EBP Theoretical Framework and Implications for Practice – EBP Topic Selection: Polypharmacy Management in Older Adults
EBP Theoretical Framework and Implications for Practice
Introduction
Polypharmacy is the use of five or more prescription medicines commonly among elderly and chronic patients population. Polypharmacy is frequently needed for chronic conditions. However, it has a greater risk of hospitalizations, cognitive deterioration and diminished QoL (Hoel et al., 2021). The literature provides explicit support for structured interventions needed in solving polypharmacy problems. These interventions need proper support from both theoretical and evidence-based clinical application programs.
The Health Belief Model (HBM) is a sustainable tool that provides practical directions for managing polypharmacy. The HBM model relies on change at personal levels since every person has different health-influencing factors and behaviours. Older adults consider medications crucial in addressing health problems but may need more information regarding the risk aspects of polypharmacy (Cheng et al., 2023). The HBM helps address these perceptions by focusing on four key areas: perceived severity, perceived benefit, perceived pe, and received barriers.
The primary approach to addressing polypharmacy often targets perceived susceptibility and perceived severity in older adults. Firstly, there is a need to create awareness for medication reviews. Secondly, the approach should focus on patients’ adherence to structured interventions, including the perceived advantages of the planned interventions, like leaving unnecessary medications and adopting better health-related practices (Cheng et al., 2023). Erasing perceived barriers, like the general concerns about stopping the medication and worrying about some conditions worsening, should also be addressed to ensure patients’ willingness to try new medication approaches (Hoel et al., 2021). Moreover, new prompts of action like taking patients’ notes and health details on EHR also encourage uncaring healthcare providers to talk about medication and review them, which helps perpetuate the highlighted topic.
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Implementing the HBM component in polypharmacy care not only empowers patients but also supports the recommendations of scientific reports. Firstly, the literature proves that structured practices like medication reviews by pharmacists prescribing approaches and patient education help provide a protective approach to polypharmacy adverse consequences. For instance, researchers such as Cheng et al. 2023 and Keller et al. 2024 underscore the role of patient-provider interchange primarily in medication compliance and safety.
The literature’s implications for practice suggest that prerequisite medication reviews need to be implemented across clinical screening to eliminate drug side effects. This is only achievable with proper patient education about the adverse aspects of polypharmacy and the essential benefits of healthy lifestyle interventions. Coordination care models should also be used when developing collaborative care models so that different caregivers develop a common aim of avoiding over-prescribing medications (Keller et al., 2024). Adopting EHR tools will allow clinicians to administer appropriate medications and use clinical reasoning.
Conclusion
Management of multiple medications to support the global health of elderly chronic disease patients needs comprehensive, logical, evidence-based approaches. However, when implemented under The Health Belief Model these interventions provide a better approach to reducing a patient’s susceptibility for polypharmacy. The patient self-care approach assists in developing perceptions in an educational context regarding treatment modality. The former comprises deciding about medicines, e.g. counselling, patent and teamwork as a way to manage the untoward effects of polypharmacy and as a way to deliver excellent, safer, more effective care.
References
Hoel, R. W., Connolly, R. M., & Takahashi, P. Y. (2021). Polypharmacy Management in Older Patients.
Mayo Clinic Proceedings, 96
(1), 242–256.
https://doi.org/10.1016/j.mayocp.2020.06.012
Keller, M. S., Qureshi, N., Mays, A. M., Sarkisian, C. A., & Pevnick, J. M. (2024). Cumulative update of a systematic overview evaluating interventions addressing polypharmacy. JAMA Network Open, 7(1), e2350963.
https://doi.org/10.1001/jamanetworkopen.2023.50963
Cheng, C., Yu, H., & Wang, Q. (2023). Nurses’ experiences concerning older adults with polypharmacy: A meta-synthesis of qualitative findings. Healthcare, 11(3), 334.
https://doi.org/10.3390/healthcare11030334
EBP Topic Selection: Polypharmacy Management in Older Adults
Polypharmacy Management in Older Adults
Polypharmacy, the simultaneous use of five or more medications, poses serious health risks, particularly for older adults who often face complex health challenges. While polypharmacy can sometimes be beneficial, it is associated with adverse effects, including increased hospitalizations, cognitive decline, and decreased quality of life. Addressing polypharmacy requires a structured approach, focusing on assessing its causes, reviewing relevant literature, and identifying practical frameworks for managing medication in older adults.
