Table 1 Study characteristics of the included studies
Study ID | Author | Year | Country | Design | Setting | Sample size | Age | Intervention | Follow-up | Outcomes | Summary of results |
|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Avorn et al. [14] | 1992 | USA | Cluster RCT | Nursing homes | NHs = 12 NHR = 823 | 65 and older | - physicians who is there prescribing of psychoactive drugs was above threshold at the baseline evaluation were invited by pharmacists for separate sessions (3 interactive visits). - All physicians of NHR received 6 literature summaries (insomnia, behavioural problems) in 3 mailings. - 4 training sessions were delivered to nurses/ nursing assistants on geriatric pharma psychology, alternatives to psychoactive drugs | 5 months | -psychoactive drug use scores -proportion of residents using antipsychotics. | -psychoactive drug use mean in intervention 27% compared to 80% in control group (P = 0.02). -antipsychotics ceased in intervention 32% versus 14% in control. - no of days/patient/ month greatly reduced in intervention than control. -no of non-recommended hypnotics ceased and substituted with alternative drugs/discontinued completely were 45% in intervention versus 21% control. |
2 | Rovner et al. [15] | 1996 | USA | RCT | Nursing homes | 1 NH (250 bed community NH) NHR = 89 | 65 and older | -As ap art of a dementia care program: implementation of new prescribing guidelines based on protocol for psychotropic drug management -Educational rounds weekly for 1 h to discuss patient’s behavioural disorders, and medical status | 6 months | - antipsychotic drug - behaviour disorders -restraint use, - and cognitive/ functional status. | -Statistically significant 71% reduction in agitation with intervention versus 49% with control |
3 | Meador et al. [16] | 1997 | USA | RCT | Nursing homes | NHs = 12 NHR = 1311 | 65 and older | -geropsychiatrist delivered educational visit to physicians (45-60 min) -NH staff received 5–6 1-h programmes over 1 week delivered by nurse educator. -after 1 month, follow up sessions - when requested, evening meetings for families. | 6 months | -Proportion of APs drug use in days/ 100 /days of stay. -severity and presence of behavioural symptoms. | -APs use per 100 days at baseline in intervention gp decreased from 25.3 days to 19.7 per 100. -Aps reduction is 23% in intervention gp to control gp. −33% NHR in intervention gp had their antipsychotics ceased. |
4 | 1998 | Sweden | Cluster RCT | Nursing homes | NH = 33 NHR = 1854 | 65 and older | -Monthly multidisciplinary meetings led by pharmacist for 12 months | 12 months | -Proportion of residents with psychotropics -non recommended hypnotics, antidepressants. | −19% of residents in the intervention gp ceased APs (p = 0.007). −37% of residents ceased non- recommended hypnotics in intervention gp (p < 0.001). | |
Schmidt et al. [19] | 2000 | Sweden | Cluster RCT | Nursing homes | NH = 36 NHR = 1549 | 65 and older | Nursing homes participated in 1995 were followed up. | three-year follow-up | Medication appropriateness | -proportion of residents prescribed non-recommended hypnotics were lower (14.0%) compared to previous study 1995 (19.0%). - in1998 5% of residents were prescribed non recommended hypnotics compared to control gp (10.1%). | |
Claesson et al. [20] | 1998 | Sweden | Cluster-RCT | Nursing homes | NH = 33 NHR = 1854 | 65 and older | - regular multidisciplinary meetings (physician, pharmacist, NH nurses/assistant) reviewed resident’s drug use on a monthly basis over 12 months. -education for selected pharmacists (5 occasions = 65.5 h), topics were drug use in elderly, geriatrics. | 14 months | Medication-related problems | -NH residents were prescribed on average 7.7o (range: 6–11) medications. - laxatives (70%) -psychotropic drugs (77%, range: 50–95%). | |
5 | Furniss et al. [21] | 2000 | England. | Cluster RCT | Nursing homes | NH = 14 NHR = 330 residents: (172 ctrl, 158 Int) | 65 and older | -Medication review led by pharmacist. - pharmacist review the medications at NH, GPs surgery, or over phone. -Pharmacist collected details of current medication, medical history and current problem identified by nursing home staff. - 3 weeks post-medicine review, NH were revisited to identify any problems and to ascertain on whether changes had been implemented. | 8 months | -no of prescribed medications -Types of medications, reason for using neuroleptic medications. -hospital admission (in-patient days) -MMSE -GDS -BASDEC -CRBRS -Falls and death | - 239 of recommendations accepted by GP (91.6%). -change of medications =144 -In total MMSE were declined. - Mean CRBRS scores increased in Int compared to ctrl - deaths in ctrl were higher than Int NHs. |
