The global demographic transition toward an aging population has brought the health challenges of older adults into sharp focus. Advances in medicine and public health have extended life expectancy, but longevity often comes with multiple chronic conditions requiring long-term pharmacotherapy. Consequently, polypharmacy, commonly defined as the use of five or more medications daily, has become a widespread phenomenon among the elderly. While appropriate medication use is essential to maintain health and quality of life, polypharmacy is frequently associated with increased risk of drug–drug interactions (DDIs), adverse drug reactions (ADRs), functional decline, falls, hospitalizations, and even mortality.1-4 Drug interactions are particularly critical in older adults due to age-related physiological changes, such as reduced hepatic metabolism, declining renal clearance, altered body composition, and heightened sensitivity to pharmacological agents. These factors not only amplify the effects of multiple medications but also complicate dosing regimens. Additionally, the elderly often use over-the-counter (OTC) drugs, herbal remedies, and dietary supplements, which further elevate the risk of harmful interactions when combined with prescription medicines. International estimates suggest that more than one-third of older adults are exposed to potentially inappropriate drug combinations, with consequences ranging from treatment failure to life-threatening complications.5-8 In India, the problem of polypharmacy and drug interactions is compounded by fragmented healthcare access, self-medication practices, and widespread availability of OTC medicines without prescription. Studies from various Indian states have shown that elderly individuals frequently lack adequate knowledge about the risks of combining multiple drugs and often fail to disclose complete medication histories to healthcare providers. Financial constraints, limited health literacy, and reliance on informal or non-professional sources of medical advice aggravate these risks. Given India’s rapidly expanding elderly population—projected to constitute nearly 20% of the total population by 2050—addressing medication safety in older adults is a pressing public health priority.9-13 Himachal Pradesh, a hilly state with a predominantly rural population, presents a unique context for this issue. Older individuals here often face limited access to specialized healthcare services, geographic barriers in reaching urban centers, and dependence on local chemists or home remedies. While community and family support structures are relatively strong, awareness about safe medication practices remains variable. Despite the growing burden of chronic diseases such as hypertension, diabetes, cardiovascular disorders, and osteoarthritis in this population, there is limited region-specific evidence on how well the elderly understand the risks of polypharmacy and drug interactions. Awareness and attitudes play a pivotal role in medication safety. Elderly individuals who recognize the dangers of drug interactions, adhere to regular medication reviews, and openly communicate with healthcare providers are more likely to avoid preventable ADRs and hospitalizations. Conversely, misconceptions—such as believing that more medicines imply better treatment, or that herbal remedies are always safe—can perpetuate unsafe practices. Understanding the knowledge, attitudes, and practices (KAP) of the elderly regarding drug interactions and polypharmacy is, therefore, essential for designing context-appropriate interventions, promoting rational drug use, and enhancing patient safety. The present study was undertaken to evaluate awareness, attitudes, and practices regarding drug interactions and polypharmacy among elderly individuals in Himachal Pradesh. By analyzing socio-demographic determinants of knowledge and attitudes, the study aims to identify critical gaps, inform targeted educational strategies, and support policy efforts toward safer prescribing and medicine use in older adults.