Problem Statement
Polypharmacy significantly impacts over half of older adults in the U.S., contributing to adverse drug events, increased hospitalizations, and rising healthcare costs. The PICO(T) question guiding this project is: In older adults, do structured polypharmacy management interventions, compared to standard care without specific polypharmacy interventions, reduce adverse drug events and improve quality of life?
P (Population): Older adults
I (Intervention): Structured polypharmacy management interventions
C (Comparison): Standard care without specific polypharmacy interventions
O (Outcome): Reduced adverse drug events and improved quality of life
Reason for Picking the Topic
Polypharmacy, which is the concurrent prescription and use of five or more medicines, is a rising health concern in older adults. Although polypharmacy might be clinically beneficial in many instances, it is associated with numerous adverse clinical consequences. Older adults with polypharmacy are highly likely to have drug-to-drug interactions and adverse events related to drug use. Also, polypharmacy is connected with frailty, reduced physical function, cognitive impairment, repeated hospitalizations, and mortality. Evidence demonstrates that polypharmacy has the potential to pose a burden on the lives of older adults and lead to negative feelings. For instance, older adults find it challenging to manage multiple medications, resulting in polypharmacy negatively affecting older adults’ medication adherence and quality of life (Cheng et al., 2023).
Young et al. (2023) emphasize that an aging population alongside polypharmacy might result in the prescription of potentially inappropriate medications, which can be both ineffective in treating the patient’s condition and result in a greater risk of experiencing adverse drug events, including drug-disease interaction, and drug-drug interaction, as well as failure to take medications because of heightened medication burden. Ultimately, these factors can lead to adverse health outcomes, including a deterioration in cognitive and health status. As around fifty percent of hospitalizations related to adverse drug events are avoidable, when adverse drug events occur, they might subsequently result in increased hospital admissions. The occurrence of adverse drug events might make a patient be prescribed more medications to treat or prevent these adverse events, further aggravating drug use and burden on patients.
Etiology of the problem
Multimorbidity, multiple prescribers, and availability of drugs are factors associated with polypharmacy in geriatric patients. According to Young et al. (2021), old age is associated with an increased risk of an individual having multiple chronic diseases, leading to a higher prevalence of concurrent use of various medications. Hoel et al. (2021) emphasize that the problem of polypharmacy is caused by numerous factors, including the accessibility of medicines in herbal stores, in stores, online, multiple pharmacies, and multiple prescribers. Due to the segmentation of healthcare systems, patients visit numerous healthcare professionals who lack shared records and unknowingly prescribe interacting or duplicative medications. When pharmacies do not have integrated prescription records, pharmacists are unaware of interacting medications or duplicates that their patients have been prescribed.
Lack of adherence to lifestyle changes is another factor contributing to polypharmacy in older adults. According to Hoel et al. (2021), treatments are prescribed to meet desired objectives, though there are strong beliefs that medications treat health problems. For instance, while the majority of patients with diabetes are treated with multiple medications, few patients adopt recommended lifestyle activities and changes that could enable them to accomplish treatment goals with fewer medications.
Epidemiology/Prevalence of the problem
Polypharmacy is a common phenomenon in both community and clinical settings, with a high prevalence among geriatric patients in the United States and across the globe. According to Keller et al. (2024), in the United States, the approximate rate of polypharmacy among adults 65 percent for adults sixty-five years and above is 65 percent. In Europe, approximates of the prevalence of polypharmacy in geriatric patients is between 26 percent and 40 percent, with the prevalence rate of polypharmacy at 49 percent, 42 percent, and 36 percent in India, South Korea, and Australia, respectively (Keller et al., 2024).
