Skip to main content

Main menu

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums

User menu

  • My alerts

Search

  • Advanced search
The College of Family Physicians of Canada
  • Other Publications
    • http://www.cfpc.ca/Canadianfamilyphysician/
    • https://www.cfpc.ca/Login/
    • Careers and Locums
  • My alerts
The College of Family Physicians of Canada

Advanced Search

  • Home
  • Articles
    • Current
    • Published Ahead of Print
    • Archive
    • Supplemental Issues
    • Collections - French
    • Collections - English
  • Info for
    • Authors & Reviewers
    • Submit a Manuscript
    • Advertisers
    • Careers & Locums
    • Subscribers
    • Permissions
  • About CFP
    • About CFP
    • About the CFPC
    • Editorial Advisory Board
    • Terms of Use
    • Contact Us
  • Feedback
    • Feedback
    • Rapid Responses
    • Most Read
    • Most Cited
    • Email Alerts
  • Blogs
    • Latest Blogs
    • Blog Guidelines
    • Directives pour les blogues
  • Mainpro+ Credits
    • About Mainpro+
    • Member Login
    • Instructions
  • RSS feeds
  • Follow cfp Template on Twitter
Research ArticleWeb exclusive

Interventions to address polypharmacy in older adults living with multimorbidity

Review of reviews

Muhammad Usman Ali, Diana Sherifali, Donna Fitzpatrick-Lewis, Meghan Kenny, Larkin Lamarche, Parminder Raina and Derelie Mangin
Canadian Family Physician July 2022, 68 (7) e215-e226; DOI: https://doi.org/10.46747/cfp.6807e215
Muhammad Usman Ali
Epidemiologist with the McMaster Evidence Review and Synthesis Team (MERST) at McMaster University in Hamilton, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Diana Sherifali
Associate Professor in the School of Nursing at McMaster University and Lead of MERST.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: dsherif@mcmaster.ca
Donna Fitzpatrick-Lewis
Senior Research Coordinator and Scientific Manager with MERST.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Meghan Kenny
Research Coordinator in the Department of Health Research Methods, Evidence, and Impact at McMaster University.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Larkin Lamarche
Assistant Professor in the School of Kinesiology and Health Sciences at York University in Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Parminder Raina
Professor in the Department of Health Research Methods, Evidence, and Impact and Scientific Director of the McMaster Institute for Research on Aging at McMaster University.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Derelie Mangin
Professor in the Department of Family Medicine, the David Braley Nancy Gordon Chair in Family Medicine, and Director and Associate Chair of Research at McMaster University.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • CFPlus
  • eLetters
  • Info & Metrics
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Additional Files
  • Figure 1.
    • Download figure
    • Open in new tab
    Figure 1.

    PRISMA flowchart: Search results for polypharmacy interventions.

Tables

  • Figures
  • Additional Files
    • View popup
    Table 1.

    Characteristics of included systematic reviews

    STUDY, YCOUNTRIESOBJECTIVEMETHODSPARTICIPANTSINTERVENTIONFUNDING SOURCE
    Johansson et al,15 2016NRTo explore the impact of strategies aiming to reduce polypharmacy on mortality, hospitalization, and change in no. of drugsAnalysis type: meta-analysis

    Setting: GP surgeries, primary care centres, GP outpatient clinic including home-dwelling and community-dwelling participants. Strategies were also carried out in internal medical clinics, hospitals, chronic care geriatric facilities, residential hospitals with continuous care wards, nursing homes, and assisted living facilities

    Inclusion criteria: age ≥65 y with polypharmacy (≥4 drugs); interventions aimed explicitly at reducing the no. of drugs; patient-relevant outcome measures such as mortality and hospitalization; electronic and nonelectronic interventions as well as mono- and interdisciplinary approaches aimed at the reduction of inappropriate polypharmacy (STOPP interventions); studies explicitly stating the reduction of polypharmacy as an objective or implicitly aimed at the optimization of drug appropriateness by discontinuing inappropriate drugs (eg, tools to detect drug-drug interactions, dosing errors, risk of ADEs, and renal drug dosing). For both study types, the no. of drugs had to be reported at baseline and follow-up

