jrnls.org logo
Submit

BROWSE ALL JOURNALS

SEE ALL 19 JOURNALS
Journal of Young PharmacistsNOW IN
Review

Drug Related Problems in Geriatric Critical Care: Challenges, Clinical Implications and Future

M K Soumya1, R. Margret Chandira2★, Sujith S Nair3★ Corresponding author

  1. 1Department of Pharmaceutics, Vinayaka Mission’s Research Foundation (VMCOP), Salem, Tamil Nadu, INDIA.
  2. 2Department of Pharmaceutics, VMCOP, Salem, Tamil Nadu, INDIA.
  3. 3Department of Pharmaceutics, Crescent College of Pharmaceutical Sciences, Kannur, Kerala, INDIA.

CORRESPONDENCE

R. Margret Chandira

M.Pharm., Ph.D, Professor and HOD, Department of Pharmaceutics Vinayaka Mission's College of Pharmacy, Yercaud Main Road, K. N. Patty, Salem-636008, Tamil Nadu, INDIA.

mchandira172@gmail.com

Received: 21-01-2026; Revised: 06-03-2026; Accepted: 15-05-2026.

Volume 18, Issue 2 · pp. 251–259 · PUBLISHED Apr-Jun 2026 · DOI: 10.5530/jyp.20260328

View on JYP original site ↗

ABSTRACT

Drug Related Problems (DRP) represent a significant and often under-recognised challenge in the care of elderly patients admitted to Intensive Care Units (ICU). Epidemiological data reveal a high prevalence of DRP among geriatric ICU patients, with trends dominated by polypharmacy, inappropriate medication use, drug-drug interactions, and adverse drug reactions. Patient-related factors such as multimorbidity, organ dysfunction, and the complexity of critical care regimens contribute to the development of DRP. Furthermore, high-risk drug classes-including sedatives, analgesics, antibiotics, anticoagulants, and cardiovascular agents-pose significant risks. Communication gaps, inadequate medication reconciliation, limited geriatric-focused therapy, and the rapid pace of ICU decision-making further complicate DRP management. DRP in elderly ICU patients are strongly associated with increased morbidity, prolonged hospitalisation, higher healthcare costs, and mortality. Evidence-based strategies, including medication review, clinical decision support systems, deprescribing, therapeutic drug monitoring, and multidisciplinary care models, have demonstrated effectiveness in reducing DRP. Pharmacists can play a crucial role by assisting with medication reconciliation, identifying risks, optimising therapy, and supporting clinicians through real-time interventions. This review highlights the importance of standardised DRP monitoring tools, enhanced pharmacist involvement, and future research focused on predictive analytics and personalised pharmacotherapy in geriatric critical care settings. Based on this aim, we collected and evaluated nearly 70 articles from various databases (using specific keywords) that were included in this review.

KEYWORDS

0% READ

FULL TEXT

INTRODUCTION

Globally, over the past decade, there has been a significant demographic shift towards the older population (WHO, 2018). The population of individuals aged 60 and older is on track to hit the 2 billion mark by 2050. Beyond physical changes, ageing is most often associated with a gradual decrease in mental capacity, a growing risk of diseases, associated comorbidities, and ultimately death (WHO, 2022). The need for multiple medications to treat diseases in older adults is a point of concern, as older adults metabolise medications differently, and this may exacerbate Drug Related Problems (DRP) as well as drug related hospital admissions (Maher et al., 2014). DRP are particularly more common in general settings and often life-threatening in the Intensive Care Unit (ICU). Dose and drug selection problems, long-term usage of multiple medications (polypharmacy), Adverse Drug Event (ADE)/Adverse Drug Reaction (ADR), Drug-Drug Interactions (DDI) etc, are some common DRP in ICU settings (Cakir et al., 2024).

According to the Pharmaceutical Care Network Europe Association (PCNE), DRP is defined as “an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes.” (VanMil (n.d)) Certain conditions like DDI, inappropriate use, poor monitoring, adverse effects, and variability of pharmacology knowledge across healthcare professionals could be related to DRP. However, there is controversy on the impact of these variables over others, such as gender, age, and social factors, on the risk of developing DRP (Freyer et al., 2018; Ferrández et al., 2018). Altered pharmacokinetics and pharmacodynamics, polypharmacy, poor adherence, hospital readmissions, and cognitive decline are the most notable variables for the geriatric population to be at higher risk for DRP. Although a significant number of DRP are avoidable (Bekele et al., 2021), their occurrence is linked to increased rates of illness, death, and medical costs, ultimately diminishing a patient's overall quality of life (Ahmad et al., 2014), In the last decade, several strategies have failed in attempts to improve elderly patient well-being and reduce healthcare costs, accounting for 15%-30% of all drug related hospital admissions. A more comprehensive approach is thus needed to clear the issues that increase the risk of ADE, DDI, etc, contributing to DRP (Greiver et al., 2019). This review on DRP in critically ill older patients is a present need.

Objectives Of The Review

This narrative review aims to summarise the extent of Drug-Related Problems (DRPs) in elderly patients admitted to critical care units, with a focus on causes, challenges and clinical implications.

METHODOLOGY

Literature search strategy

To identify relevant research on DRP among elderly patients in intensive care settings, a narrative literature review was conducted. Predefined keywords such as "drug-related problems," "adverse drug reactions," "medication errors," "geriatric inpatients," "critical care," and "pharmacist interventions" were used to search electronic databases, including PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar. The literature search included articles published between 2004 to 2025. DRP in hospitalised geriatric populations (aged ≥65 years) were selected; special consideration was given to ICU settings. Original research articles, observational studies, interventional studies, and relevant review articles were all taken. Approximately 70 eligible articles were collected and reviewed. Data extraction was done, and results were narratively described to explain patterns and trends in DRPs, their clinical consequences, and the effects of pharmacist-led treatments.

