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 interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing.
  
  
  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
  In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', '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 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).
  
  
  METHODS
  Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.
  
  
  RESULTS
  Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.
  
  
  CONCLUSIONS
  It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.
authors.affiliation: No affiliation, 12-22 Linenhall Street, Belfast, Northern Ireland, UK, BT2 8BS.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Patterson
authors.forename: Cathal A
authors.initials: CA
authors.lastname: Cadogan
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
authors.forename: Cristin
authors.initials: C
authors.lastname: Ryan
authors.forename: Carmel
authors.initials: C
authors.lastname: Hughes
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