    Exclusion criteria: studies that did not report no. of drugs; approaches investigating underprescription (eg, START interventions) because a converse effect on drug quantity was expected; interventions focusing on people receiving short-term polypharmacy (eg, terminally ill or receiving cancer chemotherapy); before-and-after studies, interrupted time-series studies, or historically controlled studies, as these study designs have serious limitations

    Study designs of included studies: 21 RCTs and 4 non-RCTs
    Sample: N=10,980

    Total no. of included studies: 25

    Mean age range: 69.7 y to 87.7 y

    Gender range, % male: 20% to 100%

    Chronic conditions: NR

    Mean no. of medications reported: 7.4
    Most studies considered strategies aimed at improving the quality (appropriateness) of the medication regimen by removing inappropriate prescriptions, without explicitly stating the reduction in the no. of drugs as a study objective. Only 5 studies explicitly aimed to reduce the quantity of drugs or the no. of potential or actual drug-related problems, such as nonadherence, expired indication, duplication, inappropriate dosage, off-label use, and contraindications

    Interventions: pharmacist led (13), physician led (3), multidisciplinary team led (8), physician or pharmacist (1)

    Description of control or comparator: usual care, other comparable interventions, no intervention

    Follow-up: 6 wk to 18 mo

    Outcomes reported:
    • Primary outcomes: mortality, hospitalization, change in no. of medications

    • Secondary outcomes: new morbidity, change in QOL, changes in physical and mental functioning, ADE, adverse drug reaction, medication error, inappropriate medication, adverse event after discontinuation of medication (safety), process of care (feasibility), user or patient satisfaction or acceptance, adherence to medication, resource utilization (eg, use of health care resources), costs (eg, reduction of drug costs, hospital costs), cost-effectiveness


    Quality appraisal: Cochrane ROB

    GRADE done: yes
    European Union’s Seventh Framework Programme for research technological development and demonstration (grant agreement no. 305 388)
    Riordan et al,21 2016United States, England (United Kingdom), New ZealandTo evaluate studies of pharmacist-led interventions on medication prescribing among community-dwelling older adults receiving primary care to identify the components of successful interventionsAnalysis type: narrative synthesis

    Setting: community

    Inclusion criteria: all cluster RCTs, quasi-RCTs, controlled before-and-after studies, interrupted timeseries designs. Community-dwelling older adults ≥65 y. Pharmacist-led interventions were included. Comparison group was usual care or other active interventions not focused on medication appropriateness. Primary outcome measure was the change in prescribing appropriateness using a validated explicit or implicit screening tool for the detection of PIP

    Exclusion criteria: studies that were ongoing, if there was a lack of reply from the author for supplementary information, or if the analysis was purely economic. Studies based on nursing home populations were excluded

    Study designs of included studies: 4 RCTs, 1 interrupted time series and repeated measures study
    Sample: N=61,006

    Total no. of included studies: 5

    Mean age range: 64.4 y to 80.4 y

    Gender range, % male: 28% to 98%

    Chronic conditions: NR

    No. of medications reported: overall NR, mean range of 5.7 to 8.2
    Pharmacist-led interventions were defined as any intervention where the pharmacist had the lead role in an intervention designed to reduce PIP or improve medication appropriateness in primary care

    Interventions led by: pharmacists

    Description of control or comparator: usual care or other active interventions not focused on medication appropriateness

    Follow-up: NR

    Outcomes reported: the primary outcome measure was change in prescribing appropriateness using a validated explicit or implicit screening tool for the detection of PIP (ie, Beers criteria, STOPP-START, MAI). Secondary outcomes included any clinical or patient self-reported outcomes (eg, QOL, patient satisfaction), change in the no. of medications used, dosage reductions, and medication switches

    Quality appraisal: Effective Practice and Organisation of Care ROB criteria; Cochrane ROB was used for RCTs