Epidemiological Findings

Australia reports the highest rate at 22.94%, followed by the USA (18.76%) and Europe (12.34%). Although Asian countries show a slightly lower overall incidence of 12.15%, the problem remains substantial (Hadia et al., 2022). Older adults aged 65 years and above are at risk for DDI due to polypharmacy. When these interactions become clinically significant, they may lead to adverse drug reactions, longer hospital stays, and an increased chance of death (Prakash et al., 2025). Among community-dwelling older adults, potential prescribing omissions are common, affecting nearly 58.6% of participants (Hanna et al., 2022). Trends also show that potential Drug Duplication (DD) has risen over the years, from 5.2% to 10.6% among those aged 65-79 and from 7.0% to 11.7% in individuals aged 80 and above. The medications most often involved in duplication were β-blockers, Angiotensin Converting Enzyme inhibitors, and calcium channel blockers in 2006. By 2021, vitamin B12, folic acid, β-blockers, and angiotensin II receptor blockers had become more common (Hanna et al., 2022; Erhan et al., 2024). Together, these findings point to the need for change in prescribing practices, particularly in vulnerable geriatric groups. Ageing also brings a gradual decline in homeostatic reserve, which varies widely from one person to the next and is further complicated by age-related changes in pharmacokinetics (Ngcobo, 2025).

CAUSES AND RISK FACTORS

Patient related Factors Role in Drug related Problems

Altered pharmacokinetic profiles due to impaired renal and hepatic clearance represent the most significant modifiable risk factors for DRP in older adults. Research also shows that prescribing drugs (renally cleared) at doses meant for younger adults is a direct cause for DRP, as the clearance of "flow-limited" drugs (those with high first-pass metabolism) is expected to decrease by 40-60% in the elderly compared to young individuals (Cohen et al., 2024). Estimating Creatinine Clearance (CrCl) alone is crucial, as in the elderly, reduced muscle mass leads to false interpretations. One study found that in elderly subjects (mean age 70), the drug's Area Under the Curve (AUC), a measure of total drug exposure, was approximately twice as high as in young subjects, and the half-life was longer due to reduced clearance (Garinc et al., 2021). This demonstrates a clear need for dose adjustments in older patients, as CrCl below 50 mL/min has a higher risk of DRP (Khananthai et al., 2024). Toxicity risk increases in drugs with high hepatic extraction ratios, decreased liver blood flow and decreased enzyme activity (Kamimura et al., 2019). Research supports the need for advanced clinical intervention by clinical pharmacists and implementing criteria (such as Beers or STOPP/START) helps to manage the DRP (Zhu et al., 2023).

Other Patient related Factors

Body Mass Index

Body Mass Index (BMI) alters pharmacokinetics, influencing drug accumulation (prolonged elimination half-life), and increasing the risk of toxicity. The inadequacy of BMI as a clinical indicator stems from its failure to account for muscle mass depletion, which is a primary driver of altered ADME (Absorption, Distribution, Metabolism and Excretion) parameters and subsequent drug-related problems in the geriatric population (Barras and Legg, 2017).

Gender

Gender-based variations in gastric emptying, total body water, and muscle mass, along WITH differences in sex hormones and Glomerular Filtration Rate (GFR), significantly alter the pharmacokinetic profiles of elderly patients. Women experience ADR (due to biological and physiological differences) nearly twice as much as men and are more likely to be hospitalised as a result (Zucker and Prendergast, 2020).

Drug related Factors Role in Drug related Problems

The most common DRP associated with Narrow Therapeutic Index (NTI) drugs are non-optimal dose and DDI, pointing to the need for Therapeutic Drug Monitoring (TDM) (Dasgupta, 2024). A study found that NTI drugs were significantly more often associated with DRP (40% of the times they were used) than non-NTI drugs (19%) (Blix et al., 2010). Current studies highlight the heightened risk of DDIs and pharmacological complexity in older adults, emphasising their status as a high-risk population (Varghese et al., 2024). Current research studies are focusing on the effectiveness of incorporating Clinical Decision Support Systems into electronic health records to provide real-time alerts on NTI-DDI, inappropriate dosing, and Potentially Inappropriate Medication (PIM) use in the elderly (Ng et al., 2025). Studies show NTI drugs have a significantly higher risk ratio for DRP compared to non-NTI drugs (Shaik Khadeer Ahamed, 2025). Multiple studies highlight the role of pharmacists’ intervention in the need for a personalised medicine approach and advanced clinical intervention, thus managing medications in the complex geriatric population and thereby improving the safety of the dosing of NTI drugs (Lee et al., 2023).

Other Drug related Factors

The number of potential DDI increases with polypharmacy; this, in turn, alters NTI pharmacokinetics (if prescribed). Inaccurate dosing of NTI drugs often leads to either treatment failure or toxic accumulation in the elderly population. In critically ill older patients, decreased renal and hepatic function is compounded by slow drug clearance, leading to accumulation and increasing the risk of toxicity (Varghese et al., 2024). The probability of ADE increases with polypharmacy. ADE in the critically ill older patients often present with symptoms (geriatric syndrome) like confusion, falls, functional decline, or malnutrition, which can be misinterpreted as the ageing process or a new medical condition, leading to a new drug addition (prescribing cascade), further complicating management and increasing DRP (Oakley and Krishnamurthy, 2023). Table 1 outlines high-risk drug classes that account for the majority of clinically significant DRP in elderly ICU patients, emphasising the need for close therapeutic monitoring.

