Five ways you can reduce inappropriate prescribing in the elderly: A systematic review
Method 3: Review of medications
Reviewing a patient’s medications regularly can reduce polypharmacy and inappropriate prescribing. This has been shown in at least 4 studies.
Physicians often unaware of what patients are, or are not, taking. One prospective observational study of medication review showed a high rate of discrepancy between medications the physician thought a patient was taking and those the patient actually was taking. This study involved patients 65 years of age or older who were taking 4 or more medications. There were 50 physicians-patient pairs blinded at the initial visit. After the initial visit, physicians were given the patient’s chart, with a request to complete a questionnaire on all prescription and nonprescription medications with dosages and frequencies of administration. All patient records contained a flow sheet for review of medications including current, discontinued, and over-the-counter medications.
Home visits were conducted 10 days after initial visits to gather detailed information from patients regarding their understanding of medication regimens. Data obtained showed that 74% of patients were taking at least 1 medication the physician was unaware of, or were not taking a medication the physician thought they were taking. Moreover, in 12% of cases, there were discrepancies in understanding about dose or frequency of medication regimens.22
“Brown bag” assessment useful. In the second study, a program promoting medication reviews between primary care physicians and their elderly patients significantly changed prescribing by physicians. In this prospective study, elderly patients taking 5 or more medications were sent a letter encouraging them to meet with their primary care physician for a medication review. Interventions included notifying the physician that their patients were at high risk for inappropriate prescribing, providing the physician with a “medication management” report that listed all prescriptions, doses, and pills dispensed per prescription, and clinical practice guidelines for effectively preventing and managing inappropriate prescribing. These guidelines emphasized the “brown bag” medication review of both nonprescription and prescription medications (ie, having the patient bring all their medication to the office in a brown bag).
With this intervention, 20% of patients reported discontinuation of a medication, 29% reported a change in medication, and 17% reported a medication that the physician did not know the patient was taking. Forty-five percent of physicians made at least 1 change in a patient’s medication regimen.23
Include all preparations patients use. A third study showed that the medication review should focus not just on prescription drugs but also on nonprescription agents such as vitamins, laxatives, minerals, analgesics, and herbal and natural remedies. This prospective cross-sectional study at 3 university affiliated geriatric clinics involved a room-to-room search of patients’ homes to identify all substances a patient might be taking. The medications identified in the home were compared with the medication list in the clinic and with medications found in the “brown bag evaluation” and by interview. The physician’s understanding of medications a patient was taking matched the patient’s actual use of medications only 52% of the time; much of the mismatch was attributable to nonprescription medications.24
Finally, in a fourth study, a randomized controlled trial, 133 community dwelling adults taking 5 or more medications were assessed at baseline by physician exam, symptom review, and objective tests of physical and cognitive functioning. Sixty-three subjects were randomized to the intervention group and 77 to the control group.
The primary intervention was a review and modification of a patient’s medication regimen by a multidisciplinary team consisting of a consultant pharmacist, physician, and nurse. This intervention was not available to the control group. Medication usage in both groups was re-evaluated at 6 weeks using a brown-bag review.
The control group decreased their medication use by an average of 0.04 medications per month, while the intervention subjects decreased their medications by an average of 1.5 drugs (although the team has actually recommended discontinuation of an average of 4.5 drugs per patient). The difference between recommended discontinuation and actual discontinuation was attributed to patients’ resistance to changing medications.
Intervention subjects saved an average of $26.92 per month in wholesale costs while control subjects saved an average of $6.75 per month. No differences in functioning were observed between groups.17
Method 4: Patient education
The most beneficial intervention may be enhancing communication between providers and patients, and educating patients about medication regimens, potential side effects, and adverse drug events.
Encourage reporting of symptoms. A recent prospective cohort study showed that 63% of preventable events were attributed to the physician’s failure to respond to medication-related symptoms; 37% were due to the patient’s failure to inform the physician of the symptoms.25