    GRADE done: no
    Health Research Board
    SPHeRE/2013/1
    Hill-Taylor et al,22 2016Ireland, Belgium, Spain, IsraelTo update the 2013 systematic review using new evidence from RCTs that assess the effectiveness of STOPP-START criteria on prescribing quality and clinical, humanistic, and economic outcomes in adults ≥65 yAnalysis type: narrative summary

    Setting: community-dwelling in hospital (patient in transition), n=2 studies; long-term care (patient in stable care), n=2 studies

    Inclusion criteria: all RCTs involving the prospective application of the STOPP or START criteria on the medication profiles of persons ≥65 y. Studies that measured robust indicators of the clinical, humanistic, and economic impact of the application of the criteria were considered valuable in assessing the effectiveness of the screening tool. Data demonstrating the impact on PIP were also considered primary outcomes

    Exclusion criteria: non-English, not related to STOPP or START criteria, research not published in peer-reviewed journal, ongoing research, ineligible participant age, ineligible criteria such as modified criteria, truncated criteria, not an RCT, study was retrospective

    Study design of included studies: RCTs
    Sample: N=1925

    Total no. of included studies: 4

    Median age range: 74.5 y to 86 y

    Gender range, % male: 28% to 47%

    Chronic conditions: NR

    Mean no. of medications reported: intervention 8.8, control 8.2
    All studies except 1 (Dalleur et al) used the full 65 STOPP and the full 22 START criteria in their interventions. Dalleur et al also did not use the duplicate therapy STOPP criteria and did not apply the START criteria

    Interventions led by: pharmacist or physician

    Description of control or comparator: NR
    Follow-up: NR

    Outcomes reported: effects on the appropriateness of prescribing as a result of the intervention were reported by all studies, although reporting and assessment were inconsistent. Clinical outcomes were reported in 3 of the 4 papers, economic indicators in 2, and QOL indicators in 1

    Quality appraisal: Cochrane ROB

    GRADE done: no
    Research grant received from the Drug Evaluation Alliance of Nova Scotia. One author received funding from the Health Research Board (Dublin, Ireland) and Atlantic Philanthropies (Dublin, Ireland) and conducted this research as part of the SPHeRE Programme under grant no. SPHeRE/2013/1
    Patterson et al,5 2014Australia, Belgium, Canada, Ireland, United StatesTo determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older peopleAnalysis type: meta-analysis

    Setting: hospital setting (7), primary care setting (2), nursing homes (3)

    Inclusion criteria:
    • People aged ≥65 y who had more than 1 long-term medical condition, including those for whom polypharmacy (≥4 medicines) was common practice (eg, those with Parkinson disease or diabetes). Trials were considered for inclusion if they included a majority (≥80%) of participants ≥65y, or if the mean age of study participants was >65 y. If studies included both older and younger people, they were included if the relevant data could be extracted. Studies in which the intervention focused on people with a single long-term medical condition or who were receiving short-term polypharmacy (eg, those who were terminally ill or were receiving chemotherapy for cancer) were excluded

    • Any interventions aimed at improving appropriate polypharmacy in any setting compared with usual care

    • Interventions that targeted polypharmacy across all ages, provided results for those ≥65 y were available separately

    • Interventions that directly or indirectly affected prescribing and were aimed at improving appropriate polypharmacy (eg, educational programs aimed at prescribers; organizational interventions such as skillmix changes, pharmacist-led medication review services, or specialist clinics; information and communication technology interventions such as clinical decision support systems or use of risk-screening tools; financial interventions such as incentive schemes for changes in prescribing practice; regulatory interventions)

    Outcome measures: validated measures of inappropriate prescribing were the main outcome measures. Increasing appropriate polypharmacy could improve indicators of morbidity, such as reductions in ADEs or hospital admissions, but clinical outcomes were not clearly reported because of confounding factors such as multimorbidity in older people. Studies in which expert opinion was used to determine medication appropriateness were excluded

    Study designs of included studies: 8 RCTs, 2 cluster RCTs, 2 controlled before-and-after studies
    Sample: N=22,438

