Drugs & Aging

, Volume 20, Issue 11, pp 817–832 | Cite as

Reduction of Polypharmacy in the Elderly

A Systematic Review of the Role of the Pharmacist
Review Article

Abstract

Polypharmacy in the elderly complicates therapy, increases cost, and is a challenge for healthcare agencies. In the context of the evolving role of the pharmacist, this systematic review examines the effectiveness of interventions led by pharmacists in reducing polypharmacy.

A computerised search was conducted using Medline, Embase geriatrics and gerontology (2001 edition), the Cochrane Library and International Pharmaceutical Abstracts (IPA) databases. A manual search of articles on polypharmacy and the role of pharmacists in the therapy of the elderly and of the reference sections of all retrieved articles was also carried out. Search terms used were ‘polypharmacy’, ‘elderly’, ‘aged’, ‘intervention’ and ‘pharmacist(s)’. Articles that fulfilled the following criteria were included: only elderly people were included in the study, or all ages were included but the study gave separate results for the elderly; the outcome was expressed as a reduction in the number of medications; a pharmacist participated in the study; and the study was a controlled or a randomised controlled study.

We initially identified 106 articles, but only 14 studies met our four inclusion criteria. Reduction in the number of medications was not the major purpose of most selected studies but often a secondary outcome. Objectives differed, the general aim being to enhance the quality of prescribing in elderly patients. These controlled studies argued in favour of the effectiveness of pharmacists’ interventions, even though the number of medications eliminated was small. Most studies were not designed to demonstrate the impact of reducing the number of drugs on the clinical consequences of polypharmacy (nonadherence, adverse drug reactions, drug-drug interactions, increased risk of hospitalisation, and medication errors).

The most frequently reported outcome related to cost savings. It was therefore difficult to assess whether the interventions benefited the patient. The methodological quality of many identified studies was poor. In particular, the study objectives were often very broad and ill-defined. Polypharmacy itself has been defined in different ways and the appropriate definition may differ according to the patient population and the study setting.

Further studies are needed to find the most effective way to reduce polypharmacy, especially in the frail elderly population, and to quantify the real advantages of simplifying their drug regimens in terms of improved quality of life.

