Prevalence and predictors of potentially inappropriate medication use among older adults with heart failure: a 2023 beers criteria–based evaluation

Older adults with heart failure (HF) are particularly vulnerable to polypharmacy and potentially inappropriate medication (PIM) use due to multimorbidity, age-related physiological changes, and complex therapeutic regimens. The 2023 American Geriatrics Society (AGS) Beers Criteria provide updated guidance to identify medications that may increase the risk of adverse outcomes in older adults and can be applied to patients with HF. This study aimed to determine the prevalence and patterns of PIM use among older adults with HF and to identify clinical factors associated with increased PIM burden using the 2023 Beers Criteria.

This retrospective cross-sectional study included 524 adults aged ≥ 65 years admitted with HF to two hospitals within the Huntsville Hospital Health System between January 2020 and May 2025. Home medications at admission were evaluated according to the 2023 AGS Beers Criteria. PIMs were categorized as generally inappropriate, disease-specific, use with caution, high-risk drug–drug interactions, or medications requiring avoidance or dose adjustment based on renal function. Multivariable negative binomial regression was used to identify predictors of PIM burden defined as the total number of PIMs per patient.

Overall, 472 patients (90.1%) were prescribed at least one PIM, and 26.2% of all home medications met Beers Criteria. Among 562 PIMs classified as potentially inappropriate, gastrointestinal (33.8%), cardiovascular (22.6%), and central nervous system agents (17.1%) were the most frequent. Clinically significant drug–drug interactions (n = 165) and renal function–related PIMs (n = 118) were also common. In multivariable analysis, higher PIM burden was independently associated with chronic kidney disease (IRR 1.38, 95% CI 1.20–1.59), depression (IRR 1.29, 95% CI 1.05–1.58), benign prostatic hyperplasia (IRR 1.26, 95% CI 1.03–1.53), and increasing number of comorbidities (IRR 1.04 per additional condition, 95% CI 1.00–1.07).

PIM use is highly prevalent among older adults with HF. Targeted medication review—particularly in patients with renal impairment or multiple comorbidities—followed by deprescribing or safer substitutions, represents a key quality-of-care intervention to reduce preventable medication-related harm in this vulnerable population.