized form;
the charts were coded, wherein only age, gender, vaccination
status, medical history, and drug charts were available. For this
study, formal consent was not required.
Results
Data from 427 residents of a nursing home were analyzed. In
total, 14 nursing home residents younger than 65 years of age
were excluded. Table 1 displays the essential demographic
characteristics of the included geriatric population in this study.
With the EU(7)-PIM list, a total of 876 PIMs were identi-
fied. All were detected under 70 criteria (from a total of 282
criteria). The most common PIMs related to medications that
act on the central nervous system (CNS). Bromazepam was the
most commonly detected PIM (n ¼ 162, 18.49%), followed by
risperidone (administered longer than 6 weeks; n ¼ 90,
10.27%). The first PIM that was not related to the CNS was
a prescription of proton pump inhibitors for longer than
8 weeks and was ranked third among the most common (n ¼
57, 6.51%). Although no single PIM in 63 nursing home resi-
dents (14.75%) was detected, 364 nursing home residents had
at least one detected PIM. In male nursing home residents,
there were 214 PIMs detected (24.43%), whereas in females,
there were 662 PIMs (75.57%; p ¼ .034). More detailed results
may be found in Table 2.
The screening performed with all five elements of the Beers
criteria led to the detection of 1,803 PIMs (Table 3). A majority
of the 782 PIMs fell under identification of the first section of
the Beers criteria (PIMs in older adults). In the second (drug–
disease or drug–syndrome interaction), 282 PIMs were
detected. The third (drugs to be used with caution) and fourth
(drug–drug interactions) found 594 and 137 PIMs, respec-
tively. Only eight PIMs were therefore detected with the fifth
section of the Beers criteria (PIMs based on kidney function).
Furthermore, at least one PIM was detected in 402 nursing
home residents, while 25 nursing home residents had no single
PIM. Benzodiazepines (n ¼ 266, 13.23%) were the most com-
mon, belonging to the first part of the Beers criteria. Overall,
the Beers criteria identified 437 PIMs (24.24%) in the male
nursing home residents and 1,366 PIMs (75.76%) in the female
residents of this study.
In order to compare the ability of the EU(7)-PIM list and the
Beers criteria to detect PIMs, a Wilcoxon signed-rank test was
Stojanović et al. 3

Table 1. Patient Demographics. Table 2. Number of PIMs and Most Common Detected PIMs Under
the EU(7)-PIM List.
Demographics
Number of PIMs per Patient EU(7)-PIM No. of Patients
Age
Range 65–99 0 63
Median (IQR) 83 (11) 1 114
Sex 2 120
Male (n, %) 13,4.31% 3 63
Female (n, %) 29,3.69% 4 31
No. of prescriptions 5 19
Total 3,642 6 10
Range 1–24 7 5
Median (IQR) 8 (5) 8 1
No. of diagnosis 11 1
Total 2,933 Most common PIM No. of PIMs
Range 1–17 Bromazepam 162
Median (IQR) 7 (4) Risperidone (⬎6 weeks) 90
No. of chronic diagnosis Proton pump inhibitors (⬎8 weeks) 57
Total 2,870 Theophylline 45
Range 0–16 Nifedipine (sustained-release) 40
Median (IQR) 7 (4) Lorazepam (⬎1 mg/day) 40
Comorbidity scales Clozapine 37
MCI (range) 0–10 Ranitidine 32
MCI (median, IQR) 3 (3) Trimetazidine 29
Most frequent diagnoses (n) Alprazolam 28
Arterial hypertension 385 Metoclopramide 27
Angina pectoris 191 Diclofenac 24
Dementia 153 Diazepam 18
Depression 140 Zolpidem (⬎5 mg/day) 17
Psychotic disorders 133 Digoxin 15
Sleep disorders 132 Nitrazepam 14
Heart failure 107 Glimepiride 13
Diabetes mellitus 78 Carbamazepine 11
COPD 70
Stroke 65 Note. PIM ¼ potentially inappropriate medication; EU(7)-PIM ¼ European
Anxiety 59 Union (7)-PIM.
Atrial fibrillation 53
Osteoporosis 49
Prostate hyperplasia 46 between the occurrence of PIMs after using the Beers criteria
Gout 35 and the number of medications prescribed (r ¼ 0.56;
Note. COPD ¼ chronic obstructive pulmonary disease; MCI ¼ Medicine p ⬍ .0001), the number of diagnoses (r ¼ 0.48; p ⬍ .0001),
Comorbidity Index; IQR ¼ interquartile range. the number of chronic diagnoses (r ¼ 0.48; p ⬍ .0001), and the
MCI (r ¼ 0.32; p ⬍ .0001). These correlations are moderate
(medication prescribed) or low (the number of diagnoses,
used. The EU(7)-PIM list detected significantly more PIMs chronic diagnoses, and MCI). A negative and negligible corre-
than the first section of the Beers criteria (2.03 + 1.63 vs. lation was detected between the occurrence of a PIM and age
1.83 + 1.27; p ¼ .0005). When all sections of the AGS’s (r ¼ 0.16; p ¼ .0008) after using the Beers criteria.
(2019) Beers criteria were used, significantly more PIMs were
detected than with the EU(7)-PIM list (4.25 + 2.98 vs. 2.03 +
1.63; p ⬍ .001). Discussion
The occurrence of a PIM detected after using the EU(7)- This study compares two approaches of the Beers criteria and
PIM list was then positively correlated with the number of the the EU(7)-PIM list to screen PIMs. To the best of the authors’
medication prescribed (r ¼ 0.60; p ⬍ .0001), the number of knowledge, this study is not only the first to compare a new
diagnoses (r ¼ 0.45; p ⬍ .0001), the number of chronic revised version of the Beers criteria with the EU(7)-PIM list but
diagnoses (r ¼ 0.45; p ⬍ .0001), and the MCI (r ¼ 0.35; is also the first to apply these two criteria in the examination of
p ⬍ .0001). These correlations are moderate (the medication nursing home residents. While two studies had both simultane-
prescribed) or low (the number of diagnoses, chronic diag- ously utilized the EU(7)-PIM list and an older version of the
noses, and MCI). A significant negative negligible correlation Beers criteria, neither of these statistically compared the ability
was found between the occurrence of a PIM and age (r ¼ of the criteria to detect PIMs. Instead, one study investigated
0.15; p ¼ .0009). An identical trend in correlation was found the prevalence of PIM use, while the other examined levels of
4 Evaluation & the Health Professions XX(X)

