The outcomes of considering goals of care in medication reviews for older adults: a systematic review

INTRODUCTION

This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English.

RESULTS

Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective.

CONCLUSIONS

There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.

Deprescribing perceptions and practice: Reported by multidisciplinary hospital clinicians after, and by medical students before and after, viewing an e-learning module

BACKGROUND

There are many barriers to deprescribing in the routine care of older inpatients with polypharmacy. Implementation is limited by factors related to clinicians, patients, and the acute care setting. A short (11 min) e-learning module for multidisciplinary hospital clinicians was developed to address two commonly reported barriers: awareness of polypharmacy and self-efficacy in deprescribing.

OBJECTIVES

1) Describe the level of awareness of polypharmacy and self-efficacy of deprescribing in multi-disciplinary hospital clinicians following completion of an online e-learning module; and 2) describe the immediate impact of an online educational module in awareness and self-efficacy of polypharmacy and deprescribing in senior medical students.

METHODS

A questionnaire was developed and administered to hospital clinicians following completion of the e-learning module. Senior medical students undertook the questionnaire pre- and post-module.

RESULTS

Overall, 99 hospital clinicians with diverse clinical roles, experience, and ages, and 30 medical students completed the questionnaire. Although most (≥80%) hospital clinicians reported a general awareness of polypharmacy and deprescribing, there was moderate to low current activity in medication review and deprescribing, a perceived lack of role in medication review by junior doctors, and minimal knowledge of deprescribing tools. Use of a previously validated self-efficacy questionnaire showed lowest self-efficacy in domains related to developing deprescribing plans and implementing them. Pre-post analysis of medical student responses found a small statistically significant improvement following viewing the module in awareness of polypharmacy, deprescribing and deprescribing tools, perception of their role in deprescribing, and self-efficacy in planning and implementation of deprescribing decisions.

CONCLUSIONS

Hospital clinicians and senior medical students had limited self-efficacy in deprescribing and hospital clinicians reported they did not deprescribe frequently. Targets for educational and behavioral interventions were identified. A short e-learning module on polypharmacy and deprescribing may be a useful component of a multi-strategic intervention to implement deprescribing into routine inpatient care.

Predictors of Mortality in the Older Population: The Role of Polypharmacy and Other Medication and Chronic Disease-Related Factors

BACKGROUND

Polypharmacy has been associated with increased mortality but the contribution of different medication-related factors to this is unknown.

AIMS

The aim of this study was to identify demographic and medication-related predictors of mortality in the older population. Given the intrinsic link between polypharmacy and multimorbidity, the secondary aim was to examine if the medicines or underlying diseases predicted mortality.

METHODS

Patients aged ≥ 65 years from an outpatient multimorbidity clinic were included. Medication-related factors included the medicines count, high-risk medicines, inappropriate medicines duplication, and potential drug-drug and drug-disease interactions. Logistic regression was used to identify mortality predictors within a year of clinic discharge from the outpatient clinic. Patients attend the clinic until medications and comorbidity management have been optimised, at which point they are discharged from the clinic, and their General Practitioner provides ongoing care.

RESULTS

A total of 584 patients were included (median age 80.0 years) and 9.9% (n = 58) died within a year of discharge. Demographics, namely age (adjusted odds ratio [aOR] 1.05; 95% CI 1.01-1.09; p = 0.018) and being male (aOR 5.10; 95% CI 2.63-9.88; p < 0.001); chronic disease, namely heart failure (aOR 3.36; 95% CI 1.78-6.35; p < 0.001); and medication-related factors, namely the number of sedative and anticholinergic medicines (aOR 1.66; 95% CI 1.19-2.33; p = 0.003) predicted mortality in the study population.

CONCLUSION

Whilst polypharmacy has been defined using the number of medicines in the literature, a combination of demographics, chronic disease and medications predicted mortality in our study. This provides guidance for the development of future tools and guidelines regarding the inclusion of key factors for identifying high-risk patients at risk of adverse health outcomes such as mortality.