Dataset Information

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

ABSTRACT:

Background

Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medication adherence amongst older, community dwelling adults.

Methods

A mixed methods review was undertaken. Eight bibliographic database and two clinical trials registers were searched between May and December 2017. Results were double screened in accordance with pre-defined inclusion/exclusion criteria related to polypharmacy, deprescribing and adherence in older, community dwelling populations. The Mixed Methods Appraisal Tool (MMAT) was used for quality appraisal and an a priori data collection instrument was used. For the quantitative studies, a narrative synthesis approach was taken. The qualitative data was analysed using framework analysis. Findings were integrated using a mixed methods technique. The review was performed in accordance with the PRISMA reporting statement.

Results

A total of 22 original studies were included, of which 12 were RCTs. Deprescribing with adherence as an outcome measure was identified in randomised controlled trials (RCTs), observational and cohort studies from 13 countries between 1996 and 2017. There were 17 pharmacy-led interventions; others were led by General Practitioners (GP) and nurses. Four studies demonstrated an overall reduction in medications of which all studies corresponded with improved adherence. A total of thirteen studies reported improved adherence of which 5 were RCTs. Adherence was reported as a secondary outcome in all but one study.

Conclusions

There is insufficient evidence to show that deprescribing improves medication adherence. Only 13 studies (of 22) reported adherence of which only 5 were randomised controlled trials. Older people are particularly susceptible to non-adherence due to multi-morbidity associated with polypharmacy. Bio-psycho-social factors including health literacy and multi-disciplinary team interventions influence adherence. The authors recommend further study into the efficacy and outcomes of medicines management interventions. A consensus on priority outcome measurements for prescribed medications is indicated.

Trial registration

PROSPERO number CRD42017075315.

SUBMITTER: Ulley J

PROVIDER: S-EPMC6339421 | biostudies-literature | 2019 Jan

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

Ulley Joanna J Harrop Deborah D Ali Ali A Alton Sarah S Fowler Davis Sally S

BMC geriatrics 20190118 1

<h4>Background</h4>Polypharmacy, and the associated adverse drug events such as non-adherence to prescriptions, is a common problem for elderly people living with multiple comorbidities. Deprescribing, i.e. the gradual withdrawal from medications with supervision by a healthcare professional, is regarded as a means of reducing adverse effects of multiple medications including non-adherence. This systematic review examines the evidence of deprescribing as an effective strategy for improving medic ...[more]

PMID: 30658576

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Project description:BackgroundPolypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults.MethodsWe searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes.ResultsThirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes.DiscussionIn community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.Registry informationPROSPERO - CRD42019132420.

Project description:Background and objectivesMedication exposure is a potential risk factor for falls and subsequent death and functional decline among older adults. However, controversy remains on the best way to assess medication exposure and which approach best predicts falls. The objective of the current study was to examine the association between different measures of medication exposure and falls risk among community-dwelling older adults.Research design and methodsThis retrospective cohort study was conducted using Falls Free PA program data and a linked prescription claims data from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Participants were community-dwelling older adults living in Pennsylvania, United States. Three measures of medication exposure were assessed: (a) total number of regular medications (polypharmacy); (b) counts of potentially inappropriate medications derived from current prescription guidance tools (Fall Risk-Increasing Drugs [FRIDs], Beers Criteria); and (c) medication burden indices based on pharmacologic mechanisms (Anticholinergic Cognitive Burden, Drug Burden Index) all derived from claims data. The associations between the different medication risk measures and self-reported falls incidence were examined with univariate and multivariable negative binomial regression models to estimate incidence rate ratios (IRRs).ResultsOverall 343 older adults were included and there were 236 months with falls during 2,316 activity-adjusted person-months (10.2 falls per 100 activity-adjusted person-months). Of the 6 measures of medication risk assessed in multivariate models, only the use of 2 or more FRIDs (adjusted IRR 1.67 [95% CI: 1.04-2.68]) independently predicted falls risk. Among the 13 FRID drug classes, the only FRID class associated with an increased fall risk was antidepressants.Discussion and implicationsThe presence of multiple FRIDs in a prescription is an independent risk factor for falls, even in older adults with few medications. Further investigation is required to examine whether deprescribing focused on FRIDs effectively prevents falls among this population.

