title: Interventions to improve the appropriate use of polypharmacy for older people.
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, hence there is growing interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients.
  
  
  OBJECTIVE
  This review sought 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.
  
  
  METHODS
  A range of literature databases including MEDLINE and EMBASE were searched in addition to handsearching reference lists. Search terms included polypharmacy, Beers criteria, medication appropriateness and inappropriate prescribing.
  
  
  METHODS
  A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older where a validated measure of appropriateness was used (e.g. Beers criteria or Medication Appropriateness Index - MAI).
  
  
  METHODS
  Three authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals.
  
  
  RESULTS
  Electronic searches identified 2200 potentially relevant citations, of which 139 were examined in detail. Following assessment, 10 studies were included. One intervention was computerised decision support and nine were complex, multifaceted pharmaceutical care provided in a variety of settings. Appropriateness of prescribing was measured using the MAI score postintervention (seven studies) and/or Beers criteria (four studies). The interventions included in this review demonstrated a reduction in inappropriate medication use. A mean difference of -6.78 (95% CI -12.34 to -1.22) in the change in MAI score in favour of the intervention group (four studies). Postintervention pooled data (five studies) showed a mean reduction of -3.88 (95% CI -5.40 to -2.35) in the summated MAI score and a mean reduction of -0.06 (95% CI -0.16 to 0.04) in the number of Beers drugs per patient (three studies). Evidence of the effect of the interventions on hospital admissions (four studies) was conflicting. Medication-related problems, reported as the number of adverse drug events (three studies), reduced significantly (35%) postintervention.
  
  
  CONCLUSIONS
  It is unclear if interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in a clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing and medication-related problems.
authors.affiliation: Health and Social Care Board, Belfast, UK. susan.patterson@hscni.net.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Patterson
authors.forename: Carmel
authors.initials: C
authors.lastname: Hughes
authors.forename: Ngaire
authors.initials: N
authors.lastname: Kerse
authors.forename: Chris R
authors.initials: CR
authors.lastname: Cardwell
authors.forename: Marie C
authors.initials: MC
authors.lastname: Bradley
mesh_terms: D000368:Aged; D011307:Drug Prescriptions / Q000592:standards; D064420:Drug-Related Side Effects and Adverse Reactions; D006801:Humans; D054539:Medication Therapy Management; D019338:Polypharmacy; D058996:Quality Improvement; D016032:Randomized Controlled Trials as Topic