Drugs & Aging

, Volume 36, Issue 3, pp 247–267 | Cite as

Interventions to Optimise Prescribing in Older People with Dementia: A Systematic Review

  • Leila Shafiee HanjaniEmail author
  • Duncan Long
  • Nancye M. Peel
  • Geeske Peeters
  • Christopher R. Freeman
  • Ruth E. Hubbard
Systematic Review



Older adults living with dementia may have a higher risk of medication toxicity than those without dementia. Optimising prescribing in this group of people is a critically important yet challenging process.


Our aim was to systematically review the evidence for the effectiveness of interventions for optimising prescribing in older people with dementia.


This systematic review searched the Pubmed, Embase, CINAHL, PsycINFO and Cochrane Library electronic databases for studies that evaluated relevant interventions. Experimental, quasi-experimental and observational studies published in English prior to August 2018 were included. Data were synthesised at a narrative level.


The 18 studies accepted for review included seven randomised, two nonrandomised controlled, five quasi-experimental and four observational studies. Half the studies were conducted in nursing homes and the other half in hospital and community settings. There was great variability in the interventions and outcomes reported and a meta-analysis was not feasible. The three randomised and four nonrandomised studies examining medication appropriateness all reported improvements on at least one measure of the outcome. Six studies reported on interventions that identified and resolved drug-related problems. The results for other outcomes, including the number of medications (10 studies), healthcare utilisation (7 studies), mortality (7 studies), quality of life (3 studies) and falls (3 studies), were mixed and difficult to synthesise because of variability in the study design and measures used.


Emerging evidence suggests that interventions in older people with dementia may have positive effects on medication appropriateness and resolution of drug-related problems; however, whether optimisation of medication results in clinically meaningful outcomes remains uncertain.



The authors would like to thank Ms. Christine Dalais (The University of Queensland Library) for her help with the development of the search strategy.

Compliance with Ethical Standards

Conflict of interest

Leila Shafiee Hanjani, Duncan Long, Nancye M. Peel, Geeske Peeters, Christopher R. Freeman and Ruth E. Hubbard declare that they have no conflicts of interest.


Leila Shafiee Hanjani is supported by an Australian Government Research Training Program (RTP), and Geeske Peeters is supported by a fellowship from the Global Brain Health Institute. This work was supported by the National Health and Medical Research Council (NHMRC) Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People (Grant no. GNT9100000). No other sources of funding were used to assist in the preparation of this article.

Supplementary material

40266_2018_620_MOESM1_ESM.pdf (114 kb)
Supplementary material 1 (PDF 114 kb)


