Medication Review During Long-Term Care: Clinical Relevance, Evidence, and Guideline-Based Approaches

Abstract

Medication review during long-term care is a pivotal process in optimizing pharmacotherapy, reducing adverse drug events, and improving outcomes among elderly and medically complex populations. This review synthesizes current evidence, highlights mechanisms underlying polypharmacy risks, and discusses guideline-based strategies for effective medication management. Emphasis is placed on epidemiology, risk factors, diagnostic considerations, management advances, and the translation of recent research into clinical practice.

Introduction

Long-term care (LTC) settings, including nursing homes and assisted living facilities, are characterized by residents with multiple comorbidities, functional impairments, and high medication burden. Medication review is an essential clinical intervention aimed at ensuring safe, effective, and appropriate drug use in this vulnerable population. The complexity of care, frequent transitions, and evolving clinical status necessitate regular reassessment of pharmacotherapy to prevent iatrogenesis and optimize quality of life. This article provides a comprehensive overview of medication review practices in LTC, integrating recent evidence and expert consensus.

Epidemiology / Disease Burden

Polypharmacy, typically defined as the regular use of five or more medications, affects up to 50-70% of LTC residents globally. Observational studies have consistently demonstrated high prevalence rates of potentially inappropriate medications (PIMs), with estimates ranging from 30% to 60% depending on the criteria used (e.g., Beers Criteria, STOPP/START). The burden of adverse drug events (ADEs) in LTC is considerable, contributing to hospitalizations, increased mortality, cognitive decline, falls, and diminished functional status. The aging population and increasing longevity have amplified the demand for LTC services and underscored the importance of systematic medication review to address this growing public health challenge.

Pathophysiology

The pharmacokinetics and pharmacodynamics of medications are significantly altered in the elderly due to age-related changes such as reduced renal and hepatic function, altered body composition, and decreased homeostatic reserve. These physiological changes increase susceptibility to drug-drug and drug-disease interactions, accumulation of active metabolites, and heightened sensitivity to both therapeutic and adverse effects. In LTC, the presence of multimorbidity further complicates medication selection, as comorbid conditions often require complex therapeutic regimens that increase the risk of iatrogenic harm. Mechanism-based understanding of these alterations is essential for tailoring pharmacotherapy and guiding medication review decisions.

Risk Factors

Risk factors for inappropriate medication use and ADEs in LTC include advanced age, cognitive impairment, polypharmacy, renal or hepatic dysfunction, multiple prescribers, recent hospitalizations, and lack of regular medication review. Specific drug classes such as sedative-hypnotics, anticholinergics, anticoagulants, and antipsychotics are particularly prone to causing harm in elderly LTC residents. Socioeconomic factors, limited communication between healthcare providers, and inadequate documentation further exacerbate the risk landscape. Recognizing these risk factors is vital for targeting high-risk individuals and implementing proactive medication review interventions.

Clinical Features

Clinical manifestations of medication-related problems in LTC are often non-specific and may include delirium, falls, unexplained functional decline, gastrointestinal disturbances, and new onset or worsening of chronic symptoms. Subtle presentations such as impaired cognition, urinary incontinence, or behavioral changes are frequently misattributed to underlying chronic disease rather than medication effects. Comprehensive medication review requires a high index of suspicion and a systematic approach to evaluating potential drug-related causes of new or worsening clinical features.

Diagnosis

Diagnosis of medication-related problems in LTC is inherently challenging due to overlapping symptomatology with geriatric syndromes and polypharmacy. Structured medication review tools, such as the Medication Appropriateness Index, Beers Criteria, STOPP/START, and comprehensive geriatric assessment, provide frameworks for systematic evaluation. Interdisciplinary collaboration incorporating physicians, pharmacists, nurses, and caregivers is essential for accurate identification of PIMs, ADEs, and drug-drug or drug-disease interactions. Routine laboratory monitoring and clinical assessment are integral components of the diagnostic process, facilitating timely recognition of issues requiring intervention.

Treatment & Management

The cornerstone of management is regular, systematic medication review, ideally conducted at least quarterly or with significant clinical changes. Key steps include compiling an accurate medication list, assessing each drug for indication, effectiveness, safety, and practicality, and deprescribing unnecessary or harmful agents. Non-pharmacological interventions should be prioritized where appropriate, particularly for behavioral and psychological symptoms. Shared decision-making with patients, families, and the interdisciplinary team is critical to align pharmacotherapy with goals of care and patient preferences. Medication reconciliation at care transitions, robust documentation, and ongoing education of staff further enhance medication safety in LTC.

Recent Advances / Emerging Therapies

Recent advances in medication review include the integration of electronic health records (EHRs) with clinical decision support systems (CDSS), which enhance identification of PIMs and facilitate real-time alerts for potential interactions. Pharmacogenomic testing is emerging as a tool to individualize drug therapy, particularly for medications with narrow therapeutic indices or high risk of adverse effects. Mobile technology and telemedicine have also expanded opportunities for remote medication review by clinical pharmacists. Research into deprescribing protocols and implementation science has yielded validated approaches for systematically discontinuing unnecessary medications, with evidence demonstrating reductions in ADEs and improved clinical outcomes.

Guideline Recommendations

International and national guidelines uniformly recommend regular medication review for all LTC residents, with particular emphasis on high-risk populations (e.g., those with polypharmacy, cognitive impairment, or recent hospitalization). The American Geriatrics Society, NICE, and other bodies advocate use of explicit criteria such as Beers and STOPP/START for identifying PIMs. Guidelines stress the importance of interdisciplinary collaboration, patient-centered care, and regular education for LTC staff. Implementation of tailored deprescribing protocols and ongoing evaluation of medication regimens are endorsed as best practices to enhance safety and efficacy.

Conclusion

Medication review during long-term care is a critical, evidence-based intervention that mitigates the risks of polypharmacy, enhances clinical outcomes, and aligns pharmacotherapy with patient-centered goals. The complexity of LTC populations necessitates ongoing vigilance, interdisciplinary collaboration, and adherence to evolving guidelines. Leveraging emerging technologies and structured frameworks will further improve the safety and quality of medication management in long-term care settings.