Patterns and appropriateness of antipsychotic prescribing in community-dwelling older adults: a retrospective study

Background Antipsychotics carry substantial risk in older adults, yet their use among community-dwelling outpatients remains insufficiently characterized in Saudi Arabia, where most prior work examined potentially inappropriate medications broadly or within psychiatric services. This study assessed patterns and appropriateness of antipsychotic prescribing and examined factors associated with prescribing without a documented qualifying indication among community-dwelling older adults across outpatient specialties. Methods We conducted a retrospective cross-sectional study of patients aged 65 or older with a qualifying outpatient antipsychotic dispensing at King Fahad Hospital of the University, Saudi Arabia, from January 2019 to May 2023. The index date was the first qualifying antipsychotic dispensing. A criteria-based algorithm classified each patient’s prescribing appropriateness using FDA-approved indications, American Psychiatric Association guidelines, and the 2023 AGS Beers Criteria. Multivariable logistic regression identified factors associated with prescribing without a documented qualifying indication. Results Among 394 patients, clearly appropriate prescribing was identified in 16.0%, while dementia- or delirium-related prescribing was classified as high-risk/context-dependent in 18.8%. Documented off-label prescribing was identified in 11.2%, 48.0% had no documented qualifying indication, and 6.1% had no diagnosis recorded within the ascertainment window. The latter group was excluded from comparative analyses. In the regression sample (n = 370), prescribing without a documented qualifying indication was more likely when the index antipsychotic was prescribed by medical or primary care (AOR 4.43, 95% CI 2.00 to 9.81; p < 0.001), neurology (AOR 2.42, 95% CI 1.27 to 4.63; p = 0.007), or other departments (AOR 3.16, 95% CI 1.16 to 8.63; p = 0.025) than by psychiatry. Conclusion Prescribing without a documented qualifying indication was common outside psychiatry, but the absence of a qualifying diagnosis in the records does not confirm inappropriate prescribing. Systematic indication documentation, medication review, and targeted stewardship may improve prescribing quality in older adults.