6 | Stein et al. [22] | 2001 | USA | Cluster RCT | Nursing homes | NH = 20 NHR = 147 | 65 and older | -Staff training sessions (30 min) -Study physician visited/telephone to all primary care physicians -physicians received messages about NSAIDs risks and benefits , algorithm for stopping NSAIDs, or aternatives such as paracetamol or topical agents and non-pharmacological management for pain. | 3 months | NSAIDs and paracetamol Use in the past week | -Mean number of days of NSAIDs use deceased in Int gp from 7.0–1.9 days compared to ctrl gp (7.0–6.2 days), P = 0.0001 - paracetamol use in Int gp increased (3.1 days) compared to ctrl (0.31 days), P = 0.0001. |
7 | Roberts et al. [23] | 2001 | Australia | Cluster RCT | Nursing homes | NH = 52 NHR = 3230 | 65 and older | -nurse education (6–9 problem-based education sessions) including geriatric medications and common problems in long care such as depression & pain. -supported by bulletins, wall charts and clinical pharmacist visits. - clinical pharmacist average contact 26 h/NH -clinical pharmacist reviewed drug regimen for 500 residents selected by home staff. | 12 months | -Mortality rate -hospital admission -Drug use -ADEs -Medication-related problems | -mean no of psycholeptics administered /resident in Int gp decreased (− 0.14,95% CI − 0.28-0.0, p = 0.044) - in the intervention group mean number of benzodiazepines Administered/ resident reduced (− 0.06, 95% CI − 0.06 to 0.04, p = 0.29). |
8 | Crotty et al. (a) [24] | 2004 | Australia | Cluster RCT | Aged care facility | NH = 10 NHR = 154 | 65 and older | −2 multidisciplinary case conferences were conducted 6–12 weeks. -pharmacists, geriatrician, residential care staff, GP, and a representative of the Alzheimer’s Association of South Australia. -medication review prepared by the resident’s GP before case conference. | 7 months | -MAI score | -Mean MAI score in Int gp 4.1 (2.1–6.1) versus 0.4 (0.4–1.2) in ctrl gp. - benzodiazepines: mean MAI score in int.gp 0.73 (0.16–1.30) versus − 0.38 (−1.02 to 0.27) in ctrl gp. |
9 | Crotty et al. (b) [25] | 2004 | Australia | RCT | long-term care facility/hospital discharge | NH = 85 NHR = 110 Discharged from 3 hospitals | 65 and older | -pharmacist transition coordinator transfers the medication-related information to the family physician and community pharmacist. -case conference at facility within month of transfer include pharmacist, nurse, family physician, community pharmacist, | 8 weeks | -MAI score -Hospital admission -Medication related problems -ADEs, -falls | -No change in MAI score in Int gp 2.5, 95% CI1.4–3.7) -In ctrl gp MAI score had worsened 6.5, 95%CI 3.9–9.1) |
10 | Crotty et al. (c) [26] | 2004 | Australia | RCT | Residential care facilities | NH = 20 NHR = 715 | 65 and older | -Educational intervention: two (30 min) outreach visits of pharmacists to doctors. - presenting detailed audit information on psychotropic use, stroke risk reduction, and fall rates. −4 (2 h training sessions) for link nurse in each facility. | 7 months | -MAI score -Hospital admissions - MRP | -No significant difference in psychotropic drug use before &after intervention (0.89,95%CI 0.69–1.15). -PRN of antipsychotics drug use increased in Int gp compared to ctrl gp (4.95,95%CI 1.69–14.50). - No significant difference in BZD drug use before & after intervention (0.89,95%CI 0.69–1.15). - No significant difference in falls (1.17, 95%CI 0.86–1.58). |
11 | Fossey et al. [27] | 2006 | UK | Cluster RCT | Nursing homes | NH = 12 NHR = 349 | 65 and older | -Training and support to care staff on non-pharmacological interventions, alternatives to neuroleptic use. -Medication review by Led by old age psychiatrist, senior nurse every 3 months -contact between psychiatrist and prescribers to provide and wrote prescribing recommendations | 12 months | -Proportion of residents receiving neuroleptics. -CMAI - QoL | - reduction in neuroleptic use/resident (19.1, 95% CI 0.5–37.7%, P = 0.045) --Neuroleptic use decrease 24% in exp. (47 to 23%) but increased in ctrl 7.6% (49.7 to 42.1%). -No significant changes in CMAI |
12 | Zermansky et al. [28] | 2006 | UK | RCT | Nursing homes and residential homes | NH = 65 NHR = 661 | 65 and older | - Pharmacist medication review by using the resident’s medical record. - consultation with the resident’s and carer. -pharmacist forward written recommendations to GP. | 6 months | -no. of changes in medication/patient -Hospital admissions -Medication-related problems -Medicine costs -Number of medicines per participant - Mortality - Falls - SMMSE -Barthel index -GP consultations | - Increase in mean number of drug changes/patient ctrl: 2.4 versus 3.1 in Int (P < 0.01) -no of falls reduced significantly - pharmacist recommendations accepted (75.6%), and 76.6% of these recommendations were implemented. |