Project description:OBJECTIVE:Growing evidence suggests that older adults are at an increased risk of injurious falls when initiating antihypertensive medication, while the evidence regarding long-term use of antihypertensive medication and the risk of falling is mixed. However, long-term users who stop and start these medications may have a similar risk of falling to initial users of antihypertensive medication. Our aim was to evaluate the association between gaps in antihypertensive medication adherence and injurious falls in older (≥65 years) community-dwelling, long-term (≥≥1 year) antihypertensive users. DESIGN:Prospective cohort study. SETTING:Irish Community Pharmacy. PARTICIPANTS:Consecutive participants presenting a prescription for antihypertensive medication to 106 community pharmacies nationwide, community-dwelling, ≥65 years, with no evidence of cognitive impairment, taking antihypertensive medication for ≥1 year (n=938). MEASURES:Gaps in antihypertensive medication adherence were evaluated from linked dispensing records as the number of 5-day gaps between sequential supplies over the 12-month period prior to baseline. Injurious falls during follow-up were recorded via questionnaire during structured telephone interviews at 12 months. RESULTS:At 12 months, 8.1% (n=76) of participants reported an injurious fall requiring medical attention. The mean number of 5-day gaps in medication refill behaviour was 1.47 (SD 1.58). In adjusted, modified Poisson models, 5-day medication refill gaps at baseline were associated with a higher risk of an injurious fall during follow-up (aRR 1.18, 95% CI 1.02 to 1.37, p=0.024). CONCLUSION:Each 5-day gap in antihypertensive refill adherence increased the risk of self-reported injurious falls by 18%. Gaps in antihypertensive adherence may be a marker for increased risk of injurious falls. It is unknown whether adherence-interventions will reduce subsequent risk. This finding is hypothesis generating and should be replicated in similar populations.

Project description:BackgroundPrevention programs, and specifically exercise, can reduce falls among community-dwelling older adults, but low adherence limits the benefits of effective interventions. Technology may overcome some barriers to improve uptake and engagement in prevention programs, although less is known on adherence for providing them via this delivery mode. We aimed to synthesize evidence for adherence to technology-based falls prevention programs in community-dwelling older adults 60 years and older. We conducted a systematic review following standard guidelines to identify randomized controlled trials for remote delivered (i.e., no or limited in-person sessions) technology-based falls prevention programs for community-dwelling older adults. We searched nine sources using Medical Subject Headings (MeSH) terms and keywords (2007-present). The initial search was conducted in June 2023 and updated in December 2023. We also conducted a forward and backward citation search of included studies. Two reviewers independently conducted screening and study assessment; one author extracted data and a second author confirmed findings. We conducted a random effects meta-analysis for adherence, operationalized as participants' completion of program components, and aimed to conduct meta-regressions to examine factors related to program adherence and the association between adherence and functional mobility. We included 11 studies with 569 intervention participants (average mean age 74.5 years). Studies used a variety of technology, such as apps, exergames, or virtual synchronous classes. Risk of bias was low for eight studies. Five interventions automatically collected data for monitoring and completion of exercise sessions, two studies collected participants' online attendance, and four studies used self-reported diaries or attendance sheets. Studies included some behavior change techniques or strategies alongside the technology. There was substantial variability in the way adherence data were reported. The mean (range) percent of participants who did not complete planned sessions (i.e., dropped out or lost to follow-up) was 14% (0-32%). The pooled estimate of the proportion of participants who were adherent to a technology-based falls prevention program was 0.82 (95% CI 0.68, 0.93) for studies that reported the mean number of completed exercise sessions. Many studies needed to provide access to the internet, training, and/or resources (e.g., tablets) to support participants to take part in the intervention. We were unable to conduct the meta-regression for adherence and functional mobility due to an insufficient number of studies. There were no serious adverse events for studies reporting this information (n = 8). The use of technology may confer some benefits for program delivery and data collection. But better reporting of adherence data is needed, as well as routine integration and measurement of training and skill development to use technology, and behavior change strategies within interventions. There may be an opportunity to rethink or reimagine how technology can be used to support people's adoption and integration of physical activity into daily life routines.

Dataset Information

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

Background

Methods

Results

Conclusions

Trial registration

Publications

Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review.

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