Drugs & Therapy Perspectives

, Volume 34, Issue 4, pp 174–185 | Cite as

Physicians’ perspectives on defining older adult patients and making appropriate prescribing decisions

  • Natalia Krzyzaniak
  • Shamsher Singh
  • Beata Bajorek
Original Research Article



Older patients are major users of pharmacotherapy due to a higher incidence of health issues. However, there is evidence of age-biased prescribing, leading to over- or underprescribing of medication, and suboptimal clinical outcomes. Although many guidelines provide cautionary statements about the use of medicines in older patients, they fail to identify what this means in practice. There is no accepted definition of an older adult that appropriately characterises this patient group. As a result, there is potential for physicians to have variable interpretations of individuals within this patient population, leading to potential inconsistencies when making pharmacotherapeutic decisions.


The aim of this study was to explore how Australian medical physicians practically defined an older adult patient in the context of providing pharmacotherapeutic care to this population.


This was a two-stage study comprising a scenario-based questionnaire (quantitative phase) and semi-structured individual interviews (qualitative phase) with Australian physicians. Qualitative data was thematically analysed and manual inductive coding was used to generate core themes.


A total of 15 physicians participated in the study. Overall, in regard to providing care to their older patients, the three key themes that emerged from physicians’ discussions were (1) using a number-based versus health status-based definition of an older patient; (2) patient ‘red flags’ influence prescribing decisions; and (3) lack of guideline support in prescribing for older patients. Most physicians ultimately defined older adult patients using a number-based description (i.e. age between 65 and 90 years) because they felt they needed some sort of ‘cut-off’ point to guide their decision making. However, in assessing an older patient, physicians considered a multitude of patient factors as influencers of their decision making during prescribing, including comorbidities, cognitive function, frailty, polypharmacy, etc., and did not solely focus on the patient’s age.


Physicians describe the complexity of decision making for older adult patients, and how this is influenced by a diverse range of factors, yet ultimately simplify the process by defaulting to number-based (age in years) guidelines and procedures.



None to declare.

Compliance with ethical standards

Conflict of interest

Natalia Krzyzaniak, Shamsher Singh and Beata Bajorek have no conflicts of interest to declare.