Study Design and Setting This study adopted a descriptive, cross-sectional design to assess awareness, attitudes, and practices regarding drug interactions and polypharmacy among elderly individuals in Himachal Pradesh. Data collection was conducted using a structured questionnaire administered through Google Forms, which enabled efficient distribution, ensured consistency in responses, and minimized logistical challenges in a geographically diverse state. Study Population and Eligibility Criteria The target population comprised elderly individuals aged 60 years and above, residing in Himachal Pradesh at the time of the survey. Participants were eligible regardless of education or occupational background, provided they gave voluntary informed consent. Individuals excluded from the study included: • healthcare professionals or medical students (to avoid bias from specialized knowledge), • elderly with severe cognitive impairment or communication difficulties (as self-report would be unreliable), and • incomplete or duplicate responses. Sample Size Calculation The minimum sample size was estimated using the single population proportion formula, assuming 50% prevalence of adequate knowledge regarding drug interactions and polypharmacy, with a 95% confidence interval and a 5% margin of error. The required sample size was 384, which was inflated to 420 participants to account for potential exclusions and ensure adequate statistical power. Sampling Strategy A purposive-cum-snowball sampling technique was employed. The survey link was disseminated via WhatsApp, Facebook, and email groups, as well as through community health workers and local networks. Respondents were encouraged to share the link further with eligible elderly individuals within their families and communities, thereby ensuring participation across diverse rural and urban settings of the state. Survey Instrument The study tool was developed after an extensive review of literature and international guidelines (World Health Organization, American Geriatrics Society, and Indian Council of Medical Research recommendations). The questionnaire comprised four major sections: 1. Socio-Demographic Information – including age, gender, residence, education, occupation, living arrangement, and income. 2. Medical and Prescription Profile – covering chronic disease history, number of medications taken, polypharmacy status, OTC medicine use, and history of adverse drug reactions (ADR) or drug-related hospitalization. 3. Knowledge Assessment – 20 multiple-choice questions (MCQs) addressing awareness of polypharmacy, drug interactions, ADRs, and safe medicine practices. Each correct answer was awarded one point (score range 0–20). Knowledge was categorized as: Excellent (16–20), Good (12–15), Fair (8–11), and Poor (0–7). 4. Attitude Assessment – 20 Likert-scale items (Agree = 2, Neutral = 1, Disagree = 0) exploring participants’ beliefs, concerns, and willingness to engage in safe medicine use. Attitude scores were classified as Highly Positive (16–20), Positive (12–15), Neutral (8–11), and Negative (0–7). Validation and Pilot Testing The questionnaire underwent content validation by experts in pharmacology, geriatrics, and public health. A pilot study with 30 elderly individuals from Himachal Pradesh was conducted to ensure clarity, cultural relevance, and comprehensibility. Minor modifications in wording were made based on feedback. The internal consistency of the tool was confirmed with a Cronbach’s alpha of 0.81, indicating good reliability. Data Collection Procedure The Google Form began with an informed consent statement, which participants had to accept before accessing the questionnaire. All items were marked as mandatory to avoid missing data. Average completion time was 10–12 minutes. Responses were automatically collated into a password-protected Google Sheet accessible only to the investigators. Data Analysis Data were exported into IBM SPSS Statistics (version 25) for analysis. Descriptive statistics (frequencies, percentages, means, standard deviations) summarized socio-demographic, medical, knowledge, and attitude variables. The chi-square test was used to examine associations between knowledge/attitude levels and socio-demographic factors. A p-value <0.05 was considered statistically significant. Ethical Considerations The study was conducted in accordance with the Declaration of Helsinki.. Participation was voluntary, responses were anonymized, and confidentiality was strictly maintained throughout the study.