Table 1: High-risk drug classes that account for major drug-related problems in the elderly.
Drug ClassSpecific DrugsDRP in the ElderlyStudy Findings
AnalgesicsNSAIDs*Increases the risk of peptic ulcer disease, acute renal failure, stroke/myocardial infarction Exacerbate diseases, including heart failure and hypertension Can interact with several drugs (e.g.: warfarin, corticosteroids)Drug of choice: Acetaminophen Nonacetylated salicylate (e.g., salsalate) Short half-life NSAID (e.g., ibuprofen) Low-dose opioid/opioid-like agents in combination with acetaminophen (Marcum and Hanlon, 2010; Holt et al., 2010).
Opioid AnalgesicsElevated risk of delirium and fallsParacetamol Other opioids (with a lower risk of delirium, e.g., tilidine/naloxone, morphine, oxycodone, buprenorphine, hydromorphone) weak NSAID (e.g., ibuprofen).
SedativesBenzodiazepinesRisk of falling (muscle-relaxing effect) with risk of hip fracture Prolonged reaction times Psychiatric reactions (can also be paradoxical, e.g., agitation, irritability, hallucinations, psychosis) Cognitive impairment Depressionshort/shorter-acting benzodiazepines zolpidem, zopiclone, zaleplone (at a low dose) opipramol sedating antidepressants (e.g., mirtazapine) neuroleptic drugs of low potency (e.g., melperone, pipamperone) (Marcum and Hanlon, 2010; Holt et al., 2010).
AnticoagulantsWarfarinMajor Bleeding Intracranial HemorrhageSymptomatic treatment Dose Adjustment Vitamin K (in case of toxicity) DOAC** Dabigatran Apixaban (Ahmed et al., 2007; Bonanad et al., 2021; Deaton and Nape, 2023).
HeparinBleeding HIT*** Osteoporosis Heparin-Induced HyperkalemiaSymptomatic treatment Dose Adjustment Protamine Sulfate (in case of toxicity) Direct Thrombin Inhibitors Argatroban Bivalirudin Fondaparinux Danaparoid DOAC (Ahmed et al., 2007; Bonanad et al., 2021; Deaton and Nape, 2023).
AntibioticsAminoglycosidesNephrotoxicity OtotoxicitySymptomatic treatment Dose Adjustment Less Nephrotoxic Aminoglycoside Tobramycin Netilmicin Select Less Nephrotoxic Antibiotics (Crass et al., 2019; Martel et al., 2025).
VancomycinNephrotoxicity Vancomycin Infusion Reaction (Red Man Syndrome)Symptomatic treatment Dose Adjustment Select Less Nephrotoxic Antibiotics Antihistamines Diphenhydramin Cimetidine (Crass et al., 2019; Martel et al., 2025).
Cardiovascular DrugsBetablockersHypotension Bradycardia Bronchospasm Fatigue HypoglycemiaSymptomatic treatment Dose Adjustment Select another category Antihypertensive Cardio-Selective Beta-Blocker Bisoprolol Metoprolol Hydrophilic Beta-Blocker Atenolol Esmolol (Hanes and Weir, 2001; Sica, 2004).
ACE**** InhibitorsHypotension Acute Kidney Injury Hyperkalemia Dry CoughSymptomatic treatment Fluid Management Dose Adjustment Potassium Binders/ Potassium Restriction Select another category Antihypertensive (Hanes and Weir, 2001; Sica, 2004).

Role of Disease related Factors in Drug related Problems

Organ reserve declines as age progresses and as exhaustion of this reserve, multi organ failure (MOF) is severe in the elderly, especially in those with pre-existing conditions developed from liver and kidney damage (Springer and Nape, 2023). Studies highlight that ADR (often associated with anticonvulsants and sulfonamides) can lead to MOF (which increases the risk of mortality if not treated properly) (Springer and Nape, 2023). Studies using scores like Sequential Organ Failure Assessment (SOFA) or Acute Physiology Age and Chronic Health Evaluation II (APACHE II) emphasise the importance of tapering dosage regimens, careful monitoring for signs of organ dysfunction and implementing strategies for avoiding nephrotoxins (provided with assistance on nutrition) to prevent or mitigate the progression to MOF (Khedkar, 2024; Silva et al., 2024). Research has found a high incidence of serious ADR in the ICU, which were related to the renal/electrolyte system (21%), resulting in acute renal failure and hepatic injuries (Joshua et al., 2009). Current studies are linking algorithms to predict the likelihood of developing MOF based on patient data (Madhan Kumar et al., 2023; Xu et al., 2021). The importance of deprescribing inappropriate medications is a strategy to reduce DRP and the associated risk of MOF. The effectiveness of pharmacist interventions in identifying and resolving DRP in geriatric inpatients and thereby improving patient outcomes, is also an unavoidable matter (Yaacob et al., 2024).

Other Disease related Factors

Chronic diseases and their associated complications, ranging from cardiovascular issues to psychiatric disorders, necessitate complex drug regimens that significantly increase the risk of DRP, particularly when complicated by hypersensitivity or drug allergies (Reddy Peddi et al., 2023). Integrating system-level preventive strategies with clinical pharmacology, geriatrics and critical care practices helps to manage risk factors.

CHALLENGES IN MANAGING DRUG RELATED PROBLEMS

Adverse Drug Reaction in Drug related Problems

ADR are defined as any noxious, undesired, or unintended response to a therapeutic agent, which may be expected or unexpected and may occur at dosages used for the prophylaxis, diagnosis, or therapy of disease, or for modifying physiological function (World Health Organisation (WHO, 1972)). ADE is an event when a patient is unintentionally harmed because of drug use, including preventable and non-preventable events. The link between an observed ADR and a suspected drug is always misinterpreted as symptoms or signs of a pathological state, rather than drug effects, leading to the addition of another drug (potentially avoidable), defined as a prescribing cascade (Krishnaswami et al., 2019). Example: A patient developed a cough after starting an ACE inhibitor. A cough syrup with guaifenesin and codeine was prescribed, leading to lethargy (Liu et al., 2009). Approximately 2.9%-8.7% of hospital admissions are associated with ADR (Kongkaew et al., 2008). Prescribing cascade may be investigated through Prescription Sequence Symmetry Analysis (PSSA) methodology (a statistical method to determine if a marker drug prescribed shortly after an index drug caused an ADR). Many studies use a combination of both PSSA and expert review to confirm and validate them in specific patient cases (Mohammad et al., 2024). The prevalence of ADR among critically ill older inpatients has specifically enhanced hospital readmissions (prevalence of 9% of drug related readmissions in older adults) and a higher risk of developing future DRP (Prasad et al., 2024).

