Introduction

Geriatric syndromes (GSs) represent a wide range of multifactorial health conditions that are highly prevalent among older adults. These health problems include cognitive impairment, delirium, depression disorders, falls, unexplained weight loss, appetite loss, and urinary incontinence.1 These syndromes typically arise from numerous physiological functions that decline due to either the aging process itself or the adverse events associated with the use of an excessive number of medications for different indications simultaneously (polypharmacy).2–5 Although medications are prescribed to alleviate symptoms and improve health outcomes in this population, paradoxically, they can contribute to or worsen these symptoms.6 Furthermore, prescribing specific drugs to treat unwanted adverse events of another medication, rather than a new indication, will add up to the drug burden and may lead to the development of GSs among older adult patients.2

Both the Beers and START/STOPP criteria mainly focus on specific medications that have been identified as potentially inappropriate for older adults due to their known risks, adverse drug events, and drug-drug interactions.7,8 In comparison, medications associated with geriatric syndromes (MAGS) list refer to a broader inclusion of GSs that may result from medication use, such as unintentional weight loss, delirium, depression, and urinary incontinence.9

MAGS include a wide range of medications that are commonly prescribed to older adults for the management of chronic conditions. Previous reports have identified eighteen medication categories which contribute to six GSs development in older patients including antiepileptic, drugs used for Parkinson disease, antipsychotics, opioid agonist, benzodiazepines, antihypertensive medications, antidiabetic, anticholinergic, antihistamines, and others.3,9

Therefore, it is necessary to address all medications that may be associated with geriatric syndromes. Identifying these medications is a key step in preventing or minimizing the risk of developing geriatric syndromes and ultimately enhancing treatment outcomes in older adult patients.

In this context, the current study aimed to identify the prevalence of MAGS prescriptions among older adult patients with various comorbidities and to determine predictors that may predispose them to the onset of geriatric syndromes.

Methodology Ethical Approval

Ethical approval for this study was obtained from the Institutional Review Board (IRB) of Jordan University of Science and Technology (JUST) and King Abdullah University Hospital (KAUH) under reference number (4/166/2024). The Institutional Review Board (IRB) at JUST/KAUH waived the requirement for informed consent, as the data were extracted retrospectively from electronic patient records, with no direct interaction or intervention involving the patients. All patient data were anonymized to ensure confidentiality and protect their privacy. The study adhered to the principles of the Declaration of Helsinki.

Study Population and Setting

Electronic medical records of older adult patients (≥ 65 years old) who visited various outpatient clinics (mainly psychiatric, endocrine, and cardiovascular clinics) at King Abdullah University Hospital (KAUH) in the last 5.5 years (1-1-2019 to 1-6-2024) were evaluated for further analysis.

Study Design and Data Collection

This retrospective study assessed the electronic medical records of older adult patients who received outpatient clinic services (diagnosis, treatment, and follow-up). Data included patient demographics (age, sex, and social characteristics), past and current medical history, chronically administered medications.

The Polypharmacy was defined and categorized into three levels: mild polypharmacy (concurrent use of 2–4 medications), major polypharmacy (concurrent use 5–9 medications), and excessive polypharmacy (concurrent use of 10 or more medications).10–12

The MAGS was evaluated based on the list of medications previously documented to be associated with an increased incidence of geriatric syndromes.9

Sample Size Calculation

At least 385 medical records pertaining to older adult patients were needed to achieve a 95% confidence interval with a margin of error of 5%. Population proportion will be considered equal to 50% to obtain the maximum possible number of records to include in this study.13 To enhance and ensure the generalizability of the data, the investigators included all eligible patients’ records (1087) during the assessment period.

Statistical Analysis

Descriptive statistics were presented, medians and 25–75 percentiles were applied for continuous variables, percentages and frequencies were used for categorical variables, and the frequency of MAGS prescriptions was evaluated. A quantile regression model was applied to evaluate variables associated with MAGS prescription frequency, including age, sex, number of comorbidities, and polypharmacy status. Statistical significance was set at a threshold of P < 0.05. Data analysis was performed using SPSS software.

Results

The social and demographic profiles of older adult patients are presented in Table 1. This study included 1087 patients (52.7% females). The median age of patients was 71 (68–77). A significant proportion of patients had peptic ulcer disease (PUD) (57.1%), hypertension (54.65%), and uncomplicated diabetes mellitus (50%). Moreover, 14.9% of the patients had minor polypharmacy, 38.3% had major polypharmacy, and 41.6% had excessive polypharmacy. Finally, the median number of medications was 8 (5–12).

Table 1 Socio-Demographic Profiles of the Study Participants (n=1087)

The classes of medications associated with MAGS in the studied patients are shown in Table 2. Most of them were taking antihypertensives (78.4%), non-opioid non-steroidal anti-inflammatory and/or analgesics (56.5%), and antidiabetics (51.8%).

Table 2 Frequency of Medication Classes Associated with Geriatric Syndromes for the Study Participants

As shown in Table 3, The majority of MAGS were linked to increased risks of falls (96%), followed by urinary incontinence (87.6%), depression (87.3%), unintentional weight and appetite loss (69.4%), cognitive impairment (53.6%), and delirium (53.5%).

Table 3 Number and Percentage of Patients Who Received Medications Associated with Specific Geriatric Syndromes

A quantile regression model was fitted to identify the variables that were significantly associated with more MAGS prescriptions (Table 4). The results showed that patients who were on minor polypharmacy medication regimens or major polypharmacy regimens showed a significantly lower number of MAGS compared with patients who had excessive polypharmacy (coefficient =−3.000, 95% CI (−3.322, −2.678), p<0.001; coefficient =−2.000, 95% CI (−2.230, −1.770), p<0.001, respectively).

