Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care

Abstract

Background: Older persons with frailty take multiple medications and are vulnerable to inappropriate prescribing. Objective: This study assesses the impact of a team-based, pharmacist-led structured medication review process in primary care on the appropriateness of medications taken by older adults living with frailty. Methods: This was a quasi-experimental pretest-posttest design in 6 primary care practices within an academic clinic in Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years and older with frailty who have polypharmacy and/or 2 or more chronic conditions (ie, high-risk group for drug-related issues). The intervention was a structured pharmacist-led medication review using evidence-based explicit criteria (ie, Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise) for potentially inappropriate prescribing, done in the context of a primary care team-based seniors’ program. We measured the changes in the number of medications pre- and postmedication review, number of medications satisfying explicit criteria of START and STOPP/Beers and determined the association with frailty level. Data were analyzed using descriptive and inferential statistics (a priori significance level of P < .05). Results: A total of 54 participants (61.1% females, mean age 81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants completed the medication review process (2 lost to hospitalization). Drug-related problems noted on medication review were untreated conditions (61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No significant changes in total number of medications taken by patients before and after, but the intervention significantly decreased number of inappropriate medications (1.15 meds pre to 0.9 meds post; P = .006). Conclusion: A pharmacist-led medication review is a strategy that can be implemented in primary care to address inappropriate medications.

Systematic Medication Review in General Practice by an Interdisciplinary Team: A thorough but Laborious Method to Address Polypharmacy among Elderly Patients

“…We found an average of 7.5 recommendations per patient; all patients had at least one recommendation. This is higher than the average of 1.1-5.9 drug-related problems found in medication reviews performed jointly by a pharmacist and a GP, described in a literature review by Geurts et al [3,[22][23][24][25][26][27][28][29]. Other medication review studies reported between 84% and 98% of patients to have at least one drug-related problem compared with 100% in this study [22,25,29,30].…”

“…As these patients constituted the most complicated ones managed by each GP, they were prone to be more complicated than the patients considered in similar studies. This was supported by the number of medications recorded per patient (15.6), which was higher than those reported elsewhere (average of 4.6-12.8 medications per patient) [22][23][24][25][26][27][28][29][30][31].…”

“…The total number of drug-related problems and individuals with at least one drug-related problem depends, of course, on the population being studied. However, when considering studies with inclusion criteria similar to ours, the numbers of drug-related problems are still lower [3,22,23]. This suggests that the high frequency seen in our study is not a consequence of the inclusion criteria.…”

“…It is important to examine how many recommendations were accepted, as a high frequency of recommendations may be a result of many irrelevant recommendations [32]. We had an acceptance rate of 4.2 recommendations per patient, which is towards the higher end of those noted in similar studies [3,[22][23][24][25][26][27][28][29]. The large number of accepted recommendations may indicate that the GPs considered the recommendations relevant, and presumably arises from the consideration of more complicated patients, a thorough medication review with clinically relevant recommendations and face-to-face discussion between the medical consultant and GP.…”

“…We assumed that our definition of a recommended change in medication corresponds to outcomes observed in other medication review studies, e.g., drug-related problems and potentially inappropriate prescribing [22,23]. We found an average of 7.5 recommendations per patient; all patients had at least one recommendation.…”