Interventions to improve the appropriate use of polypharmacy for older
people
Patterson, S. M., Cadogan, C. A., Kerse, N., Cardwell, C. R., Bradley, M. C., Ryan, C., & Cochrane Effective
Practice and Organisation of Care Group (2014). Interventions to improve the appropriate use of polypharmacy
for older people.
Cochrane database of systematic reviews (Online)
,
10
, CD008165.
https://doi.org/10.1002/14651858.CD008165.pub3
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Cochrane database of systematic reviews (Online)
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Queen's University Belfast - Research Portal:
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Copyright © 2014 The Cochrane Collaboration.
This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2014, Issue 10:
Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of
polypharmacy for older people. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD008165.
http://dx.doi.org/10.1002/14651858.CD008165.pub3.
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Download date:10. Aug. 2022
Interventions to improve the appropriate use of
polypharmacy for older pe op le (Review)
Patterson SM, Cadogan CA, Kerse N, Card well CR, Bradley MC, Ryan C, Hughes C
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2014, Issue 10
http://www.thecochranelibrary.com
Interventions to improve the appropriate use of polypharmacy for older people (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
5BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
21DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Postintervention analysis, Outcome 1 Change in MAI score. . . . . . . . . . . 77
Analysis 1.2. Comparison 1 Postintervention analysis, Outcome 2 Change in MAI (e xcl Crotty 2004a). . . . . . 78
Analysis 1.3. Comparison 1 Postintervention analysis, Outcome 3 Change in MAI (excl Crotty 2004a and Spinewine
2007). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 1.4. Comparison 1 Postintervention analysis, Outcome 4 Summated MAI score. . . . . . . . . . . 79
Analysis 1.5. Comparison 1 Postintervention analysis, Outcome 5 Number of Beers drugs per patient. . . . . . 80
80ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
101APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116WHAT’S N EW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116CONTRIBUTIONS O F AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
116DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
117SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
117DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
117INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iInterventions to improve the appropriate use of po lypharmacy for o lder people (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Interventions to improve the appropriate use of
polypharmacy for older pe op le
Susan M Patterson
1
, Cathal A Cadogan
2
, Ngaire K erse
3
, Chris R Cardwell
4
, Marie C Bradley
2
, Cristin Ryan
2
, Carmel Hughes
2
1
No affiliation, Belfast, UK.
2
School of Pharmacy, Queen’s University Belfast, Belfast, UK.
3
Department of General Practice and
Primary Health Care, University of Auckland, Auckland, New Zealand.
4
Centre for Public Health, Queen’s University Belfast, Belfast,
UK
Contact address: Carmel Hughes, School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern Ireland, BT9
7BL, UK.
c.hughes@qub.ac.uk.
Editorial group: Cochrane Effective Practice and Organisation of Care Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 10, 2014.
Review co ntent assessed as up-to-date: 21 August 2014.
Citation: Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the
appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD008165. DOI:
10.1002/14651858.CD008165.pub3.
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
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 interest in appropriate polypharmacy, where many medicines
may be used to achieve better clinical outcomes for patients, is growing.
Objectives
This review sought to determine which interventions, alone or in combination, are e ffective in improving the appropriate use of
polypharmacy and reducing medication-related problems in older people.
Search methods
In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and
handsearching of reference l ists was performed. Search terms included ’polypharmacy’, ’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 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beer s criteria,
Medication Appropriateness Index (MAI)).
Data collection and analysis
Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies.
Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of ef fect and 95% confidence
intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the
overall quality of evidence for each pooled outcome.
1Interventions to improve the appropriate use of polypharmacy for older people (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised
decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Inter-
ventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured
using validated tools, including the MAI score post intervention (eight studies), Beers cr iter ia (four studies), STOPP criteria (two
studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication
usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater
reduction in MAI scores between baseline and foll ow-up was seen in the intervention group when compared with the control group
(four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score
(five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fe wer Beers drugs per participant (two studies; mean difference -0.1,
95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital
admissions (five studies) and of medication-related problems (six studies) was conflicting.
Authors’ conclusions
It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant
improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.
P L A I N L A N G U A G E S U M M A R Y
A review of the ways that healthcare professionals can improve the use of suitable medicines for older people
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. This review examines studies in which health care professionals have taken action to make sure that
older people are receiving the most effective and safest medication for their illness. Actions taken included providing pharmaceutical care,
a service provided by pharmacists that involves identifying, preventing and resolving medication-related problems, as well as promoting
the correct use of medications and encouraging health promotion and education. A nother strategy was computerised de cision support,
which involves a programme on the doctor’s computer that helps him/her to sele ct appropriate 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, but it is not clear whether this always results in clinical improvement.
2Interventions to improve the appropriate use of polypharmacy for older people (Review)
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