  1. 1.
    Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: Guideline Adaptation Committee; 2016.Google Scholar
  2. 2.
    Reeve E, Bell SJ, Hilmer SN. Barriers to optimising prescribing and deprescribing in older adults with dementia: a narrative review. Curr Clin Pharmacol. 2015;10(3):168–77.Google Scholar
  3. 3.
    Page A, Etherton-Beer C, Seubert LJ, Clark V, King S, Clifford RM. Medication use to manage comorbidities for people with dementia: a systematic review. J Pharm Pract Res. 2018;48:356–67.Google Scholar
  4. 4.
    World Health Organization. Dementia. Accessed 3 Jan 2018.
  5. 5.
    Andersen F, Viitanen M, Halvorsen DS, Straume B, Engstad TA. Co-morbidity and drug treatment in Alzheimer’s disease. A cross sectional study of participants in the Dementia Study in Northern Norway. BMC Geriatr. 2011;11(1):58.Google Scholar
  6. 6.
    Bunn F, Burn A-M, Goodman C, Rait G, Norton S, Robinson L, et al. Comorbidity and dementia: a scoping review of the literature. BMC Med. 2014;12:192–206.Google Scholar
  7. 7.
    Clague F, Mercer SW, McLean G, Reynish E, Guthrie B. Comorbidity and polypharmacy in people with dementia: insights from a large, population-based cross-sectional analysis of primary care data. Age Ageing. 2017;46(1):33–9.Google Scholar
  8. 8.
    Kristensen RU, Norgaard A, Jensen-Dahm C, Gasse C, Wimberley T, Waldemar G. Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study. J Alzheimers Dis. 2018;63(1):383–94.Google Scholar
  9. 9.
    Somers M, Rose E, Simmonds D, Whitelaw C, Calver J, Beer C. Quality use of medicines in residential aged care. Aust Fam Phys. 2010;39(6):413.Google Scholar
  10. 10.
    Kuijpers MA, Van Marum RJ, Egberts AC, Jansen PA. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol. 2008;65(1):130–3.Google Scholar
  11. 11.
    Tan ECK, Jokanovic N, Koponen MPH, Thomas D, Hilmer SN, Bell SJ. Prevalence of analgesic use and pain in people with and without dementia or cognitive impairment in aged care facilities: a systematic review and meta-analysis. Curr Clin Pharmacol. 2015;10(3):194–203.Google Scholar
  12. 12.
    Parsons C. Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem. Ther Adv Drug Saf. 2017;8(1):31–46.Google Scholar
  13. 13.
    Lau DT, Mercaldo ND, Harris AT, Trittschuh E, Shega J, Weintraub S. Polypharmacy and potentially inappropriate medication use among community-dwelling elders with dementia. Alzheimer Dis Assoc Disord. 2010;24(1):56.Google Scholar
  14. 14.
    Johnell K. Inappropriate drug use in people with cognitive impairment and dementia: a systematic review. Curr Clin Pharmacol. 2015;10(3):178–84.Google Scholar
  15. 15.
    Redston MR, Hilmer SN, McLachlan AJ, Clough AJ, Gnjidic D. Prevalence of potentially inappropriate medication use in older inpatients with and without cognitive impairment: a systematic review. J Alzheimers Dis. 2018;61(4):1639–52.Google Scholar
  16. 16.
    Ramsey CM, Gnjidic D, Agogo GO, Allore H, Moga D. Longitudinal patterns of potentially inappropriate medication use following incident dementia diagnosis. Alzheimers Dement Transl Res Clin Interv. 2018;4:1–10.Google Scholar
  17. 17.
    Bosboom PR, Alfonso H, Almeida OP, Beer C. Use of potentially harmful medications and health-related quality of life among people with dementia living in residential aged care facilities. Dement Geriatr Cogn Disord Extra. 2012;2(1):361–71.Google Scholar
  18. 18.
    Renom-Guiteras A, Thurmann PA, Miralles R, Klaassen-Mielke R, Thiem U, Stephan A, et al. Potentially inappropriate medication among people with dementia in eight European countries. Age Ageing. 2018;47(1):68–74.Google Scholar
  19. 19.
    Walsh KA, O’Riordan D, Kearney PM, Timmons S, Byrne S. Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists’ interventions in secondary care. Age Ageing. 2016;45(2):201–9.Google Scholar
  20. 20.
    Page A, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C. Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel. Intern Med J. 2016;46(10):1189–97.Google Scholar
  21. 21.
    Reeve E, Trenaman SC, Rockwood K, Hilmer SN. Pharmacokinetic and pharmacodynamic alterations in older people with dementia. Expert Opin Drug Metab Toxicol. 2017;13(6):651–68.Google Scholar
  22. 22.
    Van Spall HG, Toren A, Kiss A, Fowler RA. Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA. 2007;297(11):1233–40.Google Scholar
  23. 23.
    Alldred DP, Raynor DK, Hughes C, Barber N, Chen T, Spoor P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev. 2013. Scholar
  24. 24.
    McGrattan M, Ryan C, Barry HE, Hughes CM. Interventions to improve medicines management for people with dementia: a systematic review. Drugs Aging. 2017;34(12):907–16.Google Scholar
  25. 25.
    Alldred DP, Kennedy MC, Hughes C, Chen TF, Miller P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev. 2016. Scholar
  26. 26.
    Cooper JA, Cadogan CA, Patterson SM, Kerse N, Bradley MC, Ryan C, et al. Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review. BMJ Open. 2015;5(12):e009235.Google Scholar
  27. 27.
    Clyne B, Fitzgerald C, Quinlan A, Hardy C, Galvin R, Fahey T, et al. Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials. J Am Geriatr Soc. 2016;64(6):1210–22.Google Scholar
  28. 28.
    Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014. Scholar
  29. 29.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.Google Scholar
  30. 30.
    Shafiee Hanjani L, Long D, Peel N, Peeters G, Freeman C, Hubbard R. Interventions to optimise prescribing in older people with dementia. PROSPERO 2017 (CRD42017073358). Accessed 1 Nov 2018.
  31. 31.
    Hartmaier SL, Sloane PD, Guess HA, Koch GG, Mitchell CM, Phillips CD. Validation of the minimum data set cognitive performance scale: agreement with the mini-mental state examination. J Gerontol A Biol Sci Med Sci. 1995;50(2):M128–33.Google Scholar
  32. 32.