Among the 420 elderly participants, the age distribution was fairly balanced, with the largest group being 70–74 years (27.6%), followed by 60–64 years (25.7%), ≥75 years (24.3%), and 65–69 years (22.4%). Males slightly outnumbered females (56.2% vs. 43.8%). A majority of respondents resided in rural areas (56.7%) compared with 43.3% in urban settings. Educational attainment varied widely, with 23.3% having no formal education, 29.0% completing primary school, 26.2% completing secondary school, and 21.5% attaining graduation or higher. Occupationally, homemakers (31.4%) and retired professionals/service holders (28.1%) formed the largest groups, while 21.9% were engaged in skilled or unskilled labor, and 18.6% in agriculture or self-employment. Most participants lived with their families (82.9%), while 17.1% lived alone. Income levels revealed that nearly two in five (39.5%) had monthly earnings below ₹10,000, about one-third (32.9%) earned between ₹10,001–20,000, and 27.6% reported income above ₹20,000, reflecting a mixed socio-economic profile. Table 1: Socio-Demographic Characteristics of Elderly Participants (n = 420) Variable Category Frequency (n) Percentage (%) Age (years) 60–64 108 25.7 65–69 94 22.4 70–74 116 27.6 ≥75 102 24.3 Gender Male 236 56.2 Female 184 43.8 Residence Urban 182 43.3 Rural 238 56.7 Education No formal education 98 23.3 Primary 122 29.0 Secondary 110 26.2 Graduate & above 90 21.5 Occupation (current/retired) Retired service/professional 118 28.1 Homemaker 132 31.4 Skilled/Unskilled labor 92 21.9 Others (agriculture/self-employed) 78 18.6 Living Arrangement With family 348 82.9 Alone 72 17.1 Monthly Income (INR) <10,000 166 39.5 10,001–20,000 138 32.9 >20,000 116 27.6 The majority of participants reported at least one chronic condition, with hypertension (65.2%) and diabetes mellitus (44.3%) being the most common. Osteoarthritis (36.2%), cardiovascular disease (30.5%), and chronic respiratory illnesses (23.3%) were also prevalent. Nearly half (48.6%) had two or more chronic conditions, highlighting multimorbidity. In terms of medication burden, one-third (32.4%) were on 3–4 drugs daily, 26.7% on 5–6 drugs, and 19.0% on ≥7 drugs, while 21.9% used only 1–2 drugs. Based on standard definitions, polypharmacy (≥5 drugs daily) was present in 45.7% of the sample. Use of over-the-counter (OTC) medications was reported by 40.0%. A history of adverse drug reactions (ADRs) was present in 17.6%, while 6.2% had experienced hospitalization due to drug-related complications, underlining the clinical significance of inappropriate polypharmacy in this group. Table 2: Medical and Prescription Profile of Elderly Participants (n = 420) Variable Category Frequency (n) Percentage (%) Common Chronic Conditions* Hypertension 274 65.2 Diabetes mellitus 186 44.3 Osteoarthritis 152 36.2 Cardiovascular disease (CAD/CHF) 128 30.5 Chronic respiratory illness (COPD/asthma) 98 23.3 ≥2 chronic conditions 204 48.6 Number of Medications Taken Daily 1–2 drugs 92 21.9 3–4 drugs 136 32.4 5–6 drugs 112 26.7 ≥7 drugs (polypharmacy) 80 19.0 Polypharmacy Status Present (≥5 drugs) 192 45.7 Absent (<5 drugs) 228 54.3 Use of Over-the-Counter (OTC) Medicines Yes 168 40.0 No 252 60.0 History of Adverse Drug Reaction (ADR) Yes 74 17.6 No 346 82.4 History of Hospitalization due to Drug-Related Complications Yes 26 6.2 No 394 93.8 Knowledge levels among the elderly showed substantial variability. While 58.1% correctly identified polypharmacy as taking more than five drugs daily, only 53.8% recognized age-related organ decline and multiple drug use as risk factors for drug interactions. Awareness was relatively higher regarding the role of the liver in drug metabolism (63.8%), dangers of alcohol–drug interactions (71.9%), and the risk of bleeding when blood thinners are combined with painkillers (68.1%). However, only half (51.0%) acknowledged risks of combining herbal and prescription medicines, and just 47.1% knew about the dangers of mixing alcohol with sleeping pills. Knowledge was stronger for issues like completing medication courses, carrying medicine lists to hospital visits (73.8%), and the unsafe practice of sharing medicines (76.7%). On the other hand, awareness of antacid–drug interactions (50.0%) and risks of unmonitored antihypertensive–diuretic use (56.2%) remained weak. Collectively, these findings suggest moderate but inconsistent knowledge, with gaps in nuanced areas of drug safety. Table 3: Knowledge Questions on Drug Interactions and Polypharmacy (n = 420) Q. No. Question Options (Correct in Bold) Correct (n) Correct (%) 1 Taking more than 5 medicines daily is called? a) Safe use b) Polypharmacy c) Overdose d) None 244 58.1 2 Elderly people are more prone to drug interactions due to? a) Younger age b) Multiple drugs & organ decline c) Better immunity d) Don’t know 226 53.8 3 Which organ is most responsible for drug metabolism? a) Kidney b) Liver c) Lungs d) Heart 268 63.8 4 Mixing alcohol with medicines can cause? a) No effect b) Faster cure c) Serious side effects d) Don’t know 302 71.9 5 Painkillers like NSAIDs may harm which organ with long-term use? a) Heart b) Kidney c) Lungs d) Skin 248 59.0 6 Blood thinner with other painkillers increases risk