Background: Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge. Objective: 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. Methods: 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. Results: 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. Conclusions: Very little rigorous research has been conducted on reducing unnecessary medications in frail older adults or patients approaching end of life.
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Acknowledgements 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.
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