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 interest in appropriate polypharmacy, where many
medicines may be used to achieve better clinical outcomes for patients, is growing.
This is the second update of this Cochrane Review. 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. We searched CENTRAL, MEDLINE,
Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching
of reference lists to identify additional studies. We included randomised trials,
non‐randomised trials, controlled before‐after studies, and interrupted time series.
Eligible studies described interventions affecting prescribing aimed at improving
appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy
(four or more medicines), 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). Two review authors independently reviewed abstracts
of eligible studies, extracted data and assessed risk of bias of 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 32 studies, 20
from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised
trials (one of which was a stepped‐wedge design), two non‐randomised trials and two
controlled before‐after studies. One intervention consisted of computerised decision
support (CDS); and 31 were complex, multi‐faceted pharmaceutical‐care based approaches
(i.e. the responsible provision of medicines to improve patient’s outcomes), one of
which incorporated a CDS component as part of their multi‐faceted intervention. Interventions
were provided in a variety of settings. Interventions were delivered by healthcare
professionals such as general physicians, pharmacists and geriatricians, and all 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)
‐4.76, 95% CI ‐9.20 to ‐0.33; 5 studies, N = 517; very low‐certainty evidence). It
is uncertain whether pharmaceutical care reduces the number of potentially inappropriate
medications (PIMs), (standardised mean difference (SMD) ‐0.22, 95% CI ‐0.38 to ‐0.05;
7 studies; N = 1832; very low‐certainty evidence). It is uncertain whether pharmaceutical
care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79,
95% CI 0.61 to 1.02; 11 studies; N = 3079; very low‐certainty evidence). Pharmaceutical
care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD
‐0.81, 95% CI ‐0.98 to ‐0.64; 2 studies; N = 569; low‐certainty evidence), however
it must be noted that this effect estimate is based on only two studies, which had
serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical
care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18
to 0.85; 5 studies; N = 1310; very low‐certainty evidence). Pharmaceutical care may
make little or no difference in hospital admissions (data not pooled; 12 studies;
N = 4052; low‐certainty evidence). Pharmaceutical care may make little or no difference
in quality of life (data not pooled; 12 studies; N = 3211; low‐certainty evidence).
Medication‐related problems were reported in eight studies (N = 10,087) using different
terms (e.g. adverse drug reactions, drug‐drug interactions). No consistent intervention
effect on medication‐related problems was noted across studies. It is unclear whether
interventions to improve appropriate polypharmacy, such as reviews of patients’ prescriptions,
resulted in clinically significant improvement; however, they may be slightly beneficial
in terms of reducing potential prescribing omissions (PPOs); but this effect estimate
is based on only two studies, which had serious limitations in terms of risk bias.
What is the aim of this review? The aim of this Cochrane Review was to find out which
types of approaches can improve the use of suitable medicines in older people. Researchers
collected and analysed all relevant studies to answer this question and included 32
trials in the review. Key messages 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. 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, which involves promoting
the correct use of medicines by identifying, preventing and resolving medication‐related
problems. Another strategy which we 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). What are the main results of the review? 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. It is uncertain whether the interventions improved the appropriateness
of medicines (based on scores assigned by expert professional judgement), reduced
the number of potentially inappropriate medicines (medicines in which the harms outweigh
the benefits), reduced the proportion of patients with one or more potentially inappropriate
medications, or reduced the proportion of patients with one or more potential prescribing
omissions (cases where a useful medicine has not 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, however, the interventions may slightly
decrease the number of potential prescribing omissions. How up‐to‐date is this review?
Review authors searched for studies that had been published up to February 2018.