Limited Geriatric Dosing Guidance for Intensive Care Unit Drugs

Research highlights that limitedgeriatric dosing guidance leads to DRP (PIM, ADE and errors) (Rothschild et al., 2005). Historically, older adults have been removed from clinical trials. These result in a lack of high-quality evidence on the efficacy and safety of many medications, particularly those used in the complex ICU environment, leading to under-/over dosing of drugs and PIM. There remains a critical need for extensive research targeting the pharmacokinetic complexities of older adults in intensive care to fill the current void in evidence-based dosing standards (Ding and Wang, 2021). Integrating clinical pharmacists and implementing standard guidelines and criteria (e.g., Beers, Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment STOPP/START) into the ICU team can help minimise all drug related issues and prescribing decisions (Keche et al., 2022).

Other Less-Known Facts

The high-pressure environment of critical care often fosters expedited clinical decision-making, insufficient patient education, and suboptimal transitions of care. Such systemic challenges, along with clerical errors in prescribing, significantly elevate the incidence of medication errors (Kivilienė et al., 2024).

CLINICAL IMPLICATIONS

Drug related problems contribute to prolonged intensive care unit/hospital stays and higher mortality rates

Patients with DRP had a longer hospital stay. The total number of patient days was 4,868 (79.7 DRP per 1000 patient days) (p<0.001) (Çakır et al., 2024). The mean number of drugs was significantly higher in the group with DRP than in the group without DRP (p<0.05) (Pehlivanli et al., 2023). Also, the rate of mortality (due to DRP) was higher in general hospital stays (p<0.05) (Albayrak et al., 2022).

Patients with medical errors and adverse events had significantly longer hospital stays (by an average of 8.9 days) and ICU stays (by an average of 6.8 days) (Cantor et al., 2022). The average length of stay for patients with DDI was 15 days and 8 days for patients not exposed to DDI (Moura et al., 2009) The mortality in adult ICU patients with DDI was 66.7% (Kyomya et al., 2023).

Potential for Secondary Complications: Delirium, Renal Injury, Infection Risk

The DRP role in causing or exacerbating secondary complications such as delirium, Acute Kidney Injury (AKI), and infections is notable. These complications are from inappropriate drugs of choice, dosing errors and poor monitoring. 79.3% of participants with kidney dysfunction (both acute kidney injury and chronic kidney disease) had at least one DRP (Garcia et al., 2024). Drug-induced acute kidney injury (DI-AKI) was a significant cause of AKI, accounting for 19.3% of cases (Pang et al., 2022). AKI significantly increased the risk of delirium, which enhanced the stay in hospital and mortality (Kyriakopoulos and Gupta, 2024). Failure to adjust drug dosages in impaired kidney function can lead to drug accumulation, leading to toxicity and subsequent delirium (Piccirillo et al., 2023).

Impact on post-Intensive Care Unit recovery and readmissions

DRPs contribute to readmissions and poor recovery outcomes, which are very common in patients discharged from critical care settings, causing unnecessary healthcare costs. 9% of older adults discharged from the hospital experienced a drug related readmission, with up to 22% of these being preventable (Prasad et al., 2024). DRP are common in post-ICU patients and significantly contribute to poor recovery outcomes and hospital readmission (Weber et al., 2025). The specific roles of ICU clinical pharmacists are detailed in Figure 1, and the corresponding pharmacist-led initiatives designed for DRP prevention are presented in Figure 2.

Figure 1: Role of clinical pharmacist in Intensive Care Unit (ICU) (Yin et al., 2023).
Figure 2: Programs to be implemented and developed by clinical pharmacist (Yin et al., 2023).

Barriers in the Pharmacist Role

Insufficient support from hospital management to implement clinical pharmacy services and a lack of specific financial compensation or reimbursement models for clinical services are strong barriers to the implementation and expansion of multifaceted clinical pharmacy programs. In the absence of formalised guidelines and standardised job descriptions at the institutional level, the clinical pharmacist’s role remains underutilised and frequently misunderstood as purely distributive. However, pharmacist integration is not ancillary but fundamental to ensuring patient safety and achieving optimal pharmacotherapeutic outcomes in high-acuity settings.

CONCLUSION AND FUTURE DIRECTIONS

Drug-related problems and their Multidimensional Impact

DRP remains highly prevalent, especially in critical care settings, due to the complexity of patients' conditions and polypharmacy (Cakir et al., 2024). DRP contributes to prolonged stays in general hospital settings and in the ICU, thus imposing an unnecessary burden of additional healthcare costs (Cantor et al., 2022). ADE and DDI are commonly associated with longer hospital stays. Key predictors in ADE and DDI are polypharmacy, the number of co-morbidities, and age related changes. DRP role in causing or exacerbating secondary complications (delirium, renal injury (AKI), and infections) or new health problems (misinterpreted as new diseases and treated) is notable (Garcia et al., 2024; Pang et al., 2022; Kyriakopoulos and Gupta, 2024). Readmissions and poor recovery outcomes are very common in patients discharged from critical care settings. A higher number of DRP is associated with a negative impact on patients' Health related Quality of Life (HRQoL), leading to significant drug related morbidity and mortality each year. Unresolved DRP results in unnecessary healthcare expenses and loss of productivity, too (Cantor et al., 2022).

Multidisciplinary and Preventive Focus

Preventive measures on DRP should focus on integrating professional expertise from various fields to provide patient-centred care. Teamwork (including physician, clinical pharmacist, and nurse), together with the use of electronic tools and standard guidelines and criteria, helps to develop effective patient care and treatment plans (Yin et al., 2023).