13 | Gurwitz et al. [29] | 2008 | USA and Canada | Cluster RCT | Two large long-term care facilities. | Facility = 2 Residents = 1118 | 65 and older | -Computer program (order entry with clinical decision support system). - more than 600 potentially serious drug-drug interactions alerts were reviewed. -no of ADEs were identified (preventable events including errors and drug-drug interactions were determined). -alerts included in the CDSSs were assessed to determine if any of them could have prevented the prescribing of these drugs. | 1 year in one facility and 6 months in the other | -Number of preventable ADEs - ADEs severity - ADEs preventability | -None ADEs = (1.06,95% CI 0.92–1.23) Preventable ADEs = (1.02,95% CI 0.81–1.30) |
14 | Field et al. [30] | 2009 | Canada | Cluster RCT | long-term care facility | -One long-term care Facility - 22 long-stay units Residents= 833 | 65 and older | The 22 long-stay units were randomly assigned - for Intervention units’ prescriber: Alerts related to medication prescribing for residents with renal insufficiency were displayed. -Control units: Alerts hidden and tracked - The types alerts were: maximum recommended daily dose/frequency of administration, medication to be avoided, and missing information. | 12 months | -Proportion of final drug orders alert that were appropriate | -Appropriate final drug orders proportion were high in Int (1.2, 95% CI 1.0–1.4) for frequency. -for drugs that should be avoided (2.6, 95% CI 1.4–5.0). for missing information (1.8, 95% CI 1.1 to 3.4). -Appropriate final drug orders Significant in Int (1.2 95% CI 1.0–1.4). |
15 | Patterson et al. [31] | 2010 | Ireland | Cluster RCT | Nursing homes | NH = 11 NHR = 334 | 65 and older | -intervention homes were visited monthly by trained pharmacists for 1 year. Resident’s information was collected from records, GP and community pharmacist. Interviews were conducted with the residents and next of kin to assess the need for medicines. - applied an algorithm to assess appropriateness of psychoactive medication and worked with GPs to improve the prescribing of these medications. | Monthly for 12 months | -Proportion of residents prescribed inappropriate psychoactive medications. -no of falls | - At 12 months, residents taking inappropriate psychoactive medications in Int gp (19.5%) decreased compared to ctrl gp (50%) intervention homes (0.26, 95% CI 0.14–0.49) -No change the falls rate |
16 | Testad et al. [32] | 2010 | Norway | Cluster RCT | Nursing homes | NH = 4 NHR = 211 | 65 and older | -Education and training program (2 days seminar and monthly group guidance for six months). | 12 months | -% of residents using antipsychotic drugs - Restraint use | -No statically significant difference in antipsychotic use. - Significant reduction in Aggression in Int gp at 6 & 12 month follow-up. -Significant reduction in proportion of residents restrained at 6 months but not at 12 months. |
17 | Lapane et al. [33] | 2011 | United States | Cluster RCT | Nursing homes | NH = 25 NHR = 3321 | 65 and older | - GRAM is automatically generated to assist consultant pharmacists identify residents at risk for delirium/ falls -Detailed instruction of consultant pharmacists providing targeted medication review for all residents at high-risk. - Reports within 24 h of admission and used during monthly review. | 12 months | − Mortality − Hospital admission potentially due to ADEs. | -Mortality rate /1000 resident-months, HR: 0.90 (adjusted HR 0.89, 95% CI 0.73–1.08) -Hospital admission/1000 resident-months, HR: 1.13 (adjusted HR 1.11, 95% CI 0.94–1.31). |
18 | Pope et al. [34] | 2011 | UK, Ireland | RCT | Nurse-managed continuing-care | NHR = 10 nurse-managed continuing-care Residents = 225 | 65 and older | -medical assessment by a geriatrician, and using Beer’s criteria for multidisciplinary panel medication review. - recommendations forwarded to the GP. - after 6 months, reassessment occurred | 6 months | -no of drugs prescribed -mortality -medication cost | −92.7% of patients received medication recommendations and 80.1% accepted. - total number of medications/ patient/d reduced in Int gp (11.64–11.09 compared to ctrl 11.07–11.5). |
19 | Kersten et al. [35] | 2013 | Norway | RCT | Nursing homes | NH = 22 NHR = 87 | 65 and older | -A paper-based review with a view to reduce ADS scores were conducted by clinical pharmacist. -clinical pharmacist discuss discontinue or replace an anticholinergic drug with the physician before changes were implemented. | 8 weeks | - Cognitive function - anti-cholinergic side-effects | - cognitive function not improved - anti-cholinergic side-effects not improved |