Table 3. Detection of PIMs Under the AGS’s (2019) Beers Criteria.

AGS’s (2019) Drug–Disease/Syndrome Drugs to Be Used
Beers Criteria PIM in Older Adults Interaction With Caution Drug–Drug Interactions Kidney Function

No. of PIM No. of Patients No. of Patients No. of Patients No. of Patients No. of Patients

0 59 275 85 299 420

1 133 70 167 121 6
2 113 47 111 6 1
3 79 25 53 — —
4 32 7 9 1 —
5 8 3 2 — —
6 3 — — — —

Rank of most Most common

common PIM Most common PIM (n) Most common PIM (n) Most common PIM (n) Most common PIM (n) PIM (n)

1 Benzodiazepines (266) Dementia—antipsychotics (91)
2 Antipsychotics (163)
3 Antidepressants (142)
4 Proton pump
inhibitors (57)
5 “Z-drugs” (47)
6 Sulfonylureas (41)
7 Nonselective
NSAIDs (31)
8 Digoxin (15)
9 Antispasmodics (7)
10 Barbiturates (4)
Diuretics (210) Combination of three or more CNS Tramadol (3)
drugs (122)
Dementia—benzodiazepines (77) Antipsychotics (151) RAAS inh. þ Kþ-sparing diuretics (4) Pregabalin (3)
History of falls/fractures— SSRIs (118) Opioids þ benzodiazepines (3) Spironolactone (1)
benzodiazepines (34)
Dementia—“Z-drugs” (22) ASA—primary Opioids þ gabapentin/pregabalin (1) Ranitidine (1)
prevention (56)
History of falls/fractures—SSRI (17) Mirtazapine (28) Anticholinergic þ anticholinergic (1) —
History of falls/fractures— Carbamazepine (12) Alpha-1 blockers þ loop diuretics (1) —
antipsychotics (16)
Dementia—anticholinergics (11) TMP–SMX (7) Warfarin þ NSAIDs (1) —
Parkinson disease—antiemetics (5) Tramadol (5) Warfarin þ amiodarone (1) —
History of falls/fractures— SNRIs (3) Warfarin þ TMP–SMX (1) —
“Z-drugs” (4)
History ulcer—nonselective TCAs (3) — —
NSAIDs (2)

Note. AGS ¼ American Geriatric Society; ASA ¼ acetylsalicylic acid; CNS ¼ central nervous system; NSAID ¼ nonsteroid anti-inflammatory drugs; PIM ¼
potential inappropriate medications; PPI ¼ proton pump inhibitors; RAAS ¼ renin angiotensin aldosterone system; SSRI ¼ selective serotonin reuptake inhibitors;
SNRI ¼ serotonin and norepinephrine reuptake inhibitor; TCAs ¼ Tricyclic antidepressants; TMP–SMX ¼ trimethoprim–sulfamethoxazole.

