Electronic prescribing and other forms of technology to reduce inappropriate medication use and polypharmacy in older people: a review of current evidence

This review provided an overview of the current evidence in relation to the use of e-prescribing and other forms of technology, such as CDSS, to reduce inappropriate prescribing in older people. The evidence indicates that various types of e-prescribing and CDSS interventions have the potential to reduce inappropriate prescribing and polypharmacy in older people, but the magnitude of their effect varies according to study design and setting. There was significant heterogeneity in the studies reported in terms of study designs, intervention design, patient settings, and outcome measures with patient outcomes seldom reported. Widespread diffusion of these interventions has not occurred in any of the health care settings examined. Overall, health care providers report being satisfied with e-prescribing systems and see the systems as having a positive impact on the safety of their prescribing practices, yet the problem of overriding or ignoring alerts persists. The problem of large numbers of inaccurate and insignificant alerts and this issue, along with the other barriers that have been identified, warrant further investigation.     

Factors leading to excessive polypharmacy

There are numerous risk factors for patients to develop excessive polypharmacy. The most prominent risk factors are associated with sociodemographics and the patients’ conditions. Risk factors associated with patient behavior, such as patient’s self medication with all types of medications, have not been observed to the same extent but might be at the same level of importance for patients developing excessive polypharmacy. Risk factors related to physicians, and the interaction between patient and physician, are studied to a much lesser extent. The few studies conducted regarding the large variation in physicians’ individual prescribing practices, in terms of polypharmacy, add another perspective to the complexity of the area. Interventions aiming to improve communication between GP and hospital specialist, to create support systems for medical reviews that include all patients’ medications, and to improve the knowledge of multiple prescribing might have the largest potential to better manage excessive polypharmacy.     

Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes

Different styles of interventions can reduce medication exposure in older adults. However, the evidence for their clinical effectiveness and sustainability is conflicting and lacking. There are some data to guide clinicians on which medicines are more likely to be inappropriate in older people, which medicines are more likely to cause ADWEs, and which medicines should be tapered slowly rather than stopped. To reduce the likelihood of clinically significant adverse events, clinicians should undertake a step-wise approach to discontinuing medications and do so under appropriate supervision. Further research to determine the most effective ways to discontinue medications, and to provide a better understanding of the clinical benefits of various interventions is required. Large RCTs evaluating multidisciplinary interventions and clinical outcomes of changes in medicines regimen across different settings are required to confirm the findings of the studies performed so far.     

Medication adherence to multidrug regimens

Despite the fact that medication adherence has been extensively described in the literature over the last several decades, a quote by Becker and Maiman from over 35 years ago best captures the current state of our understanding: “Patient compliance[sic adherence] has become the best documented, but least understood, health behavior.” Future research is greatly needed to identify and translate safe and effective interventions into routine clinical practice to improve adherence. Only then can we begin to make significant improvements to the medication use process and, in turn, the health of older adults.     

Potentiality of STOPP/START criteria used in primary care to effectively change inappropriate prescribing in elderly patients

PurposeTo analyse the potentiality of STOPP/START criteria for changing inappropriate prescribing (IP) in elderly polypharmacy patients, and their usefulness as perceived by general practitioners (GPs).Subjects and methodsThis was a cross-sectional study with 100 patients aged ≥ 65 years on four medications or more, from 20 GP lists across three health centres. The study variables included: age, sex, comorbidity, medications, IP (STOPP/START criteria), and GP adherence to recommendations, reasons for not adhering and perception of the toolkit's usefulness. Data were collected from electronic medical records and interviews with GPs.ResultsPatients (mean age 77 ± 5.7 years, 64% women) were prescribed a mean of 12.3 drugs/person, 8.7 for chronic conditions. We identified 92 instances of IP in 58 patients (95%CI 48–68%): 55 STOPP criteria in 42 patients (most involving acetylsalicylic acid 20%, NSAIDs 18% or benzodiazepines 16%) and 37 START in 31 patients. For all GPs, ≥ 1 instance of IP was detected, only two accepting all the recommendations. GPs adhered to 43/92 recommendations (46.7%, 95%CI 36.3–57.1%): 22/55 STOPP (40%, 95%CI 27–53%) and 21/37 START (56.8%, 95%CI 39.5-74.1%). Key reasons for not adhering were not being the prescribing physician (42%) and not seeing benefits (44%). While 95% trusted the recommendations, only 65% thought them feasible.ConclusionsDetecting IP using STOPP/START criteria is no guarantee of improving prescribing to the same extent, since GPs accept < 50% of recommendations. While GPs generally appreciate the relevance of the tool and claim to trust it, many believe applying it is not feasible in practice, time being the main barrier cited.     