20 | Milos et al. [36] | 2013 | Switzerland | RCT | Nursing homes or community | NHR = 279 | 75 years or older | Pharmacists-led medication review that included assessment of relevant parts of (EMRs) and collection of patient’s blood sample data. - clinical pharmacist-initiated medication reviews based on the background information to identify DRPs. | 2 months | - no of PIMs. - DRPs | −6% decreased in PIM in Int gp -Total no of DRPs in the intervention group was 431 [mean 2.5 (1.5) / patient (range 0–9) - No significant difference between the no of DRPs in nursing home patients [mean 2.53 (1.33)] and community-dwelling patients [mean 2.55 (1.29)] Significant in changes in the actions taken by the physician were for lowered dosage. |
21 | Frankenthal et al. [37] | 2014 | Israel | RCT | chronic care geriatric facility | NH = 1 NHR = 359 | 65 and older | -medication review conducted by pharmacist -to identify PIMs and PPOs medications screened with STOPP/ START criteria then followed up with recommendations to the chief physician. - chief physician decided to accept or not. | 12 Months | -medication appropriateness -mortality -hospital admission -QoL -MRP -medication cost | -significant decreased in the average number of drugs prescribed in Int gp (P < .001). - significant decreased in the average number of falls in Int gp (P = .006). -decrease in the average drug costs in Int gp by US$29. - hospitalization, FIM scores, and QoL were same in both groups. |
22 | García-Gollarte, et al. [38] | 2014 | Spain | Cluster-RCT | Nursing homes | NH = 36 NHR = 716 | 65 and older | −30 doctors received educational intervention. - The educational intervention included general drug use in elderly, STOPP START workshop, and adverse drug reactions in older people. -participants also received educational material and references - on-demand support (via phone) for 6 months provided by the educator. | 6 Months | - Medication appropriateness (STOPP-START) -Hospital admissions Medication appropriateness (STOPP-START) -Falls | - The mean number of inappropriate drugs was higher in ctrl gp (1.29–1.56) compared to Int gp (0.81–1.13). -no of falls increased in the ctrl gp from 19.3–28% and not significantly change in the intervention group from 25.3–23.9%. |
23 | Pitkala et al. [39] | 2014 | Finland | Cluster-RCT | Assisted living facilities | Facility = 20 Residents = 227 | 65 and older | -two 4-h interactive training sessions for nursing staff aimed to enable nurses to recognize potentially harmful medications and corresponding adverse drug events. -the second 4-h sessions: case-study-based. - nurses in this intervention were asked to identify potential MDR and highlight these to the consulting doctor. | 12 months | -Medication appropriateness -Hospital admissions -Mortality -QoL -MMSE | -mean number of potentially harmful drugs lowered in int gp (−0.43, 95% CI-0.71 to −0.15) and not changed in ctrl gp (+ 0.11, 95% CI − 0.09 to + 0.31) (P = .004). -HR QoL decreased in Int gp (− 0.038, 95% CI − 0.054 to − 0.022) compared to ctrl gp (− 0.072,95% CI − 0.089 to − 0.055) (P = .005). -hospital admission decreased significantly in int gp (1.4 days/person/year, 95% CI 1.2 to −1.6) compared to ctrl gp (2.3 days/person/year; 95% CI 2.1to −2.7), RR = 0.60, 95% CI 0.49 to − 0.75, P < .001). |
24 | Connolly et al. [40] | 2015 | New Zealand | Cluster-RCT | RACFs | NH = 36 NHR = 1998 | 65 and older | - Gerontology nurse specialist delivered staff education and clinical coaching. - benchmarking of resident indicators including restraint use, falls, etc.). - multidisciplinary team meeting (1 h) monthly for the first 3 months. | 14 months | - Hospital admissions (ambulatory sensitive hospitalisations, total acute admissions). -Mortality | -no differences between Int and ctrl gp in rates of ambulatory sensitive hospitalisations admission (1.07; 95% CI 0.85–1.36; P = 0.59). -no difference in mortality (1.11; 95% CI 0.76–1.61; P = 0.62). |
25 | Potter et al. [41] | 2016 | Australia | RCT | RACFS | Facility = 4 Residents = 95 | 65 and older | -medication review followed by discontinuing non-beneficial medications conducted by a GP and a geriatrician/clinical Pharmacologist - During deprescribing, the GP reviewed participants weekly. | 12 months | -no of falls -mortality -no of fallers -cognitive function -QoL | -mortality 26% in int gp and 40% in ctrl gp (HR 0.60, 95%CI 0.30 to 1.22). -QoL Changes in Int gp (− 1.0 ± 4.3) compared to ctrl gp (− 1.0 ± 4.7). -Falls -Patients with one or more falls in int gp (0.56, 95% CI 0.42–0.69) compared to ctrl gp(0.65, 95% CI 0.50–0.77), (p = 0.40) |