of? a) Diabetes b) Fever c) Bleeding d) No effect 286 68.1 7 Herbal medicines taken with prescribed drugs can be? a) Always safe b) Sometimes harmful c) Always harmful d) Don’t know 214 51.0 8 Stopping medicines suddenly without advice is? a) Harmless b) Dangerous c) Recommended d) Don’t know 318 75.7 9 Polypharmacy can increase risk of? a) Falls & hospitalizations b) Faster recovery c) Better memory d) None 276 65.7 10 Which group is at highest risk of polypharmacy complications? a) Children b) Elderly c) Middle-aged d) None 294 70.0 11 Taking medicines prescribed for someone else is? a) Useful b) Unsafe c) Harmless d) Recommended 322 76.7 12 Antibiotics with wrong medicines can lead to? a) Faster healing b) Resistance & side effects c) Weight loss d) No effect 284 67.6 13 Regular medicine review with doctor helps to? a) Reduce harmful interactions b) Increase costs c) Waste time d) None 252 60.0 14 Self-medicating with OTC drugs in elderly is? a) Safe b) Risky c) Encouraged d) Harmless 278 66.2 15 Awareness of drug interaction helps in? a) Safe use of medicines b) Cure of all diseases c) Avoiding doctor visits d) None 306 72.9 16 Taking sleeping pills with alcohol may cause? a) Faster sleep b) Respiratory depression c) Strong immunity d) No harm 198 47.1 17 Antacids taken with some medicines can? a) Increase benefits b) Reduce drug absorption c) No effect d) Don’t know 210 50.0 18 Combining antihypertensives and diuretics without monitoring may lead to? a) Stronger bones b) Low blood pressure c) Better eyesight d) None 236 56.2 19 Why is it dangerous to hide medicine use from the doctor? a) Saves money b) Risk of harmful interactions c) Harmless habit d) Don’t know 288 68.6 20 Elderly should carry a medicine list during hospital visits because? a) For memory b) Helps doctors avoid drug interactions c) Not needed d) Waste of time 310 73.8 Attitudinal patterns revealed a blend of caution and misconceptions. A majority (71.0%) believed that taking many medicines is harmful, and 80.0% emphasized the importance of disclosing all medications—including herbal and OTC—to doctors. However, 26.2% still felt self-medication was safe for minor symptoms, and 36.7% believed polypharmacy was unavoidable in old age. Encouragingly, most participants expressed willingness to stop unnecessary medicines if advised by a doctor (78.1%) and felt regular reviews were important (77.1%). A large majority (81.0%) agreed that awareness of drug interactions can prevent serious complications, while 73.3% acknowledged the role of pharmacists in guiding about interactions. Yet, misconceptions persisted—30.0% trusted herbal remedies as always safe with prescribed drugs, and nearly one-third (28.1%) equated more medicines with better treatment. These patterns highlight a generally favorable but still vulnerable attitudinal landscape. Table 4: Attitude Towards Drug Interaction and Polypharmacy (n = 420) Q. No. Attitude Statement Agree n (%) Neutral n (%) Disagree n (%) 1 I believe taking many medicines at once is harmful. 298 (71.0) 72 (17.1) 50 (11.9) 2 I trust that doctors always prescribe only necessary medicines. 262 (62.4) 98 (23.3) 60 (14.3) 3 I feel it is important to inform doctors about all medicines I take (including herbal/OTC). 336 (80.0) 48 (11.4) 36 (8.6) 4 I believe self-medication is safe if symptoms are minor. 110 (26.2) 88 (21.0) 222 (52.9) 5 I think polypharmacy is unavoidable in old age. 154 (36.7) 102 (24.3) 164 (39.0) 6 I am willing to stop unnecessary medicines if doctor advises. 328 (78.1) 60 (14.3) 32 (7.6) 7 I am concerned about side effects of taking many medicines. 290 (69.0) 80 (19.0) 50 (11.9) 8 I believe herbal/home remedies are always safe with prescribed medicines. 126 (30.0) 100 (23.8) 194 (46.2) 9 I feel regular review of medicines is necessary. 324 (77.1) 58 (13.8) 38 (9.1) 10 I think discussing drug interactions with doctors/pharmacists is important. 302 (71.9) 74 (17.6) 44 (10.5) 11 I do not mind carrying a medicine list to the hospital. 286 (68.1) 72 (17.1) 62 (14.8) 12 I believe more medicines mean better treatment. 118 (28.1) 94 (22.4) 208 (49.5) 13 I feel family members should help in managing my medicines. 332 (79.0) 54 (12.9) 34 (8.1) 14 I am comfortable asking my doctor about reducing medicines. 278 (66.2) 86 (20.5) 56 (13.3) 15 I worry about forgetting to take multiple medicines daily. 244 (58.1) 94 (22.4) 82 (19.5) 16 I believe pharmacists can guide about drug interactions. 308 (73.3) 70 (16.7) 42 (10.0) 17 I think regular blood tests are unnecessary unless I feel sick. 132 (31.4) 98 (23.3) 190 (45.2) 18 I feel more confident when I understand my medicines’ purpose. 322 (76.7) 66 (15.7) 32 (7.6) 19 I am afraid to question my doctor about prescribed medicines. 160 (38.1) 96 (22.9) 164 (39.0) 20 I believe awareness of drug interactions can prevent serious complications. 