Abstract <p>Background: Polypharmacy and the use of potentially inappropriate medications (PIMs) are major issues in the elderly regarding adverse drug events and poor health outcomes. This study determines the prevalence of polypharmacy and PIMs in older adults in Pakistan using the Beers Criteria 2023. Methods: A prospective cross-sectional study was carried out from October 2023 to April 2024 on 653 geriatric patients (≥65 years) admitted to King Abdullah Teaching Hospital, Mansehra, and Jinnah International Hospital, Abbottabad. The definition of polypharmacy is the use of ≥5 medications simultaneously, and PIMs were assessed using the Beers Criteria 2023. SPSS version 26 was used for data analysis. Results: Among the study population, 63.9% were found to have polypharmacy, and 87.6% were given at least one PIM. The most commonly prescribed PIMs include omeprazole (16.4%), enoxaparin (13.2%), and furosemide (9.3%). Category A PIMs (medications that should be avoided in older adults) constitute 34.5% of all PIMs. Polypharmacy was significantly associated with diabetes mellitus (<i>p</i> = 0.007) and acute coronary syndrome (<i>p</i> = 0.049). Similarly, PIMs use were significantly higher among patients with diabetes mellitus (<i>p</i> = 0.002) and acute coronary syndrome (<i>p</i> = 0.003). Conclusion: The study showed that polypharmacy and PIMs use are highly prevalent in elderly Pakistani patients, and it considerably points toward the need for medication reviews and deprescribing strategies to improve medication safety. Implementing Beers Criteria-based prescribing guidelines and enhancing awareness among healthcare providers, particularly clinical pharmacists, could help optimize medication use and improve outcomes in geriatric care.</p>