Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review

Abstract

ObjectiveTo summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people.DesignCochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation).SettingAll healthcare settings.ParticipantsOlder people (≥65 years) with ≥1 long-term condition who were receiving polypharmacy (≥4 regular medicines).Primary and secondary outcome measuresPrimary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes.Results12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers’ criteria and Screening Tool of Older Person's Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported.ConclusionsThe included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice.

Consenso brasileiro de medicamentos potencialmente inapropriados para idosos

“…1 Muitas RAM são evitáveis se houver uma preocupação com a identificação e a prevenção do uso de medicamentos potencialmente inapropriados (MPI) e de combinações indesejáveis. 4 Esse fato é de grande relevância clínica, em especial na população idosa, por diversos fatores:…”

Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments

“…Furthermore, polypharmacy impacts significantly health outcomes and healthcare resources. While traditionally polypharmacy has been classified in terms of the number of medicines (usually defined as the use of five or more medicines) [14], Patterson et al suggested, as part of a Cochrane review in 2012 (later updated in 2014), that there should be a change in emphasis from 'inappropriate polypharmacy' (prescribing of multiple medicines which are either inappropriate or no longer indicated) to 'appropriate' or 'optimal polypharmacy' (appropriate prescribing of multiple medicines) [15][16][17].…”

“…The review findings were based upon ten papers, with the authors concluding that, while there is uncertainty about the elements of intervention that impact positively appropriate polypharmacy, pharmaceutical care appears to improve prescribing [16,17].…”

“…Several published systematic literature reviews have focused on aspects of polypharmacy management [15][16][17], but with little emphasis on grey literature, notably policies and guidelines. The aim of this review was to summarise and review critically current policies and guidelines on polypharmacy management in older people (publications dated: 01 January 2010 -30 June 2015).…”

“…The definitions of appropriate and inappropriate polypharmacy were expanded from those of Patterson et al [15][16][17]. Appropriate polypharmacy is present when: all medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the patient; therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future; medicines have been optimised to minimise the risk of ADRs; and the patient is motivated and able to take all medicines as intended.…”