Community-Level Pharmaceutical Interventions to Reduce the Risks of Polypharmacy in the Elderly: Overview of Systematic Reviews and Economic Evaluations

Abstract

Background: Patients over 65 years of age taking multiple medications face several risks, and pharmaceutical interventions can be useful to improve quality of care and reduce those risks. However, there is still no consensus on the effectiveness of these interventions aimed at promoting changes in clinical, epidemiological, economic, and humanistic outcomes for various service delivery, organizational, financial, and implementation-based interventions. The objective of this overview of systematic reviews was to summarize evidence on the effectiveness of community-level pharmaceutical interventions to reduce the risks associated with polypharmacy in the population over 65 years of age. Method: This overview used a previously described protocol to search for systematic review articles, with and without meta-analysis, and economic evaluations, without any language or time restrictions, including articles published up to May 2018. The following databases were searched: the Cochrane Library, Epistemonikos, Health Evidence, Health Systems Evidence, Virtual Health Library, and Google Scholar. The basic search terms used were “elderly,” “polypharmacy,” and “pharmaceutical interventions.” The findings for outcomes of interest were categorized using a taxonomy for health policies and systems. Equity-related questions were also investigated. The studies were evaluated for methodological quality and produced a narrative synthesis. Results: A total of 642 records were retrieved: 50 from Health Evidence, 197 from Epistemonikos, 194 from Cochrane, 116 from Health Systems Evidence, and 85 from the Virtual Health Library. Of these, 16 articles were selected: 1 overview of systematic reviews, 12 systematic reviews, and 3 economic evaluations. There is evidence of improvement in clinical, epidemiological, humanistic, and economic outcomes for various types of community-level pharmaceutical interventions, but differences in observed outcomes may be due to study designs, primary study sample sizes, risk of bias, difficulty in aggregating data, heterogeneity of indicators and quality of evidence included in the systematic reviews that were assessed. It is necessary to optimize the methodological designs of future primary and secondary studies. Conclusion: Community-level pharmaceutical interventions can improve various clinical, epidemiological, humanistic and economic outcomes and potentially reduce risks associated with polypharmacy in the elderly population.

Patterns and Characteristics of Polypharmacy Among Elderly Residents in Danish Nursing Homes

“…On the other hand, risks may arise when inappropriate polypharmacy exists, which is defined as an irrational prescription of too many drugs [ 12 ]. Appropriate polypharmacy occurs when the decisions concerning the prescription of multiple drugs to one patient rely on evidence-based practices, achieving the desired clinical effect without compromising the patient’s quality of life by acquiring a reduction in drug toxicity [ 13 ]. However, inappropriate polypharmacy occurs when the prescription of multiple drugs to one patient fails to achieve the desired therapeutic effect, only resulting in increased risks and harmful health outcomes [ 13 ].…”

“…The prevalence of PIMs was also higher among females [ 15 ]. Inappropriate polypharmacy results in an increased risk of avoidable negative health outcomes [ 13 ] and has been associated with higher risks of adverse drug events (ADEs) [ 16 ], drug interactions, for example, drug–drug interactions (DDIs) [ 17 ], medication nonadherence and functional decline [ 18 ]. A subcategory of ADEs are adverse drug reactions (ADRs), defined as harmful or unpleasant reactions related to use of drugs [ 19 ].…”

“…Hanlon et al [ 20 ] determined that polypharmacy consistently increases the risk of ADRs in elderly patients. In particular, it has been reported that this issue is higher in nursing homes [ 13 ], and patients on nine or more drugs are more than twice as likely to experience an ADR than those receiving less than nine [ 21 ]. This poses a serious problem because ADRs are difficult to distinguish from symptoms that are already present in the elderly, such as delirium and falls [ 22 ], making it difficult to choose the correct treatment, which can possibly lead to further inappropriate prescriptions [ 14 ].…”

Implementation of pharmaceutical care for older adults in the brazilian public health system: a case study and realistic evaluation

“…Systematic review and meta-analysis studies show significant results in terms of economic benefit, hospital admissions, length of hospital stay, mortality and resolution of drug-related problems, but indicate that such results are possible and conclusive only when clinical pharmaceutical services adopt systematic analysis of pharmacotherapy [2,[10][11][12]. It is evident that, when patients are systematically monitored by a pharmacist, they may exhibit better results related to blood pressure, glycated hemoglobin, albuminuria, renal failure and hyperlipidemia, including polymedicated elderly patients [13].…”

Medicines use review service in community pharmacies in Spain: REVISA project

“…Community pharmacy services play an important role in controlling some factors related to medicine use [9][10][11][12], and pharmaceutical services integrated with primary healthcare services are critical to achieve the desired outcomes and to significantly reduce harms that can otherwise arise from multiple medicine use, such as non-adherence or medicine-related problems [13].…”