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Background: Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population. Aim: The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs). Methods: Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression. Results: The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24–0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62–4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08–16.81), hypertension (OR = 2.14, 95% CI = 1.34–3.44), diabetes (OR = 2.72, 95% CI = 1.69–4.39) or depression (OR = 1.91, 95% CI = 1.19–3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03–3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19–0.85) and remote (OR = 0.58, 95% CI = 0.29–1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37–4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02–8.83), depression (OR = 2.67, 95% CI = 1.50–4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39–5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31–5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03–0.34) and remote (OR = 0.51, 95% CI = 0.25–1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50–6.30) or depression (OR = 3.32, 95% CI = 1.70–6.47). Conclusion: Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients. [ABSTRACT FROM AUTHOR]