340 (81.0) 48 (11.4) 32 (7.6) When knowledge scores were aggregated, only 17.1% of participants achieved “Excellent” knowledge (16–20), while 30.5% demonstrated “Good” knowledge (12–15). More than one-third (34.8%) scored in the “Fair” range, and 17.6% were classified as having “Poor” knowledge, reflecting significant gaps in understanding drug interactions. Attitudes were relatively more favorable: 20.5% held a “Highly Positive” outlook, and 39.0% a “Positive” outlook. However, 27.6% were neutral and 12.9% expressed negative attitudes. These distributions suggest that while a majority of the elderly possess moderate awareness and generally positive attitudes, there remains a large proportion vulnerable to unsafe practices due to inadequate knowledge or indifference. Table 5: Distribution of Knowledge and Attitude Scores (n = 420) Knowledge Score Categories Category Score Range (20 Questions) Frequency (n) Percentage (%) Excellent 16–20 72 17.1 Good 12–15 128 30.5 Fair 8–11 146 34.8 Poor 0–7 74 17.6 Total — 420 100.0 Attitude Score Categories Category Score Range (20 Items) Frequency (n) Percentage (%) Highly Positive 16–20 86 20.5 Positive 12–15 164 39.0 Neutral 8–11 116 27.6 Negative 0–7 54 12.9 Total — 420 100.0 Analysis of socio-demographic associations revealed that residence, education, and occupation significantly influenced knowledge levels. Urban respondents were substantially more likely to have good-to-excellent knowledge compared to rural participants (57.2% vs. 33.8%, p<0.001). Education showed a clear gradient: only 20.0% of those without formal education had adequate knowledge, compared to 69.4% among graduates and above (p<0.001). Occupation also mattered, with service/professionals (63.3%) showing much higher knowledge than homemakers (37.5%) or retired elderly (42.2%) (p=0.007). By contrast, age and gender were not significantly associated with knowledge, suggesting that structural determinants such as education and place of residence are stronger predictors of awareness than biological or generational factors. Table 6a: Association Between Knowledge Level and Socio-Demographic Variables (n = 420) Variable Category Excellent–Good Knowledge (%) Fair–Poor Knowledge (%) χ² value p-value Age (years) 60–64 49.0 51.0 7.21 0.125 65–69 45.3 54.7 ≥70 39.5 60.5 Gender Male 47.1 52.9 1.64 0.421 Female 44.6 55.4 Residence Urban 57.2 42.8 16.34 <0.001*** Rural 33.8 66.2 Education No formal 20.0 80.0 74.86 <0.001*** Primary 34.2 65.8 Secondary 50.1 49.9 Graduate+ 69.4 30.6 Occupation Retired 42.2 57.8 12.04 0.007** Homemaker 37.5 62.5 Service/Professional 63.3 36.7 Similar patterns emerged for attitudes. Urban residents were more likely to demonstrate positive or highly positive attitudes (69.2%) compared with rural participants (48.7%) (p<0.001). Education again showed a striking influence: only 31.4% of those without formal schooling had favorable attitudes versus 77.1% of graduates and above (p<0.001). Occupational status also shaped outlooks, with service/professionals reporting significantly more positive attitudes (74.5%) than homemakers (50.6%) or retirees (55.9%) (p=0.012). Neither age nor gender showed significant associations. These findings reinforce the role of education, residence, and occupation as key determinants of safe attitudes toward drug use, highlighting the need for targeted interventions among rural, low-literacy, and non-professional groups. Table 6b: Association between Attitude Level and Socio-Demographic Variables (n = 420) Variable Category Positive–Highly Positive Attitude (%) Neutral–Negative Attitude (%) χ² value p-value Age (years) 60–64 63.2 36.8 5.86 0.182 65–69 59.4 40.6 ≥70 54.8 45.2 Gender Male 61.7 38.3 1.25 0.531 Female 58.9 41.1 Residence Urban 69.2 30.8 13.98 <0.001*** Rural 48.7 51.3 Education No formal 31.4 68.6 69.22 <0.001*** Primary 45.6 54.4 Secondary 62.0 38.0 Graduate+ 77.1 22.9 Occupation Retired 55.9 44.1 10.84 0.012* Homemaker 50.6 49.4 Service/Professional 74.5 25.5

This study provides important insights into the awareness, attitudes, and practices regarding drug interactions and polypharmacy among elderly individuals in Himachal Pradesh. The findings highlight a moderate level of knowledge, generally favorable attitudes, but significant gaps in understanding and behavior, particularly among rural, less-educated, and non-professional elderly. Nearly half of the participants (45.7%) were found to be on polypharmacy regimens (≥5 drugs daily), a proportion comparable to international estimates ranging between 40–60% among elderly populations in developed countries. Similar rates have also been reported in Indian studies conducted in Karnataka and Maharashtra, where the burden of multimorbidity was strongly linked with inappropriate polypharmacy. In our study, nearly 49% of participants reported two or more chronic conditions, with hypertension and diabetes mellitus being the most