Literature Review
Recent studies highlight the benefits of managing polypharmacy in older adults to prevent health risks. Keller et al. (2024) found that structured interventions, like medication reviews, significantly reduced hospital visits and adverse drug events. This study showed that regular reviews help identify unnecessary medications and reduce potential drug interactions. Cheng et al. (2023) explored healthcare providers’ experiences with polypharmacy and emphasized the importance of communication between patients and providers. They noted that patients are often unaware of the risks of multiple medications. Young et al. (2021) analyzed data from U.S. physician offices and observed a high rate of polypharmacy in older adults with multiple health conditions, leading to more adverse drug events and hospitalizations. Together, these studies suggest that structured polypharmacy management can improve patient outcomes and reduce risks, supporting the need for regular medication assessment and patient education on medication safety.
Appraising Literature
Literature provides strong evidence supporting the need for structured polypharmacy management in older adults. Multiple studies consistently show that interventions like medication reviews reduce adverse drug events and hospitalizations. The evidence is reliable, as it comes from various settings, including clinical trials and healthcare provider experiences. These findings indicate that regular medication assessments can significantly improve patient outcomes, including reducing the risks associated with multiple medications. Based on consistent results across studies, enough evidence supports changing current practices and implementing structured polypharmacy management strategies in healthcare settings for older adults.
Theoretical Framework to Implement the Evidence-Based Project
The Health Belief Model (HBM) will guide the project, focusing on individual beliefs and attitudes towards health behaviors. HBM can help address older adults’ perceptions regarding medication necessity, aiding in discussions around medication reduction and adherence to lifestyle changes. Through emphasis on the perceived risks of polypharmacy and the benefits of medication review, healthcare providers can more effectively motivate older adults to engage in polypharmacy management strategies. EBP Theoretical Framework and Implications for Practice – EBP Topic Selection: Polypharmacy Management in Older Adults
Implications for Practice
Implementing polypharmacy management in clinical practice involves regular medication reviews, patient education, and collaborative care. Clinicians can incorporate findings from this research by establishing protocols for assessing medication necessity, minimizing unnecessary prescriptions, and coordinating with multiple prescribers to avoid duplicative treatments. Integrating decision-support tools into electronic health records (EHR) can further assist in identifying high-risk medication combinations. Additionally, educating patients on the risks associated with polypharmacy may encourage them to adopt lifestyle modifications that can reduce their reliance on medication.
PICO (T) Question
P (Population): Older adults
I (Intervention): Structured polypharmacy management interventions
C (Comparison): Standard care without specific polypharmacy interventions
O (Outcome): Reduced adverse drug events and improved quality of life
T (Time): Over a 6-month intervention period
PICOT: “
In older adults, do structured polypharmacy management interventions, compared to standard care without specific polypharmacy interventions, reduce adverse drug events and improve quality of life?”
Author(s) and Publication Year
Study Purpose
Setting and Sample
Study Design
Outcome Measures
Findings/Themes
Evidence Level/Quality
Burrow et al. (2023)
Examined the effects of medication review interventions compared to standard care on hospitalized adult patients
Review of relevant randomized trials in databases from 2014 to 2017
N=25 trials, including 15076 participants
Systematic review of randomized controlled trials (RCTs)
Mortality rate, quality of life, readmissions, emergency department (ED) contacts
Medication review interventions reduced hospital readmissions and ED contacts, but there were few effects on mortality and quality of life due to the uncertainty of evidence.
