Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists' interventions in secondary care

Abstract

Introduction: potentially inappropriate prescribing (PIP) in older hospitalised patients, and in particular those with dementia, is associated with poorer health outcomes. PIP reduction is therefore essential in this population.

Methods: a comprehensive electronic literature search was conducted using 12 databases from inception up to and including September 2014. Inclusion criteria were controlled trials (randomised or non-randomised) of interventions involving pharmacists conducted in hospitals, with an objective of the study being PIP reduction in patients 65 years or older or patients with dementia of any age, using any validated PIP tool as an outcome measure. Risk of bias assessments were conducted utilising the Cochrane Collaboration's tool.

Results: a total of 1,752 records were found after duplicates were removed. Four trials (n = 1,164 patients; two randomised, two non-randomised) from three countries were included in the quantitative analysis. All studies were at moderate risk of bias. No study focused specifically on dementia patients. Three trials reported statistically significant reductions in the Medication Appropriateness Index score in the intervention group (mean difference from admission to discharge = -7.45, 95% CI: -11.14, -3.76) and other PIP tools such as Beers Criteria. One trial reported reduced drug-related readmissions and another reported increased adverse drug reactions.

Conclusion: multi-disciplinary teams involving pharmacists may improve prescribing appropriateness in older inpatients, though the clinical significance of observed reductions is unclear. More research is required into the effectiveness of pharmacists' interventions in reducing PIP in dementia patients. Additionally, easily assessed and clinically relevant measures of PIP need to be developed.

Keywords: dementia; inappropriate prescribing; pharmacist; secondary care; systematic review.