title: A meta-synthesis of potentially inappropriate prescribing in older patients.
abstract: BACKGROUND
  Potentially inappropriate prescribing (PIP) is commonly seen amongst the older population in all clinical settings, as indicated by several prevalence studies in several countries. Quantitative work such as this confirms that this is a global public health problem likely to grow in tandem with ageing of the global population. However, less attention has been focused on why it is happening and how it can be prevented.
  
  
  OBJECTIVE
  The objective of this paper is to synthesise qualitative studies that explore PIP in older patients, in an effort to understand why it happens from a prescriber's perspective and to generate a new theory to guide future interventional studies aimed at minimising it in older people. To date, there is no published systematic synthesis of this type.
  
  
  METHODS
  Papers were deemed suitable for inclusion if they used qualitative methods, explored some area of PIP in patients over 65 years of age, were published in English and had available published abstracts. Four databases were systematically searched for papers published up to the end of April 2013: PubMed, Embase, CINAHL and Web of Knowledge. No date restrictions were applied. Key words searched were: Qualitative AND (Inappropriate* OR Appropriate* OR Safe) AND (Elderly OR Aged OR Geriatric* OR Old*) AND Prescri*. Reference lists were then searched for other suitable papers. Critical Appraisal Skills Programme criteria were used to assess quality. Meta-ethnography was used to synthesise the papers.
  
  
  RESULTS
  Out of 624 papers identified, seven papers were deemed relevant. Four key concepts were identified as being causal factors in PIP: (1) the need to please the patient, (2) feeling of being forced to prescribe, (3) tension between prescribing experience and prescribing guidelines and (4) prescriber fear. These were re-interpreted in a line of argument synthesis indicating that some doctors have self-perceived restrictions with regard to prescribing appropriately because of a combination of factors, rather than any one dominant factor.
  
  
  CONCLUSIONS
  Prevention of PIP may be favourably influenced by addressing the key interactive determinants of inappropriate prescribing behaviour.
authors.affiliation: Pharmaceutical Care Research Group, School of Pharmacy, Cavanagh Pharmacy Building, University College Cork, College Road, Cork, Ireland, shanecull@hotmail.com.
authors.forename: Shane
authors.initials: S
authors.lastname: Cullinan
authors.forename: Denis
authors.initials: D
authors.lastname: O'Mahony
authors.forename: Aoife
authors.initials: A
authors.lastname: Fleming
authors.forename: Stephen
authors.initials: S
authors.lastname: Byrne
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006299:Health Services for the Aged; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D008297:Male; D010819:Physician's Role