Interventions to improve the appropriate use of polypharmacy for older people
Abstract
Background
Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence there is growing interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients.
Objectives
This review sought to determine which interventions alone, or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication‐related problems in older people.
Search methods
A range of literature databases including MEDLINE and EMBASE were searched in addition to handsearching reference lists. Search terms included polypharmacy, Beers criteria, medication appropriateness and inappropriate prescribing.
Selection criteria
A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older where a validated measure of appropriateness was used (e.g. Beers criteria or Medication Appropriateness Index ‐ MAI).
Data collection and analysis
Three authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study specific estimates were pooled, using a random‐effects model to yield summary estimates of effect and 95% confidence intervals.
Main results
Electronic searches identified 2200 potentially relevant citations, of which 139 were examined in detail. Following assessment, 10 studies were included. One intervention was computerised decision support and nine were complex, multifaceted pharmaceutical care provided in a variety of settings. Appropriateness of prescribing was measured using the MAI score postintervention (seven studies) and/or Beers criteria (four studies). The interventions included in this review demonstrated a reduction in inappropriate medication use. A mean difference of ‐6.78 (95% CI ‐12.34 to ‐1.22) in the change in MAI score in favour of the intervention group (four studies). Postintervention pooled data (five studies) showed a mean reduction of ‐3.88 (95% CI ‐5.40 to ‐2.35) in the summated MAI score and a mean reduction of ‐0.06 (95% CI ‐0.16 to 0.04) in the number of Beers drugs per patient (three studies). Evidence of the effect of the interventions on hospital admissions (four studies) was conflicting. Medication‐related problems, reported as the number of adverse drug events (three studies), reduced significantly (35%) postintervention.
Authors' conclusions
It is unclear if interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in a clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing and medication‐related problems.
PICOs
Plain language summary
A review of the ways that healthcare professionals can improve the use of suitable medicines for older people
Taking medicines for chronic illnesses both to treat symptoms and to prevent diseases getting worse is common in older people. However, taking too many medicines can cause harm. This review examines studies in which healthcare professionals have taken action to make sure that older people are receiving the most effective and safe medication for their illness. The actions taken included pharmaceutical care, a service provided by pharmacists, which involves identifying, preventing and resolving medication‐related problems, as well as promoting the correct use of medications and encouraging health promotion and education. Another strategy was computerised decision support, a programme on the doctor’s computer that helps him/her to decide on the right treatment.
This review provides limited evidence that interventions, such as pharmaceutical care, may be successful in ensuring that older people are receiving the right medicines and reducing medication‐related problems in this group, but it is not clear if this always results in clinical improvements.