Characteristics of inappropriate multiple medication use in older urological outpatients

ObjectivesTo investigate polypharmacy and potentially inappropriate medications (PIMs) in elderly patients visiting the urology department for lower urinary tract symptoms (LUTS).MethodsWe retrospectively analyzed digital medical records of individuals over the age of 65 who visited the urology department for LUTS. This cross-sectional study was conducted in 10 hospitals located in South Korea, between September 2017 and December 2017. All prescribed medications were analyzed using electronic medical records. The updated 2015 Beers criteria were used to identify and assess the appropriateness of the prescribed drugs in elderly patients.ResultsWe analyzed a total of 2143 patients aged over 65 years from 10 institutions. The mean age was 74.2 ± 6.26 years (65–97), 1634 (76.2%) were men. Patients took a mean of 6.48 ± 2.46 medications (range 0–18), and polypharmacy was found in 1762 patients (82.2%). The number of patients who received PIMs at least once was 1579 (73.7%). The average number of PIMs used per patient was 1.31 ± 1.25 (0–7). PIM use ratio was 18.9 ± 0.15% (0–67%). The number of chronic diseases, and concurrent medication and polypharmacy were predictive factors associated with PIM use.ConclusionOur multi-institutional results show that a substantial proportion of elderly patients took PIMs when visiting the urology department. Factors associated with PIMs were the number of chronic diseases and polypharmacy. Medication use in elderly patients, especially in urology, should be monitored carefully.     

Outcomes of polypharmacy in nursing home residents

This article provides a comprehensive review of the outcomes of polypharmacy in nursing homes. Our review had some limitations. First, we only included studies beginning in 1990, and significant earlier studies are not included. Only English language articles were included. We only researched studies from MEDLINE, and may have missed studies based on our search terms and search tools. There are many definitions of polypharmacy in the literature, including number of medications or inappropriate medications. In this review, we defined polypharmacy as a high number of medications, but not inappropriate medications. It was not surprising that polypharmacy was consistently associated with an increased number of potentially inappropriate drugs. The majority of studies were viewed showed that polypharmacy was associated with increased ADEs, increased DDIs, and increased hospitalizations. We were surprised that polypharmacy was not consistently linked with falls, fractures, and mortality. For the mortality studies, it has been postulated that perhaps some patients receiving 10 or more medications may have been moribund or receiving end-of-life or hospice care. It is possible that the number of medications is not as important as the number of potentially in appropriate drugs. There need to be more studies on these outcomes, using different definitions of polypharmacy. Polypharmacy was associated with increased costs. The drug-related morbidity and mortality, including those resulting from inappropriate medications and increased staff time, led to increased costs. Use of consultant pharmacists has been shown to decrease polypharmacy costs.     

Factors associated with polypharmacy in nursing home residents

The prevalence of polypharmacy is very high in the nursing home setting. In this comprehensive review, we describe the many demographic, functional status, chronic disease, and healthcare financing factors associated with polypharmacy in nursing home patients. Recognition of the factors associated with polypharmacy is the first step for practitioners. A quality improvement intervention study previously conducted by the authors of this paper demonstrated that polypharmacy can be reduced in the nursing setting as a result of systematic review of medications by physicians.     

Application of data mining for examining polypharmacy and adverse effects in cardiology patients

This article comments upon the use of data mining tools to examine clinical data. Many cardiovascular patients have co-morbid diseases that put them at risk for polypharmacy, or severe adverse reactions from the interactions of multiple medications. Clinical trials typically use too few patients with stringent inclusion/exclusion criteria that prevent an examination of the issue of polypharmacy. However, clinical data collected in the course of patient treatment can be used in conjunction with data mining to find meaningful results.     

Medication and falls: risk and optimization

The association between drugs and falls has been widely studied in the past 3 decades, with increasingly robust evidence of a causal link. Both specific classes of drugs and the total number of drugs taken are associated with falls. This review examines some of the reasons why older people are at greater risk of drug-related adverse events such as falls. We discuss the role of drugs in general and polypharmacy (the concurrent use of multiple drugs) on the risk of falling, with a focus on community-dwelling older people. We critically appraise the evidence that specific classes of drugs, such as benzodiazepines and antidepressants, increase the risk of falling and that falls can be prevented through interventions that target medications.