Featured Review: Interventions to improve the appropriate use of polypharmacy for older people

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes.

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. The Cochrane Review, 'Interventions to improve the appropriate use of polypharmacy for older people' examined studies in which healthcare professionals have taken action to make sure that older people are receiving the most effective and safest medicines for any illness they may have. Actions taken included providing a service, known as pharmaceutical care, which involves promoting the correct use of medicines by identifying, preventing and resolving medicine‐related problems. Another strategy the reviewers were interested in was using computerised decision support, which involves a programme on the doctor’s computer that aids the selection of appropriate treatment(s).

This is an important research area as polypharmacy is the single most commonly identified risk factor associated with potentially inappropriate prescribing in older people.  Potentially inappropriate prescribing has been linked to a range of negative clinical outcomes including hospitalisations.

The review authors found 32 relevant trials from 12 countries that involved 28,672 older people. These studies compared interventions aiming to improve the appropriate use of medicines with usual care. Based on the assessments of the certainty of the evidence, the results of the review showed that:

  •  it is uncertain whether the interventions improved the appropriateness of medicines (based on scores assigned by expert professional judgement)
  •  it is uncertain whether the interventions reduced the number of potentially inappropriate medicines (medicines in which the harms outweigh the benefits)
  • it is uncertain whether the interventions reduced the proportion of patients with one or more potentially inappropriate medications
  • the interventions may slightly decrease the number of potential prescribing omissions
  • it is uncertain whether the interventions reduced the proportion of patients with one or more potential prescribing omissions (cases where a useful medicine has not been prescribed) because the certainty of the evidence is very low
  • the interventions may lead to little or no difference in hospital admissions or quality of life
  • no consistent intervention effect was observed across studies in terms of medication-related problems

Review author Audrey Rankin said:

“It is vital that the available evidence is identified and appraised, so that interventions that are effective in ensuring appropriate polypharmacy in older people can be implemented in clinical practice. This review provides an updated and detailed appraisal of current available evidence, the findings of which are relevant to informing future policy, practice and research.

The addition of 20 studies to this updated review, which now includes 32 studies, highlights a notable increase in intervention studies aimed at improving appropriate polypharmacy in older people. However, these additional 20 studies had little impact on the overall findings of the review and the included studies were limited by their small sample sizes and poor certainty of evidence.

Based on the studies included in the review, it is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients’ prescriptions, resulted in clinically significant improvements. The interventions may be slightly beneficial in terms of reducing the number of potential prescribing omissions; however, this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.”

In advancing future research in this area, it would be important that researchers provide more detailed descriptions of the interventions in terms of how they were developed and delivered. This would help in understanding how the interventions were intended to achieve their desired effects, as well as promoting replication of effective interventions in other settings. It would also be important to ensure greater consistency in terms of the assessment outcomes that are used in evaluating interventions. Members of our research group recently published a core outcome set for interventions aimed at improving appropriate polypharmacy for older people in primary care, which may help in streamlining the outcomes that are routinely measured in trials in this area.

Tuesday, September 11, 2018