Emerging Tools

Use of VigiLanz (clinical surveillance and patient safety solution) and VigiFlow (pharmacovigilance database system) ensures patient safety. Artificial Intelligence-Powered Apps integrated into mobile phones and smart devices help to send alarms to confirm medication ingestion and provide personalised reminders and educational content, which has been shown to improve adherence. AI models are to be trained on multiple datasets to improve Machine Learning (ML). The integration of AI with Pharmacogenomics Clinical Annotation Tool (PharmCAT), Electronic Pharmacogenomics Assistant (ePGA) etc., tools enables the selection and dosing of drugs tailored to a patient's specific genetic profile, improving efficacy and minimising adverse effects (Srivastav et al., 2025). Integrating pharmacist-led safety strategies with advanced decision-support systems holds promise for minimising DRP and improving clinical outcomes among critically ill older adults.

DECLARATIONS

The figures and tables are original illustrations developed independently by the authors using data from the cited references. They are not reproduced or adapted from previously published sources and therefore do not contain any copyrighted material.

REFERENCES

As published

Showing references and in-text citations exactly as published.

  1. 1.Ahmad, A.; Mast, M. R.; Nijpels, G.; Elders, P.; Dekker, J.; Hugtenburg, J.. Identification of drug related problems of elderly patients discharged from hospital. Patient Preference and Adherence. 2014;8:155–165. https://doi.org/10.2147/PPA.S48357DOIGOOGLE SCHOLAR
  2. 2.Ahmed, I.; Majeed, A.; Powell, R.. Heparin induced thrombocytopenia: diagnosis and management update. Postgraduate Medical Journal. 2007;83(983):575–582. https://doi.org/10.1136/pgmj.2007.059188DOIGOOGLE SCHOLAR
  3. 3.Albayrak, A.; Başgut, B.; Bıkmaz, G. A.; Eyupoglu, S.; Erturk, S.; Ozcelikay, A. T.. Clinical pharmacist assessment of drug related problems among intensive care unit patients in a Turkish university hospital. BMC Health Services Research. 2022;22:79. https://doi.org/10.1186/s12913-022-07494-5DOIGOOGLE SCHOLAR
  4. 4.Barras, M.; Legg, A.. Drug dosing in obese adults. Australian Prescriber. 2017;40(5):189–193. https://doi.org/10.18773/austprescr.2017.053DOIGOOGLE SCHOLAR
  5. 5.Bekele, F.; Tsegaye, T.; Negash, E.; Fekadu, G.. Magnitude and determinants of drug related problems among patients admitted to medical wards of Southwestern Ethiopian hospitals: a multicenter prospective observational study. PLoS ONE. 2021;16(3):e0248575. https://doi.org/10.1371/journal.pone.0248575DOIGOOGLE SCHOLAR
  6. 6.Bonanad, C.; García-Blas, S.; Torres Llergo, J.; Fernández-Olmo, R.; Díez-Villanueva, P.; Ariza-Solé, A. et al. Direct oral anticoagulants versus warfarin in octogenarians with nonvalvular atrial fibrillation: a systematic review and meta-analysis. Journal of Clinical Medicine. 2021;10(22):5268. https://doi.org/10.3390/jcm10225268DOIGOOGLE SCHOLAR
  7. 7.Çakır, A.; Memiş, H.; Gün, Z. Ü.; Bıçakcıoğlu, M.. Evaluation of drug related problems of intensive care unit patients by clinical pharmacists: a retrospective study. Turkish Journal of Pharmaceutical Sciences. 2024;21(4):274–283. https://doi.org/10.4274/tjps.galenos.2023.44459DOIGOOGLE SCHOLAR
  8. 8.Cantor, N.; Durr, K. M.; McNeill, K.; Thompson, L. H.; Fernando, S. M.; Tanuseputro, P. et al. Increased mortality and costs associated with adverse events in intensive care unit patients. Journal of Intensive Care Medicine. 2022;37(8):1075–1081. https://doi.org/10.1177/08850666221084908DOIGOOGLE SCHOLAR
  9. 9.Cohen, E. B.; Li, X.; Chen, M.; Lucena, M. I.; Kullak-Ublick, G. A.; Caplan, D. et al. Drug-induced liver injury in the elderly: consensus statements and recommendations from the IQ-DILI Initiative. Drug Safety. 2024;47(4):301–319. https://doi.org/10.1007/s40264-023-01390-5DOIGOOGLE SCHOLAR
  10. 10.Crass, R. L.; Cojutti, P. G.; Pai, M. P.; Pea, F.. Reappraisal of linezolid dosing in renal impairment to improve safety. Antimicrobial Agents and Chemotherapy. 2019;63(8):e00605–19. https://doi.org/10.1128/AAC.00605-19DOIGOOGLE SCHOLAR
  11. 11.Dasgupta, A.. Introduction to therapeutic drug monitoring: frequently and less frequently monitored drugs. In Therapeutic Drug Monitoring. 2nd ed. Academic Press. 2024;1–35. https://doi.org/10.1016/B978-0-443-18649-3.00005-7DOIGOOGLE SCHOLAR
  12. 12.Deaton, J. G.; Nappe, T. M.. Warfarin toxicity. In StatPearls. StatPearls Publishing. 2023.GOOGLE SCHOLAR
  13. 13.Ding, X.; Lian, H.; Wang, X.. Management of very old patients in intensive care units. Aging and Disease. 2021;12(2):614–624. https://doi.org/10.14336/AD.2020.0914DOIGOOGLE SCHOLAR