I/High
Carollo et al. (2024)
Evaluated the impact of various medication reviews and deprescribing interventions in older adults
Review of experimental and cohort studies on interventions for managing polypharmacy in older adults (randomized controlled trials (RCTs) and non-randomized interventional studies and prospective cohort studies)
Systematic review and meta-analysis
Primary outcomes: medication appropriateness, incidence of adverse drug reactions (ADRs), hospital readmissions, emergency department (ED) visits, and quality of life
Medication review and deprescribing interventions improved medication appropriateness and clinical outcomes, such as reduced incidence of ADRs, hospital readmissions, and ED visits. However, the effect on mortality and quality of life was still being determined due to the heterogeneity of the evidence.
I/Moderate
Herrinton et al. (2023)
I investigated the effectiveness and safety of pharmacist-led and bundled deprescribing quality intervention on hyperpolypharmacy in older adults.
Older patients 76 years and older who were prescribed ten or more medications
N=2470 patients in an integrated care setting with different deprescribing workflows
Randomized controlled trial
Change in the number of medications
Geriatric outcomes: falls, pain, cognition, and urinary incontinence
Use of medical services, adverse drug withdrawal effects
Slight reductions in prescribed drugs in the intervention and control groups;
No significant difference was found in the senior outcomes, use of medical services, and adverse drug withdrawal effects. Further research must establish the impact in less-integrated settings and more specific populations.
II/Moderate
Mangin et al. (2023)
Studied the feasibility of implementing a structured pathway for managing polypharmacy in older adults and piloted instruments for measuring effects on health outcomes
Older patients (70 years and above) with five or more long-term medications N=39
Randomized controlled feasibility study
Feasibility outcomes: process, resource, management, and scientific after TAPER implementation (Team approach to polypharmacy evaluation and reduction).
All feasibility outcomes performed well, giving the go-ahead for the intervention to be tested in a larger RCT to determine whether it reduces polypharmacy and improves health outcomes.
II/Moderate
Omuya et al. (2023)
Investigate and map the effect of deprescribing on clinical outcomes to manage polypharmacy in older adults.
14 RCTs included
Systematic review of RCTs
Drug number and use, morbidity, hospitalizations, emergency room use, falls, and quality of life
Deprescribing interventions reduced drug number and use, morbidity, cost of hospitalizations and ED visits, falls and related injuries, and improved quality of life.
I/High
Veronese et al. (2024)
Assessed the effect of deprescribing on health outcomes in older patients and the breadth of the evidence
231 RCTs involving 44193 patients
Systematic review and meta-analysis of RCTs
Number of potentially inappropriate medications (PIMs); injurious falls, mortality
Deprescribing reduced the number of PIMs in the studied patients and decreased the rate of dangerous falls and mortality in end-of-life situations. Further research is recommended to establish the impact of deprescribing on other clinical outcomes.
I/High
Zhou et al. (2023)
Investigated the impact of deprescribing on clinical outcomes in older adult patients
Review of RCTs with participants 60 years and older
Systematic review and meta-analysis
Falls, hospitalization rates, mortality, ED visits, medication adherence, quality of life, incidence of ADRs, potentially inappropriate medication (PIM), and potential prescription omission (PPO).
Deprescribing interventions reduced PPO, PIM, and ADRs. They also enhanced medication compliance.
I/High
Conclusion
Addressing polypharmacy in older adults is crucial to improving their health outcomes and quality of life. Healthcare providers can effectively reduce the risks associated with multiple medications through targeted interventions, patient education, and collaborative care. This project underscores the need for evidence-based frameworks and comprehensive, patient-centered approaches to polypharmacy management. Applying theoretical models like the HBM can also enhance patient engagement and adherence to recommended practices.
References
Alamer, A. S. (2024). Behavior change theories and models within health belief model research: A five-decade holistic bibliometric analysis. Cureus.
https://doi.org/10.7759/cureus.63143
Bülow, C., Clausen, S.S., Lundh, A., & Christensen, M. (2023). Medication review in hospitalized patients to reduce morbidity and mortality.