References

  1. 1.
    McLeod DC. Contribution of clinical pharmacists to patient care. Am J Hosp Pharm1976; 33: 904–11PubMedGoogle Scholar
  2. 2.
    Denham MJ, Barnett NL. Drug therapy and the older person: role of the pharmacist. Drug Saf 1998; 19(4): 243–50PubMedCrossRefGoogle Scholar
  3. 3.
    American College of Physicians, American Society of Internal Medicine. Pharmacist scope of practice. Ann Intern Med 2002; 136: 79–85Google Scholar
  4. 4.
    Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533–43PubMedGoogle Scholar
  5. 5.
    Omori DM, Potyk RP, Kroenke K. The adverse effects of hospitalisation on drug regimens. Arch Intern Med 1991; 151: 1562–4PubMedCrossRefGoogle Scholar
  6. 6.
    Kroenke K, Pinholt EM. Reducing polypharmacy in the elderly: a controlled trial of physician feedback. J Am Geriatr Soc 1990; 38: 31–6PubMedGoogle Scholar
  7. 7.
    Meyer TJ, Van Kooten D, Marsh S, et al. Reduction of polypharmacy by feedback to clinicians. J Gen Intern Med 1991; 6: 133–6PubMedCrossRefGoogle Scholar
  8. 8.
    Montamat SC, Cusack B. Overcoming problems with polypharmacy and drug misuse in the elderly. Clin Geriatr Med 1992; 8(1): 143–58PubMedGoogle Scholar
  9. 9.
    Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001; 49(2): 200–9PubMedCrossRefGoogle Scholar
  10. 10.
    Beers MH, Munekata M, Storrie M. The accuracy of medication histories in the hospital medical records of elderly persons. J Am Geriatr Soc 1990; 38: 1183–7PubMedGoogle Scholar
  11. 11.
    Barat I, Andreasen F, Damsgaard EMS. The consumption of drugs by 75-year-old individuals living in their own homes. Eur J Clin Pharmacol 2000; 56: 501–9PubMedCrossRefGoogle Scholar
  12. 12.
    Lamy PP. New dimensions and opportunities. Drug Intell Clin Pharm 1985; 19: 399–402PubMedGoogle Scholar
  13. 13.
    Kennerfalk A, Ruigomez A, Wallander MA, et al. Geriatric drug therapy and healthcare utilization in the United Kingdom. Ann Pharmacother 2002; 36: 797–803PubMedCrossRefGoogle Scholar
  14. 14.
    Thomas HF, Sweetnam PM, Janchawee B, et al. Polypharmacy among older males in South Wales. Eur J Clin Pharmacol 1999; 55: 411–5PubMedCrossRefGoogle Scholar
  15. 15.
    Bjerrum L, Sogaard J, Hallas J,et al. Polypharmacy: correlation with sex, age and drug regimen. Eur J Clin Pharmacol 1998; 54: 197–202PubMedCrossRefGoogle Scholar
  16. 16.
    Jeandel C, Graille M, Ferry JC. La prescription médicamenteuse chez la personne âgée: a propos d’une enquête dans la région Nord-Est. Rev Geriatr 1996; 21(7): 483–7Google Scholar
  17. 17.
    Fourrier A, Letenneur L, Dartigues J, et al. Consommation médicamenteuse chez le sujet âgé vivant à domicile et en institution à partir de la cohorte Paquid: importance de la polymédication et utilisation des psychotropes. Rev Geriatr 1996; 21(7): 473–82Google Scholar
  18. 18.
    Espino DV, Lichtenstein MJ, Hazuda HP, et al. Correlates of prescription and over-the-counter medication usage among older Mexican Americans: The Hispanic EPESE study. J Am Geriatr Soc 1998; 46: 1228–34PubMedGoogle Scholar
  19. 19.
    Blenkiron P. The elderly and their medication: understanding and compliance in a family practice. Postgrad Med J 1996; 72: 671–6PubMedCrossRefGoogle Scholar
  20. 20.
    Stoehr GP, Ganguli M, Seaberg EC, et al. Over-the-counter medication use in an older rural community: the MoVIES Project. J Am Geriatr Soc 1997; 45: 158–65PubMedGoogle Scholar
  21. 21.
    Gurwitz JH, Soumerai SB, Avorn J. Improving medication prescribing and utilization in the nursing home. J Am Geriatr Soc 1990; 38: 542–52PubMedGoogle Scholar
  22. 22.
    Broderick E. Prescribing patterns for nursing home residents in the US: the reality and the vision. Drugs Aging 1997; 11: 255–60PubMedCrossRefGoogle Scholar
  23. 23.
    Zuniga C. Prescription médicamenteuse chez la personne âgée à l’Hôpital de Gériatrie de Genève. Data on file, 1996Google Scholar
  24. 24.
    Beers MH, Drag J, Hasegawa J, et al. Influence of hospitalisation on drug therapy in the elderly. J Am Geriatr Soc 1989; 37: 679–83PubMedGoogle Scholar