    Coon JT, Abbott R, Rogers M, Whear R, Pearson S, Lang I, et al. Interventions to reduce inappropriate prescribing of antipsychotic medications in people with dementia resident in care homes: a systematic review. J Am Med Dir Assoc. 2014;15(10):706–18.Google Scholar
  33. 33.
    Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.Google Scholar
  34. 34.
    Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.Google Scholar
  35. 35.
    National Institutes of Health. Quality assessment tool for before-after (pre-post) studies with no control group. Systematic evidence reviews and clinical practice guidelines. Washington, DC: National Institutes of Health; 2014.Google Scholar
  36. 36.
    Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: University of Ottawa; 2001. Accessed 17 Jan 2018.
  37. 37.
    Gustafsson M, Sjölander M, Pfister B, Jonsson J, Schneede J, Lövheim H. Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial. Eur J Clin Pharmacol. 2017;73:827–35.Google Scholar
  38. 38.
    Potter K, Flicker L, Page A, Etherton-Beer C. Deprescribing in frail older people: a randomised controlled trial. PLoS One. 2016;11(3):e0149984.Google Scholar
  39. 39.
    Jordan S, Gabe-Walters ME, Watkins A, Humphreys I, Newson L, Snelgrove S, et al. Nurse-led medicines’ monitoring for patients with dementia in care homes: a pragmatic cohort stepped wedge cluster randomised trial. PLoS ONE. 2015;10(10):e0140203.Google Scholar
  40. 40.
    Pitkälä KH, Juola A-L, Kautiainen H, Soini H, Finne-Soveri UH, Bell JS, et al. Education to reduce potentially harmful medication use among residents of assisted living facilities: a randomized controlled trial. J Am Med Dir Assoc. 2014;15(12):892–8.Google Scholar
  41. 41.
    Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, et al. Clinical medication review by a pharmacist of elderly people living in care homes—randomised controlled trial. Age Ageing. 2006;35(6):586–91.Google Scholar
  42. 42.
    Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33(6):612–7.Google Scholar
  43. 43.
    Furniss L, Burns A, Craig SKL, Scobie S, Cooke J, Faragher B. Effects of a pharmacist’s medication review in nursing homes. Randomised controlled trial. Br J Psychiatry. 2000;176:563–7.Google Scholar
  44. 44.
    Sakakibara M, Igarashi A, Takase Y, Kamei H, Nabeshima T. Effects of prescription drug reduction on quality of life in community-dwelling patients with dementia. J Pharm Pharm Sci. 2015;18(5):705–12.Google Scholar
  45. 45.
    Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-positive approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430–4.Google Scholar
  46. 46.
    Jordan S, Gabe M, Newson L, Snelgrove S, Panes G, Picek A, et al. Medication monitoring for people with dementia in care homes: the feasibility and clinical impact of nurse-led monitoring. Sci World J. 2014;2014:843621.Google Scholar
  47. 47.
    Ghibelli S, Marengoni A, Djade CD, Nobili A, Tettamanti M, Franchi C, et al. Prevention of inappropriate prescribing in hospitalized older patients using a computerized prescription support system (INTERcheck®). Drugs Aging. 2013;30(10):821–8.Google Scholar
  48. 48.
    Lang PO, Vogt-Ferrier N, Hasso Y, Le Saint L, Dramé M, Zekry D, et al. Interdisciplinary geriatric and psychiatric care reduces potentially inappropriate prescribing in the hospital: interventional study in 150 acutely ill elderly patients with mental and somatic comorbid conditions. J Am Med Dir Assoc. 2012;13(4):406.e1–7.Google Scholar
  49. 49.
    Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648–54.Google Scholar
  50. 50.
    Halvorsen KH, Ruths S, Granas AG, Viktil KK. Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes. Scand J Prim Health Care. 2010;28(2):82–8.Google Scholar
  51. 51.
    Poudel A, Peel NM, Mitchell CA, Gray LC, Nissen LM, Hubbard RE. Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities. Clin Interv Aging. 2015;10:1043.Google Scholar
  52. 52.
    Brunet NM, Sevilla-Sánchez D, Novellas JA, Jané CC, Gómez-Batiste X, McIntosh J, et al. Optimizing drug therapy in patients with advanced dementia: a patient-centered approach. Eur Geriatr Med. 2014;5(1):66–71.Google Scholar
  53. 53.
    Saad M, Harisingani R, Katinas L. Impact of geriatric consultation on the number of medications in hospitalized older patients. Consult Pharm. 2012;27(1):42–8.Google Scholar
  54. 54.
    Chan VT, Woo BK, Sewell DD, Allen EC, Golshan S, Rice V, et al. Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit. Int Psychogeriatr. 2009;21(1):195–9.Google Scholar
  55. 55.
    Gustafsson M, Sjolander M, Pfister B, Schneede J, Lovheim H. Effects of pharmacists’ interventions on inappropriate drug use and drug-related readmissions in people with dementia: a secondary analysis of a randomized controlled trial. Pharmacy (Basel). 2018;6(1):E7.Google Scholar
  56. 56.
    Pfister B, Jonsson J, Gustafsson M. Drug-related problems and medication reviews among old people with dementia. BMC Pharmacol Toxicol. 2017;18(1):52–62.Google Scholar
  57. 57.
    Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. 2002;359(9300):57–61.Google Scholar
  58. 58.
    Reeve E, Farrell B, Thompson W, Herrmann N, Sketris I, Magin P, et al. Evidence-based clinical practice guideline for deprescribing cholinesterase inhibitors and memantine. Sydney: The University of Sydney; 2018.Google Scholar
  59. 59.
    Millar AN, Daffu-O’Reilly A, Hughes CM, Alldred DP, Barton G, Bond CM, et al. Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes. Trials. 2017;18(1):175.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Centre for Health Services Research, Faculty of MedicineThe University of QueenslandBrisbaneAustralia
  2. 2.Department of PharmacyPrincess Alexandra HospitalWoolloongabbaAustralia
  3. 3.Global Brain Health InstituteTrinity CollegeDublinIreland
  4. 4.Centre for Optimising Pharmacy Practice-based Excellence in ResearchThe University of QueenslandBrisbaneAustralia
  5. 5.PA-Southside Clinical Unit, Faculty of MedicineThe University of QueenslandBrisbaneAustralia

Personalised recommendations