[Medication review of the polymedicated patient in primary care]

Interventions to improve the appropriate use of polypharmacy for older people

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. This is the second update of this Cochrane Review.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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).

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"]

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient.

[Potentially inappropriate prescription according to the "STOPP" Criteria in heavily polymedicated elderly patients]

INTRODUCTION

Appropriate prescribing is especially relevant in elderly people. The objective of this study is to analyse the potentially inappropriate prescription (PIP) in heavily polymedicated elderly patients according to the criteria Screening Tool of Older Person's Prescriptions.

PATIENTS AND METHODS

A descriptive cross-sectional study was conducted in Primary Care on patients assigned to the Siero-Sariego (Asturias) Health Centre, who were over 64 years old and heavily polymedicated (consumption >10 drugs for six months). The 65 Screening Tool of Older Person's Prescriptions criteria were reviewed in the electronic Primary Care patient records, collecting sociodemographic variables, prescribed medications, and chronic diseases. Frequency distributions were made for each criterion, and causes related to PIP were explored using contingency tables, the Spearman correlation coefficient, and logistic regression.

RESULTS

A total of 349 polymedicated elderly patients were analysed with a prevalence of 6.4 (95% CI:5.76-7.08), a mean age of 79.2 years (SD:3.7), 62.2% were female, 14% institutionalised, a Charlson index of 2.9. The mean of number of drugs was 11.5 (SD:1.7), and the most frequent pathologies were high blood pressure (64%), diabetes (46%), and osteoarticular diseases (41%). There was at least one PIP in 72.9% of heavily polymedicated elderly patients [(Mean: 1.32 (SD:1.2)]. The Screening Tool of Older Person's Prescriptions criteria least complied with were: therapeutic duplication (25.2%), use of long-acting benzodiazepines (15.8%), and inappropriate use of aspirin (10.9%). An association was found between having any inappropriate prescription and the number of medications prescribed (OR=1.22 [95% CI:1.04-1.43]) and inversely to the Charlson index (OR=0.76 [95% CI:0.65-0.89]).

CONCLUSIONS

PIP is common in heavily polymedicated elderly patients. Special attention must be paid to the use of psychotropic drugs, which are implicated in a high volume of PIP.

[Adherence to treatment, by active ingredient, in patients over 65 years on multiple medication]

AIM

To assess the level of adherence, by active ingredient, to treatment and associated factors in polymedicated patients over 65 years-old.

DESIGN

Observational, descriptive and cross-sectional study over polymedicated patients over 65 years of the Costa del Sol Health District and the North Malaga Health Area. The study was performed between January 2011 and September 2012 on 375 subjects obtained by simple random sampling from lists provided by each health centre. Data was collected by means of an interview with structured questions. Informed consent was given and signed by all patients before interview.

STUDY VARIABLES

Main results variable adherence to treatment (Morisky-Green's test).

PREDICTABLE VARIABLES

Prescription by active ingredient, socio-demographic variables, health care centre variables, and treatment associated variables. A descriptive analysis of variables was performed. Statistical inference was determined using univariate analysis (t test of Student or Mann-Whitney U, and Chi-squared), and controlling for confounding factors by multivariate analysis (linear and logistic regression).

RESULTS

The result for therapeutic compliance was 51.7%. No statistically significant differences were observed as regards sex and age. A relationship was found in those who resided in rural areas (P=.001), lived with family (P<.05), and were not at risk of suffering from anxiety (P=.046).

CONCLUSIONS

We found similar patient adherence to treatment despite the prescribing generic drugs. Failure to therapeutic compliance was greater in those patients who lived by themselves, in a city close to the coast, or in those patients who were at risk of suffering from anxiety.