    Total no. of included studies: 12

    Mean age: intervention 76.4 y, control 76.3 y

    Gender (% male): 35%

    Chronic conditions: all study participants had more than 1 chronic condition. Conditions included asthma, diabetes, dyslipidemia, hypertension, cardiovascular disease, and dementia

    No. of medications reported: on average, participants were receiving >4 medications at baseline. In 11 of the 12 studies for which data were available (9878 participants), the mean no. of medications prescribed was 9.4 (intervention participants) and 8.9 (control participants)
    Eleven studies examined multifaceted interventions of pharmaceutical care provided by pharmacists in various settings. One unifaceted study examined computerized decision support provided to GPs in their practices. In hospital settings, pharmacists worked as part of multidisciplinary teams in outpatient clinics, in inpatient services on hospital wards, or as part of the hospital discharge process. In community settings, pharmaceutical care services were provided in community-based family medicine clinics. In nursing homes, pharmacists provided multidisciplinary case conferences, staff education, and a drug therapy management service. Physicians delivered the intervention via a computerized support program in 1 study, whereas in all other studies criteria-based processes were used to develop recommendations for improving the appropriateness of prescribing

    Participant education was provided as part of the pharmaceutical care intervention in 4 of 6 studies that had face-to-face interventions, and these participants were given directive guidance and specialized medication scheduling tools (eg, monitored dosage systems) to encourage adherence to their prescribed medication regimens

    Education was provided to prescribers and other team members as part of the intervention in 5 studies Interventions led by: pharmacists (6), physicians (1), team (5)

    Description of control or comparator: usual care

    Follow-up: range 1 mo to 12 mo

    Outcomes reported:
    • Primary outcome was appropriateness of medications prescribed, as measured by a validated instrument (eg, Beers criteria)

    • Prevalence of appropriate medication, as defined by a validated tool (eg, START criteria)

    • Secondary outcomes were medication-related problems in older people (eg, adverse drug reactions, drug-drug interactions, medication errors); adherence to medication; QOL


    Quality appraisal: Cochrane ROB
    GRADE done: yes
    No funding
    Tasai et al,23 2019All studies were conducted in high-income Western countries: Denmark, Germany, the Netherlands, Northern Ireland, Portugal, Republic of Ireland, Spain, Sweden, New Zealand, and United StatesTo assess the impact of medication reviews delivered by community pharmacists to elderly patients on polypharmacyAnalysis type: meta-analysis

    Setting: community

    Inclusion criteria: patients ≥65 y who were taking ≥4 prescribed medications; interventions were delivered by community pharmacists; studies measured 1 of these outcomes: hospitalization, ED visits, QOL, adherence. Studies were included regardless of language of publication

    Exclusion criteria: NR

    Study design of included studies: RCTs
    Sample: N=4633

    Total number of included studies: 4 (3 included in meta-analysis)

    Mean age range: 74.8 y to 75.9 y

    Gender, % male: 38.6%

    Chronic conditions: NR

    No. of medications reported: ≥7
    Medication review

    Interventions led by: community-based pharmacists

    Description of control or comparator: NR

    Follow-up: NR

    Outcomes reported: hospitalization, ED visit, QOL, adherence

    Quality appraisal: Cochrane Effective Practice and Organisation of Care Group

    GRADE done: no
    Naresuan University Research Fund
    • ADE—adverse drug event; ED—emergency department; GRADE—Grading of Recommendations Assessment, Development and Evaluation; MAI—Medication Appropriateness Index; NR—not reported; PIP—potentially inappropriate prescribing; QOL—quality of life; RCT—randomized controlled trial; ROB—risk of bias; START—Screening Tool to Alert to Right Treatment; STOPP—Screening Tool of Older Persons’ Prescriptions.

    • View popup
    Table 2.