  14. 14.Erhan, T.; Wastesson, J. W.; Fastbom, J.. Trends in drug duplications in Swedish older adults: a nationwide register study from 2006 to 2021. Drugs and Aging. 2024;41(9):775–781. https://doi.org/10.1007/s40266-024-01145-6DOIGOOGLE SCHOLAR
  15. 15.Ferrández, O.; Allemann, S. S.; Seitz, L.; van Mil, J. W. F.; Hersberger, K. E.; Arnet, I.. Validation of a score to identify inpatients at risk of a drug related problem during a 4-year period. Saudi Pharmaceutical Journal. 2018;26(5):703–708. https://doi.org/10.1016/j.jsps.2018.02.020DOIGOOGLE SCHOLAR
  16. 16.Freyer, J.; Proske, O.; Thürmann, P. A.; Jaehde, U.. Drug related problems in geriatric rehabilitation patients after discharge-a prevalence analysis and clinical case scenario-based pilot study. Research in Social and Administrative Pharmacy. 2018;14(7):628–637. https://doi.org/10.1016/j.sapharm.2017.07.009DOIGOOGLE SCHOLAR
  17. 17.Garcia, G.; Pacchini, V. R.; Zamoner, W.; Balbi, A. L.; Ponce, D.. Drug-induced acute kidney injury: a cohort study on incidence, identification of pathophysiological mechanisms, and prognostic factors. Frontiers in Medicine. 2024;11:1459170. https://doi.org/10.3389/fmed.2024.1459170DOIGOOGLE SCHOLAR
  18. 18.Garin, N.; Phillips, C.; Basile, I.; Uribe, O.; Espinoza, M. A.; Meltzer, N.. Drug related problems in clinical practice: a cross-sectional study on their prevalence, risk factors and associated pharmaceutical interventions. Scientific Reports. 2021;11(1):883. https://doi.org/10.1101/2022.09.12.22279865DOIGOOGLE SCHOLAR
  19. 19.Greiver, M.; Dahrouge, S.; O'Brien, P.; Lofters, A.; Bartlett, G.; Glazier, R. et al. Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada. Implementation Science. 2019;14:55. https://doi.org/10.1186/s13012-019-0904-4DOIGOOGLE SCHOLAR
  20. 20.Hadia, R.; Rajesh, J.; Joshi, D.; Bhil, D.; Dipika, M.; Maheshwari, R.. Incidence of adverse drug reactions among elderly patients: a systematic review and meta-analysis. Journal of Scientific Society. 2022;49(2):91–102. https://doi.org/10.4103/jss.jss_50_22DOIGOOGLE SCHOLAR
  21. 21.Hanna, V.; Chahine, B.; Al Souheil, F.. Under-prescription of medications in older adults according to START criteria: a cross-sectional study in Lebanon. Health Science Reports. 2022;5(5):e759. https://doi.org/10.1002/hsr2.759DOIGOOGLE SCHOLAR
  22. 22.Holt, S.; Schmiedl, S.; Thürmann, P. A.. Potentially inappropriate medications in the elderly: the PRISCUS list. Deutsches Ärzteblatt International. 2010;107(31-32):543–551. https://doi.org/10.3238/arztebl.2010.0543DOIGOOGLE SCHOLAR
  23. 23.Joshua, L.; Devi, P.; Guido, S.. Adverse drug reactions in medical intensive care unit of a tertiary care hospital. Pharmacoepidemiology and Drug Safety. 2009;18(7):639–645. https://doi.org/10.1002/pds.1761DOIGOOGLE SCHOLAR
  24. 24.Kamimura, K.; Ikeda, K.; Kawai, H.. Considerations of elderly factors to manage the complication of liver cirrhosis in elderly patients. World Journal of Gastroenterology. 2019;25(15):1817–1827. https://doi.org/10.3748/wjg.v25.i15.1817DOIGOOGLE SCHOLAR
  25. 25.Keche, Y. N.; Gaikwad, N. R.; Wasnik, P. N.; Siddiqui, S.; Nagpure, K.; Dhaneria, S.. Usefulness of STOPP/START criteria and Beers criteria for prescribing in geriatric patients in a tertiary health care center, Raipur, Central India. Journal of Family Medicine and Primary Care. 2022;11(11):7064–7071. https://doi.org/10.4103/jfmpc.jfmpc_733_22DOIGOOGLE SCHOLAR
  26. 26.Khananthai, S.; Wananukul, S.; Jarernsiriporn, N.; Sookaneknun, P.. Evaluation of drug related problems in the chronic kidney disease clinic at the university hospital in Thailand. Pharmacy Practice. 2024;22(2):2949.GOOGLE SCHOLAR
  27. 27.Khedkar, C.. Reliability of APACHE II and SOFA scoring system in assessing the outcomes in ICU patients with sepsis and MODS- a cross-sectional study. International Journal of Pharmaceutical and Clinical Research. 2024;16(8):1610–1613.GOOGLE SCHOLAR
  28. 28.Kivilienė, J.; Paukštaitienė, R.; Stievano, A.; Blaževičienė, A.. The relationship between clinical environment and adverse events reporting: evidence from Lithuania. Healthcare. 2024;12(2):252. https://doi.org/10.3390/healthcare12020252DOIGOOGLE SCHOLAR
  29. 29.Kongkaew, C.; Noyce, P. R.; Ashcroft, D. M.. Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies. Annals of Pharmacotherapy. 2008;42(7):1017–1025. https://doi.org/10.1345/aph.1L037DOIGOOGLE SCHOLAR
  30. 30.Krishnaswami, A.; Steinman, M. A.; Goyal, P.; Ziaeian, B.; Albert, M. A.; Cagirgi, G. et al. Deprescribing in older adults with cardiovascular disease. Journal of the American College of Cardiology. 2019;73(20):2584–2595. https://doi.org/10.1016/j.jacc.2019.03.467DOIGOOGLE SCHOLAR
