Abstract
Background
Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication‐taking ability and medication adherence are necessary to ensure safe and effective use of medications.
Objectives
To evaluate the effectiveness of interventions designed to improve medication‐taking ability and/or medication adherence in older community‐dwelling adults prescribed multiple long‐term medications.
Search methods
We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.
Selection criteria
We included randomised controlled trials (RCTs), quasi‐RCTs, and cluster‐RCTs. Eligible studies tested interventions aimed at improving medication‐taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.
Data collection and analysis
Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta‐analyses when possible and used a random‐effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta‐analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication‐taking ability and medication adherence. Secondary outcomes included health‐related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.
Main results
We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster‐RCTs, and four quasi‐RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three‐arm RCT design.
Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies.
Five studies evaluated interventions for improving medication‐taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes).
No studies involved educational or behavioural interventions alone for improving medication‐taking ability. Low‐quality evidence from five studies, each using a different measure of medication‐taking ability, meant that we were unable to determine the effects of mixed interventions on medication‐taking ability.
Low‐quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta‐analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low‐quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent.
Low‐quality evidence suggests that educational only interventions (SMD 0.16, 95% CI ‐0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI ‐0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta‐analysis including four studies with unclear or no available results. Very low‐quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes.
Low‐quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta‐analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low‐quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low‐quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies).
Moderate‐quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low‐quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality.
Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.
Authors’ conclusions
Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication‐taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well‐designed RCTs are needed to investigate the effects of interventions for improving medication‐taking ability and medication adherence in older adults prescribed multiple medications.
Plain language summary
Interventions for helping older adults prescribed multiple medications to use and take their medications
Background: Older people are often prescribed multiple medications, which can be challenging to manage. Medication‐taking errors and non‐adherence (under‐use or over‐use of medication) can lead to negative health outcomes. Assisting older people to better use and adhere to their medications could reduce adverse medication events, such as medication‐related hospital admissions, and could improve health outcomes.
Question: What are the findings of studies testing ways to improve older people’s ability to use and adhere to multiple medications?
Search strategy: To find relevant studies, we searched seven online databases, trial registries, and the reference lists of previous reviews, retrieving studies published until June 2019.
Selection criteria: We included randomised controlled trials (RCT) or studies of similar design comparing a group of people receiving an intervention to improve medication‐taking ability or medication adherence with a group receiving usual care (no intervention) or receiving a different intervention. We included trials that studied older adults (≥ 65 years) living at home (or being discharged from hospital back to home) who were using four or more regular prescription medications.
Main results: We identified 50 studies, involving 14,269 participants. All studies tested interventions versus usual care, with six studies also comparing two different types of interventions.
Fourteen studies tested educational interventions whereby people received education regarding their medications or a health professional reviewed their medications. Seven studies tested behavioural interventions such as changing dosing times, re‐packaging medications into multi‐compartment pill boxes to make medication regimens easier to take, or sending text message adherence reminders. Twenty‐nine studies tested mixed educational and behavioural interventions.
The studies identified were very different in terms of what interventions people received, where interventions were delivered, and how and when people’s medication‐taking ability or adherence was measured. Due to these differences and problems with how the trials were conducted, the quality of the evidence was considered low or very low overall.
Low‐quality evidence means that the impact of mixed interventions on medication‐taking ability could not be determined, and no studies were identified that assessed educational only or behavioural only interventions for improving medication‐taking ability.
Low‐quality evidence suggests that compared with usual care, behavioural only and mixed interventions may improve the proportions of people who satisfactorily adhere to their prescribed medication, but very low‐quality evidence means that the effects of educational only interventions are uncertain. Low‐ and very low‐quality evidence means that no interventions were found to be effective in improving medication adherence when assessed by continuous measures such as percentage of medications consumed.
Low‐quality evidence also suggests that mixed interventions may reduce the number of emergency department visits or hospital admissions, and may lead to little or no change in health‐related quality of life (HRQoL). Moderate‐quality evidence shows that educational interventions alone probably have little or no effect on HRQoL or on emergency department or hospital admissions. The effects of behavioural interventions alone on HRQoL or emergency department or hospital admissions are uncertain because of very low‐quality evidence. We are uncertain of the effects of behavioural, educational, or mixed interventions on mortality.
Studies comparing one type of intervention with another were limited in number, and we are unable to draw firm conclusions for any key outcomes.
Authors’ conclusions: Interventions varied greatly among studies, and there were problems regarding how the trials were conducted, which may have affected their results. We were unable to determine the impact of interventions on medication‐taking ability. Low‐quality evidence suggests that behavioural only and mixed educational and behavioural interventions may improve the proportions of people who adhere to their prescribed medication regimen. Low‐ and very low‐quality evidence found no type of intervention to be effective in improving medication adherence when this was assessed by a continuous measure. High‐quality studies are necessary to identify the most effective way to improve medication‐taking ability and medication adherence among older adults prescribed multiple medications.