    AMSTAR 2 ratings

    AMSTAR 2 QUESTIONSJOHANSSON ET AL,15 2016RIORDAN ET AL,21 2016HILL-TAYLOR ET AL,22 2016PATTERSON ET AL,5 2014TASAI ET AL,23 2019
    Uses elements of PICOYesYesYesYesYes
    Methods and protocols defined in advance and deviations reportedYesNoPartial yesYesNo
    Authors explained selection of the study designs for inclusionYesYesYesYesYes
    Comprehensive literature search strategy usedYesPartial yesYesYesPartial yes
    Study selection performed in duplicateYesYesYesYesYes
    Duplicate study selectionYesYesYesYesYes
    Dual data extractionYesNoYesYesYes
    Excluded study list providedYesYesNoYesNo
    Included studies described adequatelyYesYesYesYesYes
    RCTs: satisfactory ROB technique usedYesYesYesYesPartial yes
    NRSI: satisfactory ROB technique usedPartial yesNoNAYesNA
    Funding sources reportedNoNoNoNoNo
    RCT: meta-analysis–appropriate statistical methodsYesNo meta-analysis conductedYesYesYes
    NRSI: meta-analysis–appropriate statistical methodsNoNANo meta-analysis conductedYesNA
    Impact of ROB on synthesis assessedYesNANoYesYes
    Did the review authors account for ROB in individual studies when interpreting or discussing the results of the review?NoNoNoYesYes
    HeterogeneityYesNoYesYesYes
    Conflicts of interestYesYesYesYesYes
    Overall ratingModerateLowLowHighLow
    • AMSTAR 2—A Measurement Tool to Assess Systematic Reviews 2; NA—not applicable; NRSI—non-randomized studies of intervention; PICO—patient or population, intervention, comparison, and outcomes; RCT—randomized controlled trial; ROB—risk of bias.

Additional Files

  • Figures
  • Tables
  • CFPlus Additional Material

    • Appendix_A_Search_Strategy.pdf
PreviousNext
Back to top

In this issue

Canadian Family Physician: 68 (7)
Canadian Family Physician
Vol. 68, Issue 7
1 Jul 2022
  • Table of Contents
  • About the Cover
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on The College of Family Physicians of Canada.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Interventions to address polypharmacy in older adults living with multimorbidity
(Your Name) has sent you a message from The College of Family Physicians of Canada
(Your Name) thought you would like to see the The College of Family Physicians of Canada web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Interventions to address polypharmacy in older adults living with multimorbidity
Muhammad Usman Ali, Diana Sherifali, Donna Fitzpatrick-Lewis, Meghan Kenny, Larkin Lamarche, Parminder Raina, Derelie Mangin
Canadian Family Physician Jul 2022, 68 (7) e215-e226; DOI: 10.46747/cfp.6807e215

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Respond to this article
Share
Interventions to address polypharmacy in older adults living with multimorbidity
Muhammad Usman Ali, Diana Sherifali, Donna Fitzpatrick-Lewis, Meghan Kenny, Larkin Lamarche, Parminder Raina, Derelie Mangin
Canadian Family Physician Jul 2022, 68 (7) e215-e226; DOI: 10.46747/cfp.6807e215
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • METHODS
    • SYNTHESIS
    • DISCUSSION
    • Acknowledgments
    • Notes
    • Footnotes
    • References
  • Figures & Data
  • CFPlus
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

Web exclusive

  • Assessing students and residents
  • Informed decision making to avoid overdiagnosis of labour dystocia
  • Point-of-care ultrasound for evaluation of vaginal bleeding or abdominal pain in early pregnancy
Show more Web exclusive

Research

  • First-trimester surgical abortion practice in Canada in 2012
  • Focused practice in family medicine
  • Abdominal aortic aneurysm screening in an academic family practice
Show more Research

Similar Articles

Navigate

  • Home
  • Current Issue
  • Archive
  • Collections - English
  • Collections - Française

For Authors

  • Authors and Reviewers
  • Submit a Manuscript
  • Permissions
  • Terms of Use

General Information

  • About CFP
  • About the CFPC
  • Advertisers
  • Careers & Locums
  • Editorial Advisory Board
  • Subscribers

Journal Services

  • Email Alerts
  • Twitter
  • RSS Feeds

Copyright © 2023 by The College of Family Physicians of Canada

Powered by HighWire