What is the aim of this review?
The aim of this Cochrane Review was to find out whether any approaches can improve the use of suitable medicines in older people. Researchers collected and analysed all relevant studies to answer this question and included 38 trials in the review.
Taking medicine to treat symptoms of chronic illness and to prevent worsening of disease is common in older people. However, taking too many medicines can cause harm. Following our analyses, we are uncertain whether the interventions we studied improve the correct use of medicines. We need more and better research to consider these issues.
What was studied in the review?
This review examines studies in which healthcare professionals have taken action to make sure that older people are receiving the most effective and safest medicines for their illness. Actions taken included providing a service, known as pharmaceutical care. This involves promoting the correct use of medicines by identifying, preventing and resolving medication-related problems. Another strategy that we were interested in was using computerised decision support. This involves a program on the doctor’s computer that aids the selection of appropriate treatment(s) or strategies - and can involve different healthcare professionals working together.
What are the main results of the review?
The review authors found 38 relevant trials from 19 countries that involved 18,073 older people. These studies compared interventions aiming to improve the appropriate use of many medicines with usual care. It is uncertain whether the interventions improved the correct use of medicines. After analysing all the studies, we were not able to conclude that the interventions improved the appropriateness of medicines (based on scores assigned by expert professional judgement) or reduced the number of potentially inappropriate medicines (medicines in which the harms outweigh the benefits). We were also not able to say whether the interventions reduced the proportion of patients with one or more potentially inappropriate medication or reduced the proportion of patients with one or more potential prescribing omission (cases where a useful medicine has not prescribed). This is because of the quality of the evidence. However, compared to the last update of this review, there were more studies focusing on potential prescribing omissions and more studies involving a number of healthcare professionals working together. In addition, we found that the interventions may lead to little or no difference in hospital admissions or quality of life.
What are the limitations of the evidence?
The quality of the studies was low and there were substantial differences in the patient populations, how the appropriateness of medications was measured and the interventions that were delivered.
How up-to-date is this review?
Review authors searched for studies that had been published up to January 2021.
It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review.
To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.
We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'.
For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).
Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.
We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.
It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence).
Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants).