Optimisation of medications used in residential aged care facilities: a systematic review and meta-analysis of randomised controlled trials

Abstract

Background Frail older adults living in residential aged care facilities (RACFs) usually experience comorbidities and are frequently prescribed multiple medications. This increases the potential risk of inappropriate prescribing and its negative consequences. Thus, optimising prescribed medications in RACFs is a challenge for healthcare providers. Objective Our aim was to systematically review interventions that increase the appropriateness of medications used in RACFs and the outcomes of these interventions. Methods Systematic review and meta-analysis of randomised control trials (RCTs) and cluster randomised control trials (cRCTs) were performed by searching specified databases (MEDLINE, PubMed, Google scholar, PsycINFO) for publications from inception to May 2019 based on defined inclusion criteria. Data were extracted, study quality was assessed and statistically analysed using RevMan v5.3. Medication appropriateness, hospital admissions, mortality, falls, quality of life (QoL), Behavioural and Psychological Symptoms of Dementia (BPSD), adverse drug events (ADEs) and cognitive function could be meta-analysed. Results A total of 25 RCTs and cRCTs comprising 19,576 participants met the inclusion criteria. The studies tested various interventions including medication review ( n = 13), staff education ( n = 9), multi-disciplinary case conferencing ( n = 4) and computerised clinical decision support systems ( n = 2). There was an effect of interventions on medication appropriateness (RR 0.71; 95% confidence interval (CI): 0.60,0.84) (10 studies), and on medication appropriateness scales (standardised mean difference = − 0.67; 95% CI: − 0.97, − 0.36) (2 studies). There were no apparent effects on hospital admission (RR 1.00; 95% CI: 0.93, 1.06), mortality (RR 0.98; 95% CI: 0.86, 1.11), falls (RR 1.06; 95% CI: 0.89,1.26), ADEs (RR 1.04; 95% CI: 0.96,1.13), QoL (standardised mean difference = 0.16; 95% CI:-0.13, 0.45), cognitive function (weighted mean difference = 0.69; 95% CI: − 1.25, 2.64) and BPSD (RR 0.68; 95% CI: 0.44,1.06) (2 studies). Conclusion Modest improvements in medication appropriateness were observed in the studies included in this systematic review. However, the effect on clinical measures was limited to drive strong conclusions.

A systematic review of the evidence for deprescribing interventions among older people living with frailty

“…Among older people with identified frailty, there is some evidence from the included studies in this review that deprescribing is safe, as it did not adversely change hospitalisation and mortality rates. A number of systematic reviews have investigated the impact of deprescribing on mortality among general population of older people; one reported that deprescribing reduced mortality in nonrandomized studies but no changes were observed in RCTs [40]; other reviews suggested a reduction in allcause mortality with deprescribing interventions in nursing home residents [22,23]. We reported some evidence that deprescribing is feasible and well tolerated by older people living with frailty and is acceptable by healthcare professionals and patients, which is in agreement with existing studies in older people in general [41,42].…”

“…Several systematic reviews have synthesised the evidence on outcomes of deprescribing interventions among older people in general [ 20 , 21 ], or defined by setting including care homes [ 22 , 23 ], primary care and community [ 24 , 25 ] and hospitals [ 26 ]. These reviews reported that deprescribing is feasible, well tolerated, safe, and generally effective in reducing the number of inappropriate prescriptions.…”

A Systematic Review of the Evidence for Deprescribing Interventions Among Older People Living With Frailty

“…Among older people with identi ed frailty, there is some evidence from the included studies in this review that deprescribing is safe as it did not adversely change hospitalisation and mortality rates. A number of systematic reviews investigated the impact of deprescribing on mortality among general population of older people; one reported that deprescribing reduced mortality in non-randomized studies but no changes were observed in RCTs [40]; other reviews suggested a reduction in all-cause mortality with deprescribing interventions in nursing home residents [22,23]. We reported some evidence that deprescribing is feasible and well tolerated by older people living with frailty and is acceptable by healthcare professionals and patients, which is in agreement with existing studies in older people in general [41,42].…”

“…Several systematic reviews have synthesised the evidence on outcomes of deprescribing interventions among older people in general [20,21], or de ned by setting including care homes [22,23], primary care and community [24,25] and hospitals [26]. These reviews reported that deprescribing is feasible, well tolerated, safe, and generally effective in reducing the number of inappropriate prescriptions.…”

La Geriatría de Enlace con residencias en la época de la COVID-19. Un nuevo modelo de coordinación que ha llegado para quedarse

“…Los programas de coordinación entre Geriatría y residencias que incluyen la revisión de medicación suelen obtener una mejora en la adecuación de la prescripción 42 , 43 . Las geriatras de la Unidad realizaron dicha revisión en 92 pacientes, en los que se llevó a cabo una deprescripción de 81 fármacos innecesarios.…”