  1. 1.
    Hubbard RE, O’Mahony MS, Woodhouse KW. Medication prescribing in frail older people. Eur J Clin Pharmacol. 2012;69(3):319–26.CrossRefPubMedGoogle Scholar
  2. 2.
    Older, wiser, safer. NPS MedicineWise, MedicineWise News. 2013. Available at: Accessed 29 Mar 2017.
  3. 3.
    Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32(2):113–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Spinewine A, Swine C, Dhillon S, et al. Appropriateness of use of medicines in elderly inpatients: qualitative study. BMJ. 2005;331(7522):935.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    O’Mahony D, Gallagher PF. Inappropriate prescribing in the older population: need for new criteria. Age Ageing. 2008;37(2):138–41.CrossRefPubMedGoogle Scholar
  6. 6.
    Kievit W, van Hulst L, van Riel P, et al. Factors that influence rheumatologists’ decisions to escalate care in rheumatoid arthritis: results from a choice-based conjoint analysis. Arthritis Care Res. 2010;62(6):842–7.CrossRefGoogle Scholar
  7. 7.
    Boyles PJ, Peterson GM, Bleasel MD, et al. Undertreatment of congestive heart failure in an Australian setting. J Clin Pharm Ther. 2004;29(1):15–22.CrossRefPubMedGoogle Scholar
  8. 8.
    Bajorek BV, Krass I, Ogle SJ, et al. The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation. Aust J Ageing. 2002;21(1):36–41.CrossRefGoogle Scholar
  9. 9.
    Cahir C, Bennett K, Teljeur C, et al. Potentially inappropriate prescribing and adverse health outcomes in community dwelling older patients. Br J Clin Pharmacol. 2014;77(1):201–10.CrossRefPubMedGoogle Scholar
  10. 10.
    Tommelein E, Mehuys E, Petrovic M, et al. Potentially inappropriate prescribing in community-dwelling older people across Europe: a systematic literature review. Eur J Clin Pharmacol. 2015;71(12):1415–27.CrossRefPubMedGoogle Scholar
  11. 11.
    Singh S, Bajorek B. Defining ‘elderly’in clinical practice guidelines for pharmacotherapy. Pharm Pract. 2014;12:489.Google Scholar
  12. 12.
    Cruz-Jentoft AJ, Carpena-Ruiz M, Montero-Errasquín B, et al. Exclusion of older adults from ongoing clinical trials about type 2 diabetes mellitus. J Am Geriatr Soc. 2013;61(5):734–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Bellmunt J, Négrier S, Escudier B, et al. The medical treatment of metastatic renal cell cancer in the elderly: position paper of a SIOG Taskforce. Crit Rev Oncol Hematol. 2009;69(1):64–72.CrossRefPubMedGoogle Scholar
  14. 14.
    Cho ER, Yoo J, Jee SH, Kim Y. Biological age as a useful index to predict seventeen-year survival and mortality in Koreans. BMC Geriatr. 2017;17(1):7.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Jee H, Jeon BH, Kim YH, et al. Development and application of biological age prediction models with physical fitness and physiological components in Korean adults. Gerontology. 2012;58(4):344–53.CrossRefPubMedGoogle Scholar
  16. 16.
    Nakamura E, Miyao K. A method for identifying biomarkers of aging and constructing an index of biological age in humans. J Gerontol A Biol Sci Med Sci. 2007;62(10):1096–105.CrossRefPubMedGoogle Scholar
  17. 17.
    Meid AD, Lampert A, Burnett A, et al. The impact of pharmaceutical care interventions for medication underuse in older people: a systematic review and meta-analysis. Br J Clin Pharmacol. 2015;80(4):768–76.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Vrdoljak D, Borovac JA. Medication in the elderly-considerations and therapy prescription guidelines. Acta Med Acad. 2015;44(2):159–68.PubMedGoogle Scholar
  19. 19.
    House Standing Committee on Health and Ageing Inquiry into Dementia: Early diagnosis and Intervention Response by The Royal Australasian College of Physicians and the Australian and New Zealand Society for Geriatric Medicine to the Questions on Notice. In: The Royal Australasian College of Physicians (RACP) and the Australian and New Zealand Society for Geriatric Medicine (ANZSGM); 2012.Google Scholar
  20. 20.
    Australian and New Zealand Society for Geriatric Medicine. Why train in Geriatric Medicine? 2017. Available at: Accessed 25 Oct 2017.
  21. 21.
    Postgraduate Medical Council of Victoria. Intern Year. 2017. Available at: Accessed 25 Oct 2017.
  22. 22.
    Australian Aged Care Quality Agency. Nurse practitioners. Australian Government. 2014. Available at: Accessed 15 Dec 2017.
  23. 23.
    Bajramovic J, Emmerton L, Tett SE. Perceptions around concordance: focus groups and semi-structured interviews conducted with consumers, pharmacists and general practitioners. Health Expec. 2004;7(3):221–34.CrossRefGoogle Scholar
  24. 24.
    Population Composition: Regional population ageing. Australian Bureau of Statistics. 2006. Available at:!OpenDocument. Accessed 15 Dec 2016.
  25. 25.
    Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.CrossRefGoogle Scholar
  26. 26.
    Data Saturation—numbers left out in the rain, or something else? NSF Consulting. 2017. Available at: Accessed 25 Oct 2017.
  27. 27.
    Lundebjerg NE, Trucil DE, Hammond EC, et al. When it comes to older adults, language matters: Journal of the American Geriatrics Society adopts Modified American Medical Association style. J Am Geriatr Soc. 2017;65(7):1386–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Thomas DR. A general inductive approach for qualitative data analysis. Am J Eval. 2006;27(2):237–46.CrossRefGoogle Scholar
  29. 29.
    Cooper S, Endacott R. Generic qualitative research: a design for qualitative research in emergency care? Emerg Med J. 2007;24(12):816–9.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    The four main approaches. Alzheimer Europe, Luxembourg. 2009. Available at: Accessed 28 Mar 2017.
  31. 31.
    Hansen M, O’Brien K, Meckler G, et al. Understanding the value of mixed methods research: the Children’s Safety Initiative-Emergency Medical Services. Emerg Med J. 2016;33(7):489–94.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Webster-pak Community: Dispensing procedures manual. Manrex Pty Ltd, Leichhardt. 2014. Available at:
  33. 33.
    March A. Perspective: consistency, continuity, and coordination—the 3Cs of seamless patient care. The Commonwealth Fund; 2006 [updated 15/12/17]. Available from:
  34. 34.
    VanderWalde N, Hurria A, Jagsi R. Improving consistency and quality of care for older adults with cancer: the challenges of developing consensus guidelines for radiation therapy. Int J Radiat Oncol Biol Phys. 2017;98(4):721–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Campbell NL, Boustani MA, Skopelja EN, et al. Medication adherence in older adults with cognitive impairment: a systematic evidence-based review. Am J Geriatr Pharmacother. 2012;10(3):165–77.CrossRefPubMedGoogle Scholar
  36. 36.
    Adams WL, McIlvain HE, Lacy NL, et al. Primary Care for elderly people: why do doctors find it so hard? Gerontologist. 2002;42(6):835–42.CrossRefPubMedGoogle Scholar
  37. 37.
    Mutasingwa DR, Ge H, Upshur RE. How applicable are clinical practice guidelines to elderly patients with comorbidities? Can Fam Physician. 2011;57(7):e253–62.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294(6):716–24.CrossRefPubMedGoogle Scholar
  39. 39.
    Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–34.CrossRefPubMedGoogle Scholar
  40. 40.
    Reeve E, Shakib S, Hendrix I, et al. The benefits and harms of deprescribing. Med J Aust. 2014;201(7):386–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Int Med. 2010;170(18):1648–54.CrossRefGoogle Scholar
  42. 42.
    Iyer S, Naganathan V, McLachlan AJ, et al. Medication withdrawal trials in people aged 65 years and older. Drugs Aging. 2008;25(12):1021–31.CrossRefPubMedGoogle Scholar
  43. 43.
    Reeve E, Wiese MD. Benefits of deprescribing on patients’ adherence to medications. Int J Clin Pharm. 2014;36(1):26–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Orimo H, Ito H, Suzuki T, et al. Reviewing the definition of “elderly”. Geriatr Gerontol Int. 2006;6(3):149–58.CrossRefGoogle Scholar
  45. 45.
    Singh S, Bajorek B. Defining ‘elderly’ in clinical practice guidelines for pharmacotherapy. Pharm Pract. 2014;12(4):489.Google Scholar
  46. 46.
    Singh S, Bajorek B. Pharmacotherapy in the ageing patient: the impact of age per se (a review). Ageing Res Rev. 2015;24(Part B):99–110.Google Scholar
  47. 47.
    Sanderson W, Scherbov S. Rethinking age and ageing. Washington: Population Reference Bureau; 2008. Contract No. 4.Google Scholar
  48. 48.
    Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007;62(7):722–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Gunderson A, Tomkowiak J, Menachemi N, et al. Rural physicians’ attitudes toward the elderly: evidence of ageism? Qual Manag Health Care. 2005;14(3):167–76.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of Technology SydneyUltimoAustralia

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