Drugs & Aging

, Volume 30, Issue 5, pp 285–307 | Cite as

Studies to Reduce Unnecessary Medication Use in Frail Older Adults: A Systematic Review

  • Jennifer TjiaEmail author
  • Sarah J. Velten
  • Carole Parsons
  • Sruthi Valluri
  • Becky A. Briesacher
Systematic Review



Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.


To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.


A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative care, and appropriate or inappropriate. A manual review of 971 identified abstracts for the inclusion criteria (study included an intervention to reduce chronic medication use; at least 5 participants; population included patients aged at least 65 years, hospice enrollment, or indication of frailty or risk of functional decline—including assisted living or nursing home residence, inpatient hospitalization) yielded 60 articles for full review by 3 investigators. After exclusion of review articles, interventions targeting acute medications, or studies exclusively in the intensive care unit, 36 articles were retained (including 13 identified by bibliography review). Articles were extracted for study design, study setting, intervention description, criteria for identifying unnecessary medication use, and intervention outcomes.


The studies included 15 randomized controlled trials, 4 non-randomized trials, 6 pre-post studies, and 11 case series. Control groups were used in over half of the studies (n = 20). Study populations varied and included residents of nursing homes and assisted living facilities (n = 16), hospitalized patients (n = 14), hospice/palliative care patients (n = 3), home care patients (n = 2), and frail or disabled community-dwelling patients (n = 1). The majority of studies (n = 21) used implicit criteria to identify unnecessary medications (including drugs without indication, unnecessary duplication, and lack of effectiveness); only one study incorporated patient preference into prescribing criteria. Most (25) interventions were led by or involved pharmacists, 4 used academic detailing, 2 used audit and feedback reports targeting prescribers, and 5 involved physician-led medication reviews. Overall intervention effect sizes could not be determined due to heterogeneity of study designs, samples, and measures.


Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.


Nursing Home Palliative Care Medication Review Inappropriate Medication Assisted Living 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Ms. Velten was supported by a Medical Student Training in Aging Research grant by the American Federation for Aging Research. Dr. Parsons was funded by a travel grant from the School of Pharmacy, Queens University Belfast. Dr. Briesacher was supported by a Research Scientist Development Award from the National Institute of Aging (K01 AG031836). The study funders had no role in the study design, collection, analysis and interpretation of the data, writing of the manuscript, or decision to submit the manuscript for publication. Dr. Tjia was responsible for conceiving and planning the work, acquisition, analysis and interpretation of the data, and writing of the manuscript. Ms. Velten, Dr. Parsons, and Dr. Briesacher were responsible for acquisition and analysis of the data and contributed to writing of the manuscript. Ms. Valluri was responsible for data analysis and writing of the manuscript. The authors acknowledge Dr. Jerry Gurwitz for his support of this project and assistance obtaining funding for Ms. Velten, and Ms. Colleen Biggins and Mr. Shawn Gagne for assistance with preparation of this manuscript.

Conflict of Interest Statement

Dr. Briesacher received consulting funds from Novartis during the period of this work.