agreement in PIM use frequency between these criteria. These
two studies also included, on average, a younger population
and lower comorbidity.
The results of this study demonstrate the excellent ability of
both tools to detect PIMs in the population investigated. The
EU(7)-PIM list identified 876 PIMs, of which bromazepam
was the most commonly detected. In contrast, the Beers criteria
identified a total of 1,803 PIMs, of which the most commonly
detected were benzodiazepines. When the two tools were com-
pared against one another, the EU(7)-PIM list detected more
PIMs than did the first section of the AGS’s (2019) Beers
criteria. Except with age where the correlation was negative,
the number of detected PIMs after using the EU(7)-PIM list
positively correlated with all the variables investigated. Using
the AGS’s (2019) Beers criteria obtained similar results regard-
ing the direction and the size of the correlation coefficient. The
high values of the MCI, a comorbidity index created in partic-
ular for the geriatric population (Narayan & Nishtala, 2017,
2018), may account for the significant amount of PIMs
detected under both criteria.
Benzodiazepines, the most commonly detected PIM in this
study under both criteria, are commonly prescribed in older
adults, even though it is known that they can cause serious
health issues (Picton et al., 2018). Moreover, similar to the
results obtained by our study, other EU(7)-PIM list–based stud-
ies from Croatia and Lithuania detected benzodiazepines as the
most common PIMs (Grina & Briedis, 2017; Mucalo et al.,
2017). Other EU(7)-PIM studies, such as those from Brazil
(primary health-care patients) and Northern Sweden (cognitive
impairment patients), have tagged proton pump inhibitors and
zopiclone (⬎3.75 mg/day) as the most common PIMs
(Almeida et al., 2018; Sonnerstam et al., 2017). The different
populations involved in these studies may explain the differ-
ences found. Bromazepam, the most commonly detected PIM
in this and the Croatian studies, was not listed as a PIM in the
Lithuanian and Swedish studies, as this drug is not registered in
these countries in contrast to its registration in the others (e.g.,
Serbia and Croatia). As in the EU(7)-PIM–based studies, the
majority of Beers criteria–based studies detected benzodiaze-
pines as the main prescribing problem (da Costa et al., 2016;
Franchi et al., 2019; Wang et al., 2019).
It is noteworthy that the only two studies that had previously
compared the ability to detect PIMs used the modified Beers
criteria in their studies (Grina & Briedis, 2017; Muhlack et al.,
2018). While Muhlack et al. (2018) excluded a significant
number of PIMs from the Beers criteria, Grina and Briedis
Stojanović et al.
(2017), due to limited information on diseases and syndromes,
used only the first section of the Beers criteria (medications
potentially inappropriate in most older adults) in their study. As
within our study, this comparison appears to be the only proper,
realistic comparison since the first part of the Beers criteria and
the EU(7)-PIM list is similar in their structure and represents a
list of PIMs.
Although the AGS’s (2019) Beers criteria in this study were
found to be more applicable, it is still essential to consider how
criteria are constructed. To illustrate, the Beers criteria deem all
benzodiazepines to be PIMs, while the EU(7)-PIM list
approves the use of lorazepam in a dose of up to 1 mg/day.
This discrepancy between the two criteria lists can be a clinical
problem since it is reported that lorazepam is the drug most
commonly associated with falls in hospital settings (Cashin &
Yang, 2011) as with other psychotropic drugs.
As anticipated, the PIM rates positively correlated with the
number of medications prescribed, the number of diagnoses,
the number of chronic diagnoses, and the MCI. A similar cor-
relation was noted in a study that compared STOPP/START
criteria and the older Beers criteria (Ryan et al., 2009). The
only negative correlation observed was between PIMs and age
but is attributable to the fact that the Gerontology Center of
Belgrade provides all-day care; thus, the population is younger
and seriously ill members more commonly use their services.
There are several limitations to this PIM study. Its design is
only retrospective, performed cross-sectionally. PIM studies
performed in a nursing home generally prove to be impractical,
as they are challenging to perform and are complicated by those
patients who suffer from more severe or bed-bound conditions.
The population skews data collection, making interpretation of
the results quite challenging. An additional problem of PIM
studies is the unit of analysis, that is, whether to analyze data
according to patients, prescriptions (or medical orders), or pre-
scribers. Owing to the nature of this study, the data had to be
analyzed according to prescriptions.
Conclusions
In conclusion, the EU(7)-PIM and the AGS’s (2019) Beer cri-
teria identify a significant number of PIMs in the investigated
population. When the EU(7)-PIM list was compared with the
first section of the AGS’s (2019) Beers criteria, more PIMs
were detected in conjunction with the EU(7)-PIM list. How-
ever, when all parts of the AGS’s (2019) Beers criteria were
included, the situation proved to be significantly different, as
the Beers criteria detected more PIMs. Benzodiazepines, espe-
cially bromazepam, are the most commonly detected PIM. As
observed, age, the number of chronic illnesses, the number of
medications prescribed, and comorbidity status correlate with
the number of PIMs detected.
Acknowledgments
The authors would like to thank the Gerontology Center of Belgrade’s
facilities staff in their assistance in data collection.
5
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The Min-
istry of Education and Science of the Republic of Serbia has supported
the work described in this article through grant 175023.
ORCID iD
Marko Stojanović https://orcid.org/0000-0003-2097-7591
Data Accessibility Statement
The data sets generated and analyzed in this study are available from
the corresponding author on reasonable request.
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