  31. 31.Kyomya, J.; Atwiine, F.; Shegena, E. A.; Kibalama, S.. Drug related problems and associated factors among patients with kidney dysfunction at a tertiary hospital in southwestern Uganda: a prospective observational study. BMC Nephrology. 2023;24:375. https://doi.org/10.1186/s12882-023-03437-2DOIGOOGLE SCHOLAR
  32. 32.Kyriakopoulos, C.; Gupta, V.. Renal failure drug dose adjustments. In StatPearls. StatPearls Publishing. 2024.GOOGLE SCHOLAR
  33. 33.Lee, J. K.; Alshehri, S.; Kutbi, H. I.; Martin, J. R.. Optimizing pharmacotherapy in elderly patients: the role of pharmacists. Integrated Pharmacy Research and Practice. 2015;4:101–111. https://doi.org/10.2147/IPRP.S70404DOIGOOGLE SCHOLAR
  34. 34.Lee, S.; Yu, Y. M.; Han, E.; Park, M. S.; Lee, J. H.; Chang, M. J.. Effect of pharmacist-led intervention in elderly patients through a comprehensive medication reconciliation: a randomized clinical trial. Yonsei Medical Journal. 2023;64(5):336–343. https://doi.org/10.3349/ymj.2022.0620DOIGOOGLE SCHOLAR
  35. 35.Lindholm, T.; Lias, N.; Kvarnström, K.; Holmström, A. R.; Toivo, T.; Uusitalo, M. et al. Identifying medication review topics to be documented in a structured form in electronic health record systems: Delphi consensus survey. Journal of Medical Internet Research. 2025;27:e70133. https://doi.org/10.2196/70133DOIGOOGLE SCHOLAR
  36. 36.Liu, P. T.; Argento, V. S.; Skudlarska, B. A.. Prescribing cascade in an 80-year-old Japanese immigrant. Geriatrics and Gerontology International. 2009;9(4):402–404. https://doi.org/10.1111/j.1447-0594.2009.00554.xDOIGOOGLE SCHOLAR
  37. 37.Madhan Kumar, G. S.; Impanashree, V. P.; Nisha, M.; Pavan; Poorvika, K.. Multi-organ failure prediction using machine learning approach. International Journal of Scientific Research in Science and Technology. 2023;10(3):19–24. https://doi.org/10.32628/IJSRST5231032DOIGOOGLE SCHOLAR
  38. 38.Maher, R. L.; Hanlon, J.; Hajjar, E. R.. Clinical consequences of polypharmacy in elderly. Expert Opinion on Drug Safety. 2014;13:57–65.GOOGLE SCHOLAR
  39. 39.Marcum, Z. A.; Hanlon, J. T.. Recognizing the risks of chronic non-steroidal anti-inflammatory drug use in older adults. Annals of Long Term Care. 2010;18(9):24–27.GOOGLE SCHOLAR
  40. 40.Martel, T. J.; Jamil, R. T.; Afzal, M.. Vancomycin infusion reaction. In StatPearls. StatPearls Publishing. 2025.GOOGLE SCHOLAR
  41. 41.Mohammad, A. K.; Hugtenburg, J. G.; Vanhommerig, J. W.; van den Bemt, P. M. L. A.; Denig, P.; Karapinar-Carkıt, F.. Identifying and quantifying potentially problematic prescribing cascades in clinical practice: a mixed-methods study. Journal of the American Geriatrics Society. 2024;72(12):3681–3694. https://doi.org/10.1111/jgs.19191DOIGOOGLE SCHOLAR
  42. 42.Ng, Y.; Hsu, J. T. Y.; Ng, N. N. E.; Ong, J. Z. E.; Hsu, J. L. J.; Sulaimi, F. et al. Evaluating the role of clinical decision support systems in medication safety for older people: a systematic review. Age and Ageing. 2025;54(7):afaf206. https://doi.org/10.1093/ageing/afaf206DOIGOOGLE SCHOLAR
  43. 43.Ngcobo, N. N.. Influence of ageing on the pharmacodynamics and pharmacokinetics of chronically administered medicines in geriatric patients: a review. Clinical Pharmacokinetics. 2025;64(3):335–367. https://doi.org/10.1007/s40262-024-01466-0DOIGOOGLE SCHOLAR
  44. 44.Pang, H.; Kumar, S.; Ely, E. W.; Gezalian, M. M.; Lahiri, S.. Acute kidney injury-associated delirium: a review of clinical and pathophysiological mechanisms. Critical Care. 2022;26(1):258. https://doi.org/10.1186/s13054-022-04131-9DOIGOOGLE SCHOLAR
  45. 45.Park, S.; Kim, A. J.; Ah, Y.-M.; Lee, M. Y.; Lee, Y. J.; Chae, J. et al. Prevalence and predictors of medication related emergency department visit in older adults: a multicenter study linking national claim database and hospital medical records. Frontiers in Pharmacology. 2022;13:1009485. https://doi.org/10.3389/fphar.2022.1009485DOIGOOGLE SCHOLAR
  46. 46.Pehlivanli, A.; Eyupoglu, S.; Basgut, B.; Erturk, S.; Ozcelikay, A. T.. Impact of a multidisciplinary approach involving clinical pharmacist on resolving drug related problems in chronic kidney patients: a prospective interventional study. BMC Nephrology. 2023;24(1):149. https://doi.org/10.1186/s12882-023-03210-5DOIGOOGLE SCHOLAR
  47. 47.Piccirillo, A.; Perri, F.; Vittori, A.; Ionna, F.; Sabbatino, F.; Ottaiano, A. et al. Evaluating nutritional risk factors for delirium in intensive-care-unit patients: present insights and prospects for future research. Clinics and Practice. 2023;13(6):1577–1592. https://doi.org/10.3390/clinpract13060138DOIGOOGLE SCHOLAR
  48. 48.Prakash, C.; Hameed, S.; Prasad, G.; Nazir, B.; Kumar, M.; Mohan, L.. Drug-drug interactions in elderly patients on polypharmacy: a hospital-based observational study. European Journal of Cardiovascular Medicine. 2025;15(10):65–70. https://doi.org/10.61336/ejcm/25-10-13DOIGOOGLE SCHOLAR
