Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Alongside the many Cochrane reviews of pharmacological treatments are some that look at how to ensure that these treatments are used appropriately. The third update of one of these, for polypharmacy in older people, was published in October 2023. Here's the new first author, Judith Cole from the Clinical Trials Service Unit at the University of Oxford in the UK to tell us more.

Judith: Polypharmacy, or the use of multiple medicines, is common in people over 65, as many have multiple long-term conditions, such as cardiovascular disease or diabetes. For some, this level of prescribing might be inappropriate, raising the risk that the possible adverse effects of a medication will exceed its benefits. While, some other patients might not be receiving medications that they need and these are termed potential prescribing omissions.
In the context of older people, inappropriate polypharmacy can be medications that should generally be avoided in those over 65 because they are ineffective or pose unnecessarily high risk. On the other hand, their polypharmacy can be made more appropriate by prescribing medicines for an otherwise untreated medical condition.
Our review investigates the effects of interventions to improve the appropriate use of polypharmacy and reduce medication‐related problems in older people. Although we conclude that it remains uncertain whether interventions provided to improve appropriate polypharmacy, such as pharmaceutical care, led to clinically significant improvements for patients, this is still a useful guide for future research that might modify certain components of interventions to try to improve their effectiveness.
Since the second update of this review in 2018, we have found 10 new studies but we also decided to limit the review to randomised trials. In total, we now have 38 studies from 19 countries involving just over 18,000 patients.
The new studies, published from 2018 onwards, placed more emphasis on multi-disciplinary healthcare teams and collaboration between pharmacists, doctors and nurses, as well as the involvement of the patient to varying degrees in decision‐making. However, there was great variation in the types of interventions, with some consisting of a single episode of care, and others being delivered on a daily, weekly or monthly basis.
Overall, the quality of the evidence was poor and we have low or very low confidence in the pooled effect estimates. However, our results showed that pharmaceutical care may slightly reduce the number of potential prescribing omissions, but this effect estimate was based on only three studies, which had serious limitations because of the risk of bias. For all the other outcomes, we are uncertain whether pharmaceutical care had any positive effect.
Our results suggest that prescribers should carefully consider their sources of evidence to find the right balance in the 'risk/treatment paradox', to ensure that high‐risk older patients are not denied safe medications capable of materially improving their survival or quality of life while avoiding inappropriate medications for which harms are likely to outweigh benefits. It's also important for healthcare professionals to review any over the counter medicines that an older patient is taking, when reviewing their medication use.
Finally, given the quality of studies we found for the review, including those selected for this update, future research needs to ensure improved rigour in intervention design, better reporting of intervention development and delivery, and the selection and reporting of consistent outcomes.

Mike: If you would like to read this latest update, and watch for any further updates that would bring in that future research, just go to Cochrane Library dot com and search 'polypharmacy and older patients'.