Studies to Reduce Unnecessary Medication Use in Frail Older Adults: A Systematic Review

Abstract

Background

Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.

Objective

To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.

Methods

A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline—including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes.

Results

The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures.

Conclusions

Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.

Appendix

PUBMED search strategy: (“nursing homes”[MeSH] AND ([“prospective studies”[MeSH] or “retrospective studies”[MeSH] or “clinical trial”[MeSH]) AND (“drug utilization”[MeSH] or “prescription drugs”[MeSH] or “prescriptions” or “dementia/drug therapy”]). We combined these results with a search for (((“prospective studies”[MeSH] OR “retrospective studies”[MeSH] OR “clinical trial “[Publication Type] OR “drug utilization review”[MeSH]) AND (“prescriptions”[MeSH] OR “drug prescriptions”[MeSH] OR “drug utilization”[MeSH] OR “dementia/drug therapy”[MeSH] OR “dementia/therapy”[MeSH] OR “drug utilization/standards”[MeSH] OR “drug utilization/statistics and numerical data”[MeSH] OR “drug utilization/trends”[MeSH])) AND (“hospice” OR “hospices” OR “hospice care” OR “palliative care” OR “cancer” OR “end of life” OR “terminal illness” OR “terminally ill”)) AND ((“appropriate*” OR “inappropriate*” OR “drug related problems”) AND (“medication*” OR “prescribing*”)) AND (“criteria” OR “screening tool” OR “list” OR “index” OR “recommendations” OR “Delphi technique”).

IPA search strategies: (“prescriptions” or “drug prescriptions” or “drug utilization” or “dementia/drug therapy” or “dementia/therapy”) and ((“appropriate” or “inappropriate”) and (“medications” or “prescribing”)) and (“criteria” or “screening tool” or “list” or “index” or “recommendations” or “Delphi technique”)).mp.

EMBASE search strategies: ((“prospective studies” or “retrospective studies” or “clinical trial”) and (“prescriptions” or “drug prescriptions” or “drug utilization” or “dementia/drug therapy” or “dementia/therapy”) and ((“appropriate” or “inappropriate”) and (“medications” or “prescribing”)) and (“criteria” or “screening tool” or “list” or “index” or “recommendations” or “Delphi technique”)).mp.