Optimization of drug treatment in older people exposed to polypharmacy: “One size does not fit all”

Older people are prescribed an increasing number of medications, and although many drugs may have good clinical indications individually, polypharmacy is also associated with adverse health outcomes. Especially among multimorbid and frail older people, the trade-off between benefit and harm can be challenging to assess, and there is a need for strategies that can guide clinicians on how to provide the benefits of drug treatment but at the same time avoid negative consequences. The main objective of the thesis was to evaluate the effect of a thorough clinical drug review upon health-related quality of life (HRQoL) and other patient-related outcomes in older, home-dwelling patients exposed to polypharmacy. The study was conducted as a cluster randomized controlled trial with an intervention that included a clinical geriatric assessment as well as direct collaboration between the geriatrician and the patients’ family physician (FP). The primary outcome was HRQoL measured by the 15D instrument. A total of 174 patients with a mean age of 83 years were included. The main finding was that the intervention resulted in positive effects on HRQoL. Mean 15D scores deteriorated in both groups, but at a slower pace in the intervention group. Most secondary outcomes on physical and cognitive function were also in favor of the intervention, although not all reached statistical significance. There were more drug changes in the intervention group compared to the control group. Post-hoc analyses indicated that the patients with more inappropriate drug use at baseline benefited most from the intervention. The study concludes that clinical geriatric assessments and drug reviews carried out in collaboration with the patients’ FP have the potential to improve HRQoL among older people exposed to polypharmacy, and may also have positive effects on physical and cognitive functioning