Introduction: Digoxin monitoring is important in the elderly because of thetoxicity risk. The aim of this study was to evaluate the orders made by different unitsfor digoxin monitoring in the elderly.Materials and Method: Digoxin orders and results in patients aged over 65,patients’ demographic characteristics, such as age and gender, the unit from whichthe order was made, and patients’ pre-diagnoses were retrospectively recorded.Patients were divided into young-old, middle-old, and very-old groups, and theresults were divided into subtherapeutic, therapeutic, and toxic levels.Results: The percentage of young-old, middle-old, and very-old patients was39.4%, 45.3%, and 15.3%, respectively. Women were more (64.3%) and their medianage and digoxin concentrations were higher (p<0.001). Outpatients’ mediandigoxin concentrations were lower than inpatients’ median digoxin concentrations(p<0.001). A proportion of 46.6% of all digoxin levels were therapeutic; 29.2% weresubtherapeutic; and 24.2% were toxic. Subtherapeutic levels in males and toxiclevels in females predominated (p<0.001). Toxic levels were higher in inpatients,and subtherapeutic levels were higher in outpatients (p<0.001). The highest rateof therapeutic levels was observed in young-old patients (48.7%), while toxic levelswere observed most frequently in very-old patients (28.1%). The highest numberof digoxin orders in elderly patients was from the emergency department (44.2%).Conclusion: In elderly patients, more than half of the serum digoxin orders wereinappropriate. These results significantly changed according to gender, outpatientor inpatient status, age, and the ordering unit. Changes in digoxin pharmacokinetics,especially in the geriatric period, require physicians to be vigilant of subtherapeuticdrug concentrations.