Table 4 Quantile Regression of the Variables Associated with Prescription Frequency of Medications Associated with Geriatrics Syndromes

Discussion

This study assessed the prevalence of medications associated with geriatric syndrome (MAGS) in a cohort of 1087 older adult patients. Furthermore, we identified factors, including polypharmacy, which were associated with increased levels of MAGS prescription among the same population presenting various chronic comorbidities.

The median patient age was 71 years. The most common chronic conditions encountered in this study included peptic ulcer disease (57.1%), hypertension (54.65%), and uncomplicated diabetes mellitus (50%). Polypharmacy was prevalent in 94.8% of the patients, while excessive polypharmacy was observed in 41.6%. The median number of medications taken by the patients was 8, which is consistent with other studies reporting a high burden of polypharmacy in older adults.14,15

Our findings on the prevalence of excessive polypharmacy are in line with the global rate variation reported in the literature, where the prevalence of excessive polypharmacy has been found to range from 8.67% to 31%, underscoring the widespread occurrence of this issue among the older adult patients.16–18

This study demonstrated that antihypertensive medications were the most frequently prescribed MAGS. In a study from Malaysia, vasodilating antihypertensive agents were the second most prescribed MAGS.19 Similarly, the Malaysian study identified opioid analgesics as the most frequently prescribed MAGS. In contrast, our findings revealed a notably lower prevalence of opioid analgesic prescriptions, potentially due to differences in patients-centered factors, prescribers’ attitudes toward pain definition and criteria for prescribing opioids.20 Additionally, healthcare providers in Jordan tend to prioritize non-steroidal anti-inflammatory drugs (NSAIDs) as a primary treatment option over opioids. Moreover, this current study revealed that antidepressants, antipsychotics, and muscle relaxants were among the least frequently prescribed medications associated with MAGS, despite the relatively significant prevalence of depression, psychosocial and physical distress among older adults in Jordan.21–23 This finding could be explained by the fact that healthcare providers often focus primarily on managing major chronic /conditions, thus, mental health issues may be overlooked, leading to a lower prescribing frequency of antidepressants and other medications used to manage psychological and physical health conditions, which results in a lower reported prevalence of MAGS among older adult patients.

The rate of prescribing medications associated with geriatric syndromes (MAGS) varied significantly, with 96% of patients being prescribed medications associated with risk of falls and 53.5% associated with delirium risk. Falls, the most common AGS in our cohort, are a well-documented consequence of polypharmacy, particularly the use of antihypertensive and non-opioid analgesics, which were frequently prescribed in our study.

The prevalence rates of MAGS observed in our study showed variations compared to findings from previous studies. For example, similarly high rates of medication associated with fall prescriptions have been reported previously, where falls were the most common medication-associated syndrome, and every patient in the sample had at least one discharge medication associated with this syndrome.9 Another study from Japan found that impaired appetite was the most common AGS in the geriatric population.24

However, the prescription rate of medications associated with delirium and cognitive impairment (53.5% and 53.6%, respectively) observed in our study, although lower than that for falls and other geriatric syndromes, still represents a significant risk. This is in line with a previous report that delirium and cognitive impairment are common but less prevalent in MAGS than in falls.9 The relatively lower prevalence of the two MAGs, delirium, and cognitive impairment in our study compared to falls may be attributed to differences in the types of medications used or the underlying health conditions of the older adult patients. Nonetheless, the presence of medications associated with either delirium or cognitive impairment in over half of our patient population indicates the need to implement focused strategies that prioritize careful monitoring and adjustment of prescriptions, including MAGs, for older adult patients, ensuring that potential risks are minimized while maintaining therapeutic efficacy.

The regression analysis in this study further highlighted the impact of excessive polypharmacy on the prescription of MAGs. Patients with excessive polypharmacy were found to have a significantly higher number of MAGs than those with minor or major polypharmacy. This finding is consistent with the existing literature, which suggests that the likelihood of geriatric syndrome increases with the number of prescribed medications. A longitudinal study from England demonstrated a similar trend, where major polypharmacy existed in nearly one-third of study population was significantly associated with a 21% higher rate of falls over a period of 2 years. Another prospective cohort study reported that excessive polypharmacy was significantly associated with decreased functional and cognitive capabilities in contrast to the non-polypharmacy cohort.25

Study Limitations

This study had several limitations. First, the sample was obtained only from outpatient clinics at a single medical center, which may limit the applicability of the findings to other medical settings. However, KAUH serves more than 20% of the population who reside nearby and have access to healthcare facilities there. Second, the retrospective nature of the study may introduce bias, as it relies on previously collected data, which could affect the accuracy and completeness of the information. However, the research teams ensured that completed patients records with all necessary data were included to achieve the study objectives.

Conclusion

This study highlights the significant impact of excessive polypharmacy in older adult patients, demonstrating its major role in increasing the prescription pattern of MAGS. The significant correlation between excessive polypharmacy and the prevalence of MAGS, such as falls, urinary incontinence, and depression, emphasizes the complexity of managing multiple chronic conditions among older adult patients such as cardiovascular diseases, hypertension, and diabetes. Efforts to manage these comorbidities are often associated with increased MAGS prescribing, which complicates treatment regimens and elevates the risk of adverse events. These findings indicate the necessity for effective measures to reduce polypharmacy and optimize medication use, with the aim of reducing the MAGS and enhancing health-related outcomes in geriatric patients.

Acknowledgment

The study was approved by the Deanship of Research at Jordan University of Science and Technology (JUST) (approval number: 0027-2024).

Funding

Funding for this research was provided by the Deanship of Research at Jordan University of Science and Technology, Grant No. 20240027.

Disclosure

The authors report no conflicts of interest in this work.

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