W6A

Daniela Pereda

St. Thomas University

Dr. Carol Patton

NUR 611: Advanced Practice Nursing Integrated Practice

June 7, 2026

The Role Of The Family Nurse Practitioner In Identifying And Managing Polypharmacy In Older Adults During Annual Wellness Visits.

Polypharmacy refers to the prescription of 5 or more drugs at a time. It is an increasing problem for the safety of patients, especially older people. As patients get older, the higher the chances of them having chronic disease burden, being prescribed multiple medications by multiple providers, and having an adverse drug event (ADE), drug-drug interaction, and hospitalization. Additionally, physiological changes with age such as decreased renal clearance, altered hepatic metabolism and decreased levels of albumin increase the sensitivity of medications and potential for harm. There is increased awareness, but significant evidence to practice gaps. This review compares four peer-reviewed studies published between 2022 and 2024 that have examined interventions tackling polypharmacy in older people, highlights research gaps and suggests a methodology to aid the resolution of these gaps.

Literature Review

McDonald et al. (2022) carried out MedSafer Study which is a stepped-wedge cluster RCT implemented in 11 Canadian hospitals. The study utilized 5,698 adult participants (age 65+). During the discharge process, personalized deprescribing reports were created for the clinicians using an electronic clinical decision support tool. Overall, the intervention had a significant effect on the reduction of potentially inappropriate medications (PIMs), with 55.4% of intervention patients and 29.8% of control patients reaching an acceptable number of PIMs in the 30 days after discharge (p < 0.05). There was no statistically significant difference in 30-day post-discharge ADEs between the intervention and control groups. While cost-effective targeting of low-risk, non-beneficial medications may not help to minimize short-term clinical harm.

Jungo et al. (2023) performed the OPTICA cluster RCT in Swiss primary care with 43 GPs and 323 patients aged ≥ 65 years who had multimorbidity and polypharmacy. The program of OPTICA, in contrast to MedSafer's discharge intervention, was a 12-month intervention in outpatient care which involved an eCDSS-led medication review, with shared decision making between GP and patient. Similar to MedSafer, there was no statistically significant improvement in overall medication appropriateness, but there was a reduction in the number of safety events in the intervention group at 6 and 12 months. Both RCTs showed that digital decision support has the potential to influence prescribing practice, but was not consistently associated with any clinical outcomes. It shows a missing link between the activity of deprescribing and the downstream benefit for patients.

However, Vasilevskis et al. (2023) reported significantly more positive outcomes for the Shed-MEDS RCT, involving 372 hospitalized adults age 50 years and older moving to post-acute care (PAC) facilities. The intervention was not a clinician-centered one but was patient-centered, undertaken by the pharmacist and the nurse practitioner, with the aim of getting patient preferences and goals of treatment. The intervention group experienced a significantly lower number of medications at PAC facility discharge and 90-day follow-up, with no evidence of negative safety outcomes. Rather than relying primarily on technology, the key factor in successful, long-term safe medication reduction may be getting the patient to be the focus of the deprescribing process, as Shed-MEDS shows, when compared with MedSafer and OPTICA.

Thompson and McDonald (2024) performed a narrative review in the Annual Review of Medicine in which a synthesis of overall deprescribing literature was performed. The study reveals that deprescribing is generally safe and feasible, but there is ongoing uncertainty regarding long-term clinical outcomes. Importantly, they pointed out that all of the outcome measures used in the trials were inconsistent, ranging from PIM counts to rates of ADEs, appropriateness scores, QOL etc., which makes it nearly impossible to combine data from different trials, and hampers the growing body of evidence. They also found that barriers to implementation were not being addressed, such as clinician inertia and patient reluctance. This review provides the context for the three RCTs cited above, and sheds light on why, despite the best efforts of well-designed RCTs, a consistent conclusion has not been reached: polypharmacy is a complex phenomenon that cannot be broken down into a single tractable intervention.

Gaps in the Literature

Three gaps were identified in this research and the first one was the lack of study that assessed the sustainability of the reduction beyond 12 months. This made it hard to determine whether there was continuation of medication reductions or not. The second gap is the homogenous nature of the study populations, mostly White, European or North American, and included hospital-accessible groups. It implies that the study outcomes cannot be generalized to all diverse community-dwelling populations. The third gap is the absence of any single trial that incorporates patient-centered communication, digital decision support, and multi-disciplinary team participation in a similar sufficiently powered trial.

Proposed Methodology

A pragmatic multi-site randomized controlled trial of two interventions is proposed for the enrollment of adults 65 years or older who are taking five or more medications from 2 or more providers and reside in the community. A variety of primary care clinics in urban, suburban and rural areas would be represented. Patients would be randomly assigned in 1:1 ratio to a combination pharmacist-physician medication review with STOPP/START criteria plus patient centered shared decision making compared to usual care. There is evidence of sustained effects after four structured visits over 12 months, followed by a visit at 18 months and 24 months. Primary outcomes include the PIM count, ADE incidence, hospitalization, secondary outcomes. there are also quality of life and functional status. Representativeness gaps could be addressed with equity-focused subgroup analyses by race, income, and by living in rural vs. urban areas. This design combines the best features of MedSafer, Shed-MEDS, and OPTICA into one extended and equity-focused design.

Conclusion

The literature reviewed shows that using an electronic decision support system or patient-centered deprescribing interventions are effective at reducing medicines burden, but that these interventions alone do not routinely result in short-term clinical benefit. The proposed methodology addresses identified gaps with an integrated, equity-focused design that is longitudinal. The coordinated, patient-centered and system-supported strategies need to be evaluated in various representative populations, and medication safety improvements for older adults require these approaches.

References

Jungo, K. T., Ansorg, A.-K., Floriani, C., Rozsnyai, Z., Schwab, N., Meier, R., Valeri, F., Stalder, O., Limacher, A., Schneider, C., Bagattini, M., Trelle, S., Spruit, M., Schwenkglenks, M., Rodondi, N., & Streit, S. (2023). Optimising prescribing in older adults with multimorbidity and polypharmacy in primary care (OPTICA): cluster randomised clinical trial. BMJ, 381, e074054. https://doi.org/10.1136/bmj-2022-074054

McDonald, E. G., Wu, P. E., Rashidi, B., Wilson, M. G., Bortolussi-Courval, É., Atique, A., Battu, K., Bonnici, A., Elsayed, S., Wilson, A. G., Papillon-Ferland, L., Pilote, L., Porter, S., Murphy, J., Ross, S. B., Shiu, J., Tamblyn, R., Whitty, R., Xu, J., & Fabreau, G. (2022). The MedSafer Study-Electronic Decision Support for Deprescribing in Hospitalized Older Adults: A Cluster Randomized Clinical Trial. JAMA Internal Medicine, 182(3), 265–273. https://doi.org/10.1001/jamainternmed.2021.7429

Thompson, W., & McDonald, E. G. (2023). Polypharmacy and Deprescribing in Older Adults. Annual Review of Medicine, 75(1). https://doi.org/10.1146/annurev-med-070822-101947

Vasilevskis, E. E., Shah, A. S., Hollingsworth, E. K., Shotwell, M. S., Kripalani, S., Mixon, A. S., & Simmons, S. F. (2023). Deprescribing Medications Among Older Adults From End of Hospitalization Through Postacute Care: A Shed-MEDS Randomized Clinical Trial. JAMA Internal Medicine, 183(3), 223–231. https://doi.org/10.1001/jamainternmed.2022.6545