  49. 49.Prasad, N.; Lau, E. C. Y.; Wojt, I.; Penm, J.; Dai, Z.; Tan, E. C. K.. Prevalence of and risk factors for drug related readmissions in older adults: a systematic review and meta-analysis. Drugs and Aging. 2024;41(1):1–11. https://doi.org/10.1007/s40266-023-01076-8DOIGOOGLE SCHOLAR
  50. 50.Reddy Peddi, D.; Pallekonda, H.; Reddy, V.. Evaluation of the prevalence and risk factors of drug related problems in hypertension and type 2 diabetes mellitus patients at a tertiary care hospital: a cross-sectional study. Cureus. 2023;15(7):e42775. https://doi.org/10.7759/cureus.42775DOIGOOGLE SCHOLAR
  51. 51.Rothschild, J. M.; Landrigan, C. P.; Cronin, J. W.; Kaushal, R.; Lockley, S. W.; Burdick, E. et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine. 2005;33(8):1694–1700. https://doi.org/10.1097/01.ccm.0000171609.91035.bdDOIGOOGLE SCHOLAR
  52. 52.Shaik Khadeer, Ahamed.. Clinical insights into narrow therapeutic index drugs. International Journal of Current Science Research and Review. 2025;8(3). https://doi.org/10.47191/ijcsrr/V8-i3-13DOIGOOGLE SCHOLAR
  53. 53.Sica, D. A.. Angiotensin-converting enzyme inhibitors side effects-physiologic and non-physiologic considerations. Journal of Clinical Hypertension. 2004;6(7):410–416. https://doi.org/10.1111/j.1524-6175.2004.02866.xDOIGOOGLE SCHOLAR
  54. 54.Silva, M.; Wacker, D. A.; Driver, B. E.; Miner, J. R.; Smith, S. M.; Puskarich, M. A. et al. Senolytics To slOw Progression of Sepsis (STOP-Sepsis) in elderly patients: study protocol for a multicenter, randomized, adaptive allocation clinical trial. Trials. 2024;25:698. https://doi.org/10.1186/s13063-024-08474-2DOIGOOGLE SCHOLAR
  55. 55.Springer, C.; Nappe, T. M.. Anticonvulsants toxicity. In StatPearls. StatPearls Publishing. 2023.GOOGLE SCHOLAR
  56. 56.Srivastav, A. K.; Mishra, M. K.; Lillard, J. W.; Singh, R.. Transforming pharmacogenomics and CRISPR gene editing with the power of artificial intelligence for precision medicine. Pharmaceutics. 2025;17(5):555. https://doi.org/10.3390/pharmaceutics17050555DOIGOOGLE SCHOLAR
  57. 57.van Mil, J. W. F.; Horvat, N.; Westerlund, T.; Richling, I.. PCNE classification for drug related problems V9.1. PCNE. n.d..GOOGLE SCHOLAR
  58. 58.Varghese, D.; Ishida, C.; Patel, P.; Park, K. H.. Polypharmacy. In StatPearls. StatPearls Publishing. 2024.GOOGLE SCHOLAR
  59. 59.Weber, C.; Meyer-Massetti, C.; Schönenberger, N.. Pharmacist-led interventions at hospital discharge: a scoping review of studies demonstrating reduced readmission rates. International Journal of Clinical Pharmacy. 2025;47(1):15–30. https://doi.org/10.1007/s11096-024-01821-yDOIGOOGLE SCHOLAR
  60. 60.WHO Meeting on International Drug Monitoring: the Role of National Centres (1971: Geneva, Switzerland), and World Health Organization. International drug monitoring: the role of national centers, report of a WHO meeting held in Geneva from 20 to25September1971.WorldHealthOrganization. 1972.GOOGLE SCHOLAR
  61. 61.World Health Organization. Ageing and health. 2018.GOOGLE SCHOLAR
  62. 62.World Health Organization. Ageing and health. 2022.GOOGLE SCHOLAR
  63. 63.Xu, F.; Chen, X.; Li, C.; Liu, J.; Qiu, Q.; He, M. et al. Prediction of multiple organ failure complicated by moderately severe or severe acute pancreatitis based on machine learning: a multicenter cohort study. Mediators of Inflammation. 2021;5525118. https://doi.org/10.1155/2021/5525118DOIGOOGLE SCHOLAR
  64. 64.Yaacob, N. L. C.; Loganathan, M.; Hisham, N. A.; Kamaruzzaman, H.; Isa, K. A. M.; Ibrahim, M. I. M. et al. The impact of pharmacist medication reviews on geriatric patients: a scoping review. Korean Journal of Family Medicine. 2024;45(3):125–133. https://doi.org/10.4082/kjfm.23.0220DOIGOOGLE SCHOLAR
  65. 65.Yin, J.; Shi, H.; Li, C.. Effect of participation of typical clinical pharmacists in patient medication in ICUs with different approaches: an investigation and case analysis. Heliyon. 2023;9(3):e14345. https://doi.org/10.1016/j.heliyon.2023.e14345DOIGOOGLE SCHOLAR
  66. 66.Zhu, X.; Zhang, F.; Liu, R.; Zhang, J.; Guo, J.; Zhang, X. et al. Evaluation of potentially inappropriate medications for the elderly according to Beers, STOPP, START, and Chinese criteria. Frontiers in Pharmacology. 2023;14:1265463. https://doi.org/10.3389/fphar.2023.1265463DOIGOOGLE SCHOLAR
  67. 67.Zucker, I.; Prendergast, B. J.. Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of Sex Differences. 2020;11(1):32. https://doi.org/10.1186/s13293-020-00308-5DOIGOOGLE SCHOLAR

Cite this article

SELECT FORMAT

Soumya, M. K., Chandira, R. M., & Nair, S. S. (2026). Drug Related Problems in Geriatric Critical Care: Challenges, Clinical Implications and Future. Journal of Young Pharmacists, 18(2), 251–259. https://doi.org/10.5530/jyp.20260328