Background

Dementia is a progressive syndrome caused by underlying neurodegenerative processes and characterised by a decline from a previously attained cognitive level that affects memory, thinking, behaviour and activities of daily living [1]. The demographic shifting toward ageing populations is generating significant increases in dementia prevalence. In 2019, the number of people living with dementia worldwide was 55 million and this number is projected to increase to 139 million by 2050 [1]. In Saudi Arabia, there are no accurate national data about the prevalence of dementia, although Middle Eastern countries are predicted to have one of the highest dementia prevalence estimations in the world by 2050 [2]. Dementia is a leading cause of death globally, and it has been estimated that Alzheimer’s disease and other dementias are one of the leading causes of death for females in Saudi Arabia [3]. Increasing age is the strongest known risk factor for dementia, with the incidence doubling with every five-year increment in age [1]. Ageing is also combined with a gradual decline in physical function and a growing risk of multiple chronic conditions that usually require prescribing of multiple medications (polypharmacy) [4, 5].

Polypharmacy has been described using a numerical threshold, commonly four or five medications [6, 7]. Given the high prevalence of comorbid medical conditions and frailty among people with dementia (PwD), the risks of polypharmacy, drug-drug and drug-disease interactions are greater than among their older counterparts [8,9,10,11,12]. Polypharmacy may increase the possibility of adverse drug reactions, reduced medication adherence, and potentially inappropriate prescribing (PIP) [13]. PIP is the prescribing of medications where the risk of potential harm exceeds the potential benefit, and a safer option is available to treat the condition [14]. It has been linked to negative consequences in older adults such as adverse drug events, hospitalisation, mortality, and increased healthcare costs [15,16,17,18,56, 57]. A growing body of evidence has shown that successful deprescribing interventions were multidisciplinary in nature, with many including the provision of patient educational materials [58]. Currently, most of the medication optimisation and deprescribing interventions for PwD which are described in the literature are of poor quality, have multiple methodological limitations, have only targeted certain medication classes, have focused on medication-related outcomes instead of patient-centred outcomes, or been restricted to inpatients or those residing in long-term care facilities [59,60,61]. Future research should focus on the development and evaluation of complex, multidisciplinary and theory-based interventions for PwD that can be implemented in ambulatory care settings and cover multiple medications instead of specific medication classes [59, 61].

It is anticipated that the findings from this study will add to the limited evidence base that currently exists on appropriateness of prescribing for PwD in Saudi Arabia. In highlighting areas where prescribing may be considered potentially inappropriate, this should draw healthcare providers’ attention to this issue, particularly during clinical encounters with this patient population and when planning medication reconciliation and review activities. Healthcare providers’ attitudes and willingness towards improving prescribing and use of medications for PwD in Saudi Arabia should be explored in future research, along with the views of PwD and their caregivers in Saudi Arabia, as key partners in medication management.

Strengths and limitations

The present study has explored, for the first time, the prescribing patterns and appropriateness of prescribing for PwD in Saudi Arabia. The availability of medical diagnostic information and other clinical data through EHRs enabled us to apply a comprehensive set of STOPP criteria. However, it is important to consider the study’s limitations. Firstly, the STOPP criteria were assessed based on data extracted from EHRs, while medications prescribed by healthcare providers outside the hospital setting could not be captured. In addition, this study did not identify reports from participants’ family members or carers about patients’ self-medication, consider medications obtained without prescription (such as those bought over the counter), or medications prescribed “as needed”, which might have resulted in an underestimation of the prevalence of polypharmacy and PIP, especially for analgesic medications. Whilst the prevalence of prescribing of chronic NSAIDs was low in this study, a survey-based cross-sectional study using the Saudi National Survey for Elderly Health, which included around 3,000 Saudi older adults, reported that NSAIDs were used by 50% of the participants [62]. However, comparison is limited because PwD were not included in this survey. Moreover, other factors such as presence of comorbidities or recent hospitalisation, which may have had an impact on the prevalence of PIP, were not investigated in this study. We acknowledge some limitations to the approaches used to identify study participants– diagnostic codes may have been inaccurate and some patients with advanced dementia may not have been receiving a dementia medication. Whilst these may have resulted in an underestimation of the prevalence of people with dementia, we believe that using both of these approaches to identify study participants helped to mitigate the limitations of using one of these approaches in isolation. The use of electronic health records, such as those used in this study, is limited by the quality and volume of data recorded. The exclusion of those who died during the study period may have contributed to a survivor bias which may have affected the prevalence of PIP; however, we were limited by the data available to us from patients’ electronic records. Finally, the results are based on PwD who visited ambulatory care clinics of a single tertiary hospital in Riyadh; therefore, the findings may not be generalisable to all PwD across Saudi Arabia or different healthcare settings. Future work is needed to corroborate our findings across a more representative sample in Saudi Arabia. Tools such as the STOPP criteria are useful for both alerting healthcare providers to the use of potentially inappropriate medications and monitoring effectiveness for intervention-based studies that aimed to reduce PIP [63]. However, the use of such indicators of prescribing appropriateness should not replace clinical judgment and taking a person-centred approach to patient care.

Conclusion

Our findings have revealed a high prevalence of PIP that is strongly associated with polypharmacy among PwD in the ambulatory care setting. The perspectives of key stakeholders in medicines management including health care providers, PwD, and their carers in Saudi Arabia need to be explored in future research.