  1. 1.
    Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166:605–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Lee SP, Bain KT, Maio V. Appropriate discontinuation of medications at the end of life: a need to establish consensus criteria. Am J Med Qual. 2007;22:393–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. Br Med J. 2004;329:909–12.CrossRefGoogle Scholar
  4. 4.
    Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging. 2003;20:817–32.PubMedCrossRefGoogle Scholar
  5. 5.
    Marcum ZA, Handler SM, Wright R, Hanlon JT. Interventions to improve suboptimal prescribing in nursing homes: A narrative review. Am J Geriatr Pharmacother. 2010;8:183–200.PubMedCrossRefGoogle Scholar
  6. 6.
    Verrue CL, Petrovic M, Mehuys E, Remon JP. Vander Stichele R. Pharmacists’ interventions for optimization of medication use in nursing homes : a systematic review. Drugs Aging. 2009;26:37–49.PubMedCrossRefGoogle Scholar
  7. 7.
    McGhan WF, Wertheimer AI, Marttila JK. Assessing the need for pharmacist-conducted drug regimen reviews in skilled nursing and intermediate care facilities. Contemp Pharm Pract. 1980;3:203–9.PubMedGoogle Scholar
  8. 8.
    Forsetlund L, Eike MC, Gjerberg E, Vist GE. Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomized controlled trials. BMC Geriatr. 2011;11:16.
  9. 9.
    Cruz-Jentoft AJ, Boland B, Rexach L. Drug therapy optimization at the end of life. Drugs Aging. 2012;29:511–21.PubMedCrossRefGoogle Scholar
  10. 10.
    Omnibus Budget Reconciliation Act of 1987 [OBRA-87], U.S.C. § 1395i-3 (1987).Google Scholar
  11. 11.
    Currow DC, Stevenson JP, Abernethy AP, Plummer J, Shelby-James TM. Prescribing in palliative care as death approaches. J Am Geriatr Soc. 2007;55:590–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Tjia J, Rothman MR, Kiely DK, Shaffer ML, Holmes HM, Sachs GA, et al. Daily medication use in nursing home residents with advanced dementia. J Am Geriatr Soc. 2010;58:880–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Blass DM, Black BS, Phillips H, Finucane T, Baker A, Loreck D, et al. Medication use in nursing home residents with advanced dementia. Int J Geriatr Psychiatry. 2008;23:490–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Holmes HM, Sachs GA, Shega JW, Hougham GW. Cox Hayley D, Dale W. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56:1306–11.PubMedCrossRefGoogle Scholar
  15. 15.
    Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306:840–7.Google Scholar
  16. 16.
    Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.PubMedCrossRefGoogle Scholar
  17. 17.
    Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825–32.PubMedCrossRefGoogle Scholar
  18. 18.
    The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60:616–31.Google Scholar
  19. 19.
    Roberts MS, Stokes JA, King MA, Lynne TA, Purdie DM, Glasziou PP, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51:257–65.PubMedCrossRefGoogle Scholar
  20. 20.
    Brown BK, Earnhart J. Pharmacists and their effectiveness in ensuring the appropriateness of the chronic medication regimens of geriatric inpatients. Consult Pharm. 2004;19:432–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Flood KL, Carroll MB, Le CV, Brown CJ. Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit. Am J Geriatr Pharmacother. 2009;7:151–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Ray WA, Taylor JA, Meador KG, Lichtenstein MJ, Griffin MR, Fought R, et al. Reducing antipsychotic drug use in nursing homes. A controlled trial of provider education. Arch Intern Med. 1993;153:713–21.PubMedCrossRefGoogle Scholar
  23. 23.
    Avorn J, Soumerai SB, Everitt DE, Ross-Degnan D, Beers MH, Sherman D, et al. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327:168–73.PubMedCrossRefGoogle Scholar
  24. 24.
    Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46:77–82.PubMedGoogle Scholar
  25. 25.
    Elliott RA, Woodward MC, Oborne CA. Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback. Intern Med J. 2001;31:529–35.PubMedCrossRefGoogle Scholar
  26. 26.
    Gurwitz JH, Noonan JP, Soumerai SB. Reducing the use of H2-receptor antagonists in the long-term-care setting. J Am Geriatr Soc. 1992;40:359–64.PubMedGoogle Scholar
  27. 27.
    Stein CM, Griffin MR, Taylor JA, Pichert JW, Brandt KD, Ray WA. Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: a randomized controlled trial. Med Care. 2001;39:436–45.PubMedCrossRefGoogle Scholar
  28. 28.
    Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients. Clinical Pharm Ther. 2011;89:45–854.Google Scholar
  29. 29.
    Lang PO, Vogt-Ferrier N, Hasso Y, et al. Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: interventional study of 150 actuely ill elderly patients with mental and somatic comorbid conditions. JAMDA. 2012;13:406.e1–7.Google Scholar
  30. 30.
    Davis RG, Hepfinger CA, Sauer KA, Wilhardt MS. Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans. Am J Geriatr Pharmacother. 2007;5:40–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Stuijt CC, Franssen EJ, Egberts AC, Hudson SA. Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review. Drugs Aging. 2008;25:947–54.PubMedCrossRefGoogle Scholar
  32. 32.
    Bergkvist A, Midlov P, Hoglund P, Larsson L, Eriksson T. A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management. J Eval Clin Pract. 2009;15:660–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2:257–64.PubMedCrossRefGoogle Scholar
  34. 34.
    Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33:612–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Owens NJ, Sherburne NJ, Silliman RA, Fretwell MD. The Senior Care Study. The optimal use of medications in acutely ill older patients. J Am Geriatr Soc. 1990;38:1082–7.PubMedGoogle Scholar
  36. 36.
    Suhrie EM, Hanlon JT, Jaffe EJ, Sevick MA, Ruby CM, Aspinall SL. Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. Am J Geriatr Pharmacother. 2009;7:20–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Hellstrom LM, Bondesson A, Hoglun P, Midlov P, Holmdahl L, Rickhag E, Eriksson T. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011;67:741–52.PubMedCrossRefGoogle Scholar
  38. 38.
    Allard J, Hebert R, Rioux M, Asselin J, Voyer L. Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. CMAJ. 2001;164:1291–6.PubMedGoogle Scholar
  39. 39.
    Jeffery S, Ruby CM, Twesky J, Hanlon JT. Effect of an interdisciplinary team on suboptimal prescribing in a long-term care facility. Consult Pharm. 1999;14:1386–91.Google Scholar
  40. 40.
    Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med. 2004;116:394–401.PubMedCrossRefGoogle Scholar
  41. 41.
    Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007;55:658–65.PubMedCrossRefGoogle Scholar
  42. 42.
    Lee J, McPherson ML. Outcomes of recommendations by hospice pharmacists. Am J Health Syst Pharm. 2006;63:2235–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Lipton HL, Bero LA, Bird JA, McPhee SJ. The impact of clinical pharmacists’ consultations on physicians’ geriatric drug prescribing. A randomized controlled trial. Med Care. 1992;30:646–58.PubMedCrossRefGoogle Scholar
  44. 44.
    Lucas C, Glare PA, Sykes JV. Contribution of a liaison clinical pharmacist to an inpatient palliative care unit. Palliat Med. 1997;11:209–16.PubMedCrossRefGoogle Scholar
  45. 45.
    Mannheimer B, Ulfvarson J, Eklof S, Bergqvist M, Andersen-Karlsson E, Pettersson H, et al. Drug-related problems and pharmacotherapeutic advisory intervention at a medicine clinic. Eur J Clin Pharmacol. 2006;62:1075–81.PubMedCrossRefGoogle Scholar
  46. 46.
    Triller DM, Clause SL, Briceland LL, Hamilton RA. Resolution of drug-related problems in home care patients through a pharmacy referral service. Am J Health Syst Pharm. 2003;60:905–10.PubMedGoogle Scholar
  47. 47.
    Halvorsen KH, Ruths S, Granas AG, Viktil KK. Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes. Scand J Prim Health Care. 2010;28:82–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm. 2011;33:549–57.PubMedCrossRefGoogle Scholar
  49. 49.
    Olsson IN, Curman B, Engfeldt P. Patient focused drug surveillance of elderly patients in nursing homes. Pharmacoepidemiol Drug Saf. 2010;19:150–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9:430–4.PubMedGoogle Scholar
  51. 51.
    Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med. 2010;170:1648–54.PubMedCrossRefGoogle Scholar
  52. 52.
    Bajorek BV, Krass I, Ogle SJ, Duguid MJ, Shenfield GM. Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: a pharmacist-led multidisciplinary intervention. J Am Geriatr Soc. 2005;53:1912–20.PubMedCrossRefGoogle Scholar
  53. 53.
    Furniss L, Burns A, Craig SK, Scobie S, Cooke J, Faragher B. Effects of a pharmacist’s medication review in nursing homes. Randomised controlled trial. Br J Psychiatry. 2000;176:563–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Fossey J, Ballard C, Juszczak E, James I, Alder N, Jacoby R, et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ. 2006;332:756–61.PubMedCrossRefGoogle Scholar
  55. 55.
    Alexander GC, Sayla MA, Holmes HM, Sachs GA. Prioritizing and stopping prescription medicines. CMAJ. 2006;174:1083–4.PubMedGoogle Scholar
  56. 56.
    Woodward M. Deprescribing: achieving better health outcomes for older people through reducing medications. J Pharm Pract Res. 2003;33:323–8.Google Scholar
  57. 57.
    Scott IA, Gray LC, Martin JH, Mitchell CA. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125:529–37.PubMedCrossRefGoogle Scholar
  58. 58.
    Tjia J, Givens JL. Ethical framework for medication discontinuation in nursing home residents with limited life expectancy. Clin Geriatr Med. 2012;28:255–72.PubMedCrossRefGoogle Scholar
  59. 59.
    le Grand A, Hogerzeil H, Haaijer-Ruskamp F. Intervention research in rational use of drugs: a review. Health Policy Plan. 1999;14:89–102.PubMedCrossRefGoogle Scholar
  60. 60.
    Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56:1946–52.PubMedCrossRefGoogle Scholar
  61. 61.
    Avorn J, Gurwitz JH. Drug use in the nursing home. Ann Intern Med. 1995;123:195–204.PubMedCrossRefGoogle Scholar
  62. 62.
    Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice: the clinician’s guide. 2nd ed. New York: McGraw-Hill; 2004. p. 394.Google Scholar
  63. 63.
    Ruths S, Viktil KK, Blix HS. Classification of drug-related problems. Tidsskr Nor Laegeforen. 2007;127:3073–6.PubMedGoogle Scholar
  64. 64.
    Howard R, Ballard C, O’Brien J, Burns A. Guidelines for the management of agitation in dementia. Int J Geriatr Psychiatry. 2001;16:714–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2013

Authors and Affiliations

  • Jennifer Tjia
    • 1
    Email author
  • Sarah J. Velten
    • 2
  • Carole Parsons
    • 3
  • Sruthi Valluri
    • 4
  • Becky A. Briesacher
    • 1
  1. 1.University of Massachusetts Medical School Biotech FourWorcesterUSA
  2. 2.University of New England College of Osteopathic MedicineBiddefordUSA
  3. 3.School of Pharmacy, Queens University BelfastBelfastNorthern Ireland
  4. 4.Harvard School of Public HealthBostonUSA

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