  25. 25.
    Gupta S, Rappaport HM, Bennett LT. Polypharmacy among nursing home geriatric Medicaid recipients. Ann Pharmacother 1996; 30: 946–50PubMedGoogle Scholar
  26. 26.
    Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. Do too many cooks spoil the broth? Multiple physician involvement in medical management in elderly patients and potentially inappropriate drug combinations. CMAJ 1996; 154: 1177–84PubMedGoogle Scholar
  27. 27.
    Tamblyn R. Medication use in seniors: challenges and solutions. Thérapie 1996; 51: 269–82PubMedGoogle Scholar
  28. 28.
    Harris CM, Dajda R. The scale of repeat prescribing. Br J Gen Pract 1996; 46: 649–53PubMedGoogle Scholar
  29. 29.
    Zermansky AG. Who controls repeats? Br J Gen Pract 1996; 46: 643–7PubMedGoogle Scholar
  30. 30.
    Bliss MR. Prescribing for the elderly. BMJ 1981; 283: 203–6PubMedCrossRefGoogle Scholar
  31. 31.
    Fourrier A, Dequae L, Chaslerie A, et al. Sociodemographic characteristics and polypharmacy in the elderly people: data from the Paquid study. Post Mark Surv 1993; 7: 291–8Google Scholar
  32. 32.
    Lassila HC, Stoehr GP, Ganguli M, et al. Use of prescription medication in an elderly rural population: the MoVIES Project. Ann Pharmacother 1996; 30: 589–95PubMedGoogle Scholar
  33. 33.
    Melmon KL. Preventable drug reactions: causes and cure. N Engl J Med 1971; 284: 1361–5PubMedCrossRefGoogle Scholar
  34. 34.
    Whitaker P, Wilson R, Bargh J Chapman M, et al. Use and misuse of purchased analgesics with age. Pharm J 1995; 254: 553–6Google Scholar
  35. 35.
    Hulka BS, Kupper LL, Cassel JC, et al. Medication use and misuse: physician-patient discrepancies. J Chronic Dis1975; 28(1): 7–21PubMedCrossRefGoogle Scholar
  36. 36.
    Eraker SA, Kirscht JP, Becker MH. Understanding and improving patient compliance. Ann Intern Med 1984; 100: 258–68PubMedGoogle Scholar
  37. 37.
    Stewart RB, Cooper JW. Polypharmacy in the aged: practical solutions. Drugs Aging 1994; 4(6): 449–61PubMedCrossRefGoogle Scholar
  38. 38.
    Nolan L, O’Malley K. Prescribing for the elderly: Pt I. sensitivity of the elderly to adverse drug reactions. J Am Geriatr Soc 1988; 36: 142–9PubMedGoogle Scholar
  39. 39.
    Carbonin P, Pahor M, Bernabei R, et al. Is age an independent risk factor for adverse drug reactions in hospitalized medical patients? J Am Geriatr Soc 1991; 39: 1093–9PubMedGoogle Scholar
  40. 40.
    Hurwitz N, Wade OL. Intensive hospital monitoring of adverse reactions to drugs. BMJ 1969; 1: 531–6PubMedCrossRefGoogle Scholar
  41. 41.
    Hoddinott BC, Gowdey CW, Coulter WK, et al. Drug reactions and errors in administration on a medical ward. CMAJ 1967; 97: 1001–6Google Scholar
  42. 42.
    Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997; 45: 945–8PubMedGoogle Scholar
  43. 43.
    Sloan RW. Drug interactions. Am Fam Physician 1983; 27: 229–38PubMedGoogle Scholar
  44. 44.
    Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a prospective study of 1000 patients. J Am Geriatr Soc 1996; 44: 944–8PubMedGoogle Scholar
  45. 45.
    Lindley CM, Tully MP, Paramsothy V, et al. Inappropriate medication is a major cause of adverse drug reactions in elderly patients. Age Ageing 1992; 21: 294–300PubMedCrossRefGoogle Scholar
  46. 46.
    Borchelt M. Potentielle Neben- und Wechselwirkungen der Multimedikation im Alter: Methodik und Ergebnisse des Berliner Alterstudie. Z Gerontol Geriatr 1995; 28: 420–8PubMedGoogle Scholar
  47. 47.
    Col N, Fanale JE, Kronholm P. The role of medication noncompliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990; 150: 841–5PubMedCrossRefGoogle Scholar
  48. 48.
    Jankel CA, Fitterman LK. Epidemiology of drug-drug interactions as a cause of hospital admissions. Drug Saf 1993; 9(1): 51–9PubMedCrossRefGoogle Scholar
  49. 49.
    Caranasos GJ, Stewart RB, Cluff LE. Drug induced illness leading to hospitalization. JAMA 1974; 228: 713–7PubMedCrossRefGoogle Scholar
  50. 50.
    Colt HG, Shapiro AP. Drug-induced illness as a cause for admission to a community hospital. J Am Geriatr Soc 1989; 37: 323–6PubMedGoogle Scholar
