title: Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review.
abstract: OBJECTIVE
  To summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people.
  
  
  METHODS
  Cochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation).
  
  
  METHODS
  All healthcare settings.
  
  
  METHODS
  Older people (≥ 65 years) with ≥ 1 long-term condition who were receiving polypharmacy (≥ 4 regular medicines).
  
  
  METHODS
  Primary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes.
  
  
  RESULTS
  12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers' criteria and Screening Tool of Older Person's Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported.
  
  
  CONCLUSIONS
  The included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice.
authors.affiliation: School of Pharmacy, Queen's University Belfast, Belfast, UK.
authors.forename: Janine A
authors.initials: JA
authors.lastname: Cooper
authors.affiliation: School of Pharmacy, Queen's University Belfast, Belfast, UK.
authors.forename: Cathal A
authors.initials: CA
authors.lastname: Cadogan
authors.affiliation: Belfast, UK.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Patterson
authors.affiliation: Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
authors.forename: Ngaire
authors.identifier: http://orcid.org/0000-0002-5992-3681
authors.initials: N
authors.lastname: Kerse
authors.affiliation: School of Pharmacy, Queen's University Belfast, Belfast, UK.
authors.forename: Marie C
authors.initials: MC
authors.lastname: Bradley
authors.affiliation: School of Pharmacy, Queen's University Belfast, Belfast, UK.
authors.forename: Cristín
authors.initials: C
authors.lastname: Ryan
authors.affiliation: School of Pharmacy, Queen's University Belfast, Belfast, UK.
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Hughes
mesh_terms: D000368:Aged; D011307:Drug Prescriptions / Q000592:standards*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology*; D006760:Hospitalization; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D055118:Medication Adherence; D019338:Polypharmacy; D000067561:Potentially Inappropriate Medication List; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic
keywords: GERIATRIC MEDICINE; aged; interventions; polypharmacy; systematic review