Cochrane Database of Systematic Reviews, 1
(CD008986). https://doi.org 10.1002/14651858.CD008986.pub4
Carollo, M., Crisafulli, S., Vitturi, G., Besco, M., Hinek, D., Sartorio, A., Tanara, V., Spadacini, G., Selleri, M., Zanconato, V., Fava, C., Minuz, P., Zamboni, M., & Trifirò, G. (2024). Clinical impact of medication review and deprescribing in older inpatients: A systematic review and meta-analysis.
Journal of the American Geriatrics Society, 72
(10), 3219-3238.
https://doi.org/10.1111/jgs.19035
Cheng, C., Yu, H., & Wang, Q. (2023). Nurses’ experiences concerning older adults with polypharmacy: A meta-synthesis of qualitative findings. Healthcare, 11(3), 334.
https://doi.org/10.3390/healthcare11030334
Herrinton, L. J., Lo, K., Alavi, M., Alexeeff, S.E., Butler, K.M., Chang, C., Chang, C.C., Chu,V. L., Krishnaswami, A., Deguzman, L. H., Prausnitz, S., Mason, M.D., & Draves, M. (2023). Effectiveness of bundled hyperpolypharmacy deprescribing compared with usual care among older adults: A randomized controlled trial.
JAMA Network Open, 6
(7), e2322505. https://doi.org 10.1001/jamanetworkopen.2023.22505
Hoel, R. W., Connolly, R. M., & Takahashi, P. Y. (2021). Polypharmacy Management in Older Patients.
Mayo Clinic Proceedings, 96
(1), 242–256.
https://doi.org/10.1016/j.mayocp.2020.06.012
Keller, M. S., Qureshi, N., Mays, A. M., Sarkisian, C. A., & Pevnick, J. M. (2024). Cumulative update of a systematic overview evaluating interventions addressing polypharmacy. JAMA Network Open, 7(1), e2350963.
https://doi.org/10.1001/jamanetworkopen.2023.50963
Mangin, D., Lamarche, L., Agarwal, G., Ali, A., Cassels, A., Colwill, K., Dolovich, L., Brown, N.D., Farrell, F., Freeman, K., Frizzle, K., Garrison, S. R., Gillett, J., Holbrook, A., uric-Vrataric, J., McCormack, J., Parascandalo, J., Richardson, J., Risdon, C., …& Trimble, J. (2023). Team approach to polypharmacy evaluation and reduction: feasibility randomized trial of a structured clinical pathway to reduce polypharmacy.
Pilot and Feasibility Studies, 9
(84).
https://doi.org/10.1186/s40814-023-01315-0
Omuya, H., Nickel, C., Wilson, P., & Chewning, B. (2023). A systematic review of randomized-controlled trials on deprescribing outcomes in older adults with polypharmacy.
International Journal of Pharmacy Practice, 31
(4), 349-368.
https://doi.org/10.1093/ijpp/riad025
Veronese, N., Gallo, U., Baccardi, V., Demurtas, J., Michielon, A., Taci, X., Zanchetta, G., Davis, S.E.C., Chiumente, M., Venturini, F., & Pilotto, A. (2024). Efficacy of deprescribing on health outcomes: An umbrella review of systematic reviews with meta-analysis of randomized controlled trials.
Aging Research Reviews, 95
(102237).
https://doi.org/10.1016/j.arr.2024.102237
Young, E. H., Pan, S., Yap, A. G., Reveles, K. R., & Bhakta, K. (2021). Polypharmacy prevalence in older adults seen in United States physician offices from 2009 to 2016. PLOS ONE, 16(8), e0255642.
https://doi.org/10.1371/journal.pone.0255642
Zhou, D., Chen, Z., & Tian, F. (2023). Deprescribing interventions for older patients: A systematic review and meta-analysis.
Journal of the American Medical Directors Association, 24
(11), 1718-1725.
https://doi.org/10.1016/j.jamda.2023.07.016
EBP Theoretical Framework and Implications for Practice