  51. 51.
    Flaherty JH, Perry HM, Lynchard GS, et al. Polypharmacy and hospitalization among older home care patients. J Gerontol 2000; 55A(10): M554–9Google Scholar
  52. 52.
    American Society of Health-System Pharmacists. Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events and adverse drug reactions. Am J Health Syst Pharm 1998; 55: 165–6Google Scholar
  53. 53.
    Philips J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58: 1835–41Google Scholar
  54. 54.
    Monson RA, Bond CA. The accuracy of the medical record as an index of outpatient drug therapy. JAMA 1978; 240: 2182–4PubMedCrossRefGoogle Scholar
  55. 55.
    Sullivan SD, Kreling DH, Hazlet TK. Noncompliance with medication regimens and subsequent hospitalization: a literature analysis and cost of hospitalization estimate. J Res Pharm Econ 1992; 2: 19–33Google Scholar
  56. 56.
    Malhotra S, Karan RS, Pandhi P, et al. Drug related medical emergencies in the elderly: role of adverse drug reactions and non-compliance. Postgrad Med J 2001; 77: 703–7PubMedCrossRefGoogle Scholar
  57. 57.
    Kidder SW. Cost-benefit of pharmacist-conducted-regimen reviews. Consult Pharm 1987; 2: 394–8Google Scholar
  58. 58.
    Allard J, Hebert R, Rioux M, et al. Efficacy of a clinical medication review on the number of potentially inappropriate prescriptions prescribed for community-dwelling elderly people. CMAJ 2001; 164(9): 1291–6PubMedGoogle Scholar
  59. 59.
    Furniss L, Bums A, Craig SKL, et al. Effects of a pharmacist’s medication review in nursing homes. Br J Pschiatry 2000; 176: 563–7CrossRefGoogle Scholar
  60. 60.
    Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med 1996; 100(4): 428–37PubMedCrossRefGoogle Scholar
  61. 61.
    Lipton HL, Bird JA. The impact of clinical pharmacists’ consultations on geriatric patients’ compliance and medical care use: a randomised controlled trial. Gerontologist 1994; 34(3): 307–15PubMedCrossRefGoogle Scholar
  62. 62.
    Owens NJ, Sherburne NJ, Silliman RA, et al. The Senior Care Study. The optimal use of medications in acutely ill older patients. J Am Geriatr Soc 1990; 38: 1082–7PubMedGoogle Scholar
  63. 63.
    Rubenstein LZ, Josephson K, Wieland D, et al. Geriatric assessment on a subacute hospital ward. Clin Geriatr Med 1987; 3: 131–43PubMedGoogle Scholar
  64. 64.
    Williams RG, McCoy R, Frederick KR. Impact of pharmacy consultant services to homebound population. Consult Pharm 1987; 2: 479–82Google Scholar
  65. 65.
    Zermansky AG, Petty DR, Raynor DK, et al. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ 2001; 323: 1–5CrossRefGoogle Scholar
  66. 66.
    Blakey SA, Hixson-Wallace JA. Clinical and economic effects of pharmacy services in a geriatric ambulatory clinic. Pharmacotherapy 2000; 20(10): 1198–203PubMedCrossRefGoogle Scholar
  67. 67.
    Hood JC, Lemberger M, Stewart RB. Promoting appropriate therapy in a long-term care facility. J Am Pharm Assoc 1975; 15: 32–33, 37PubMedGoogle Scholar
  68. 68.
    Karki SD, Mott P, Rosato L. Impact of a team approach on reducing polypharmacy. Consult Pharm 1991; 6: 133–7Google Scholar
  69. 69.
    Ruggiero RJ, Cohen KR, Lauletta J, et al. Further exploration of the economic impact of a pharmacist intervention at the point of polypharmacy prescribing: a follow-up study. Pharmacy and Therapeutics 1997; 22(11): 555–6, 558, 563–572, 578Google Scholar
  70. 70.
    Tamai IY, Rubenstein LZ, Josephson KR, et al. Impact of computerized drug profiles and a consulting pharmacist on outpatient prescribing patterns: a clinical trial. Drug Intell Clin Pharm 1987; 21(11): 890–5PubMedGoogle Scholar
  71. 71.
    Thompson JF, McGhan WF, Ruffalo RL, et al. Clinical pharmacists prescribing drug therapy in a geriatric setting: outcome of a trial. J Am Geriatr Soc 1984; 32(2): 154–9PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2003

Authors and Affiliations

  1. 1.Clinical Gerontopharmacology Unit, Division of Clinical Pharmacology and ToxicologyUniversity HospitalGenevaSwitzerland

Personalised recommendations