prevalent. This multimorbidity pattern is consistent with previous research indicating that cardiovascular and metabolic disorders are the primary drivers of polypharmacy in older adults. Despite the widespread use of multiple drugs, awareness about drug interactions was only moderate. While a majority correctly identified the dangers of alcohol–drug interactions (71.9%), the role of the liver in drug metabolism (63.8%), and the risk of bleeding with anticoagulant–NSAID combinations (68.1%), awareness about more nuanced risks such as antacid–drug interactions (50.0%) and sedative–alcohol interactions (47.1%) remained poor. These gaps are concerning, as subtle interactions often go unnoticed yet contribute significantly to adverse drug reactions (ADRs) and preventable hospitalizations. The finding that 17.6% of participants had experienced an ADR and 6.2% required hospitalization due to drug-related complications underscores the clinical importance of these gaps. Encouragingly, the majority of respondents exhibited a positive orientation toward safe medication practices. Most participants expressed willingness to discontinue unnecessary medicines upon medical advice (78.1%) and emphasized the importance of communicating all medicine use to healthcare providers (80.0%). Awareness of the preventive role of drug interaction knowledge was also strong (81.0%). However, misconceptions persist — more than one-third believed polypharmacy is unavoidable in old age (36.7%), nearly 30% equated more medicines with better treatment, and a similar proportion trusted herbal remedies as always safe with prescription drugs. Such beliefs may undermine rational medicine use and increase risks of ADRs, particularly in rural and low-literacy populations where reliance on home remedies and OTC drugs is common. Our analysis revealed significant associations between knowledge/attitudes and socio-demographic characteristics. Urban residents, individuals with higher educational attainment, and those from professional/service backgrounds demonstrated significantly better knowledge and safer attitudes compared to their rural, less-educated, and homemaker counterparts. These findings are consistent with prior studies in India and elsewhere, which show that education and socioeconomic status are strong determinants of health literacy, awareness of drug safety, and adherence to rational drug use practices. Interestingly, neither age nor gender showed significant associations, suggesting that structural determinants such as access to education, occupation, and healthcare services outweigh biological or generational differences in shaping awareness and attitudes.12,13 Public Health Implications The results have several practical implications. First, the relatively high prevalence of polypharmacy and moderate knowledge levels call for targeted educational interventions to improve awareness of drug interactions, particularly among rural and low-literacy elderly. Second, the strong positive attitudes toward safe practices provide an opportunity for healthcare providers to reinforce correct behaviors through regular counseling and medication reviews. Third, pharmacists — often the most accessible health professionals in rural Himachal Pradesh — should be actively integrated into community-level initiatives to screen for polypharmacy, educate patients, and promote rational medicine use. Finally, policy-level measures are needed to regulate OTC medicine sales and promote community-based geriatric care models that emphasize medication safety. Limitations This study has certain limitations. Being an online Google Form-based survey, it may have excluded elderly individuals with limited digital access or literacy, possibly leading to underrepresentation of the most vulnerable groups. Self-reported responses are subject to recall and social desirability biases. The cross-sectional design limits causal inferences regarding associations between socio-demographic factors and knowledge or attitudes. Despite these limitations, the study provides valuable region-specific evidence and highlights key gaps that must be addressed to improve medication safety among the elderly.

In summary, the study demonstrates that while elderly individuals in Himachal Pradesh generally hold positive attitudes toward safe medication use, their knowledge of drug interactions remains fragmented, with significant disparities across education, residence, and occupation. Given the high prevalence of polypharmacy and its associated risks, tailored educational strategies, community pharmacist engagement, and stricter regulation of OTC drug sales are urgently needed. Interventions that address rural-urban and literacy gaps will be critical in ensuring safe medicine use and reducing preventable ADRs among India’s rapidly aging population.

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