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Cole JA, Gonçalves-Bradley DC, Alqahtani M, Barry HE, Cadogan C, Rankin A, Patterson SM, Kerse N, Cardwell CR, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2023; 10:CD008165. [PMID: 37818791 PMCID: PMC10565901 DOI: 10.1002/14651858.cd008165.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
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, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES To assess the effects of interventions, alone or in combination, 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 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, 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 Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the 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 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most 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) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.
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Affiliation(s)
- Judith A Cole
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | | | | | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Audrey Rankin
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | | | - Ngaire Kerse
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
| | - Chris R Cardwell
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Ioakeim-Skoufa I, Clerencia-Sierra M, Moreno-Juste A, Elías de Molins Peña C, Poblador-Plou B, Aza-Pascual-Salcedo M, González-Rubio F, Prados-Torres A, Gimeno-Miguel A. Multimorbidity Clusters in the Oldest Old: Results from the EpiChron Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10180. [PMID: 36011814 PMCID: PMC9408216 DOI: 10.3390/ijerph191610180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 06/15/2023]
Abstract
Multimorbidity is challenging for both patients and healthcare systems due to its increasing prevalence and high impact on people's health and well-being. The risk of multimorbidity increases with age, but there is still more to discover regarding the clinical profile of the oldest old. In this study, we used information from the EpiChron Cohort Study to identify multimorbidity patterns in individuals who died during the period 2010-2019 at the ages of 80-89, 90-99, and ≥100. This cohort links the demographic, clinical, and drug dispensation information of public health system users in Aragón, Spain. We saw a significantly lower number of chronic diseases and drugs and a lower prevalence of polypharmacy in centenarians compared to those aged 80-99. K-means clustering revealed different multimorbidity clusters by sex and age group. We observed clusters of cardiovascular and metabolic diseases, obstructive pulmonary conditions, and neoplasms, amongst other profiles. One in three octogenarian women had a metabolic pattern (diabetes, dyslipidaemia, and other endocrine-metabolic disorders) with the highest number of diseases (up to seven) and prevalence of polypharmacy (64%). We observed clusters of dementia and genitourinary disorders in individuals on medication with anticholinergic activity. Our study offers an opportunity to better understand the urgency of adequately addressing multimorbidity in our older adults.
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Affiliation(s)
- Ignatios Ioakeim-Skoufa
- WHO Collaborating Centre for Drug Statistics Methodology, Department of Drug Statistics, Division of Health Data and Digitalisation, Norwegian Institute of Public Health, NO-0213 Oslo, Norway
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain
| | - Mercedes Clerencia-Sierra
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Aragon Health Service (SALUD), Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
| | - Aida Moreno-Juste
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Aragon Health Service (SALUD), Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
| | | | - Beatriz Poblador-Plou
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
| | - Mercedes Aza-Pascual-Salcedo
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
- Primary Care Pharmacy Service Zaragoza III, Aragon Health Service (SALUD), ES-50017 Zaragoza, Spain
| | - Francisca González-Rubio
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
| | - Alexandra Prados-Torres
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
| | - Antonio Gimeno-Miguel
- EpiChron Research Group, Aragon Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, ES-50009 Zaragoza, Spain
- Research Network on Health Services in Chronic Patients (REDISSEC), ISCIII, ES-28029 Madrid, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), ISCIII, ES-28029 Madrid, Spain
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