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 * Note: Please use your sandbox to submit assignment # 3 by pasting it below. When uploading your improvements to the article talk page please share your exact proposed edit (not the full assignment 3).


 * Talk Page Template: CARL Medical Editing Initiative/Fall 2019/Talk Page Template

Polypharmacy 

Assignment #2
Student: Mary Holdsworth

Focus: Polypharmacy and Risk of Falls in the Elderly

1. How you searched for a source

Cochrane Database of Systematic Reviews: searched “elderly” and “polypharmacy”

PubMed: applied 5 year publication date filter, and filters for Systematic Reviews, Reviews, and Practice Guidelines

2. What potential sources were identified and considered (give examples of 1 or 2).


 * 1) Park, H., Satoh, H., Miki, A., Urushihara, H., & Sawada, Y. (2015). Medications associated with falls in older people: systematic review of publications from a recent 5-year period. European Journal of Clinical Pharmacology, 71(12), 1429–1440. doi: 10.1007/s00228-015-1955-3
 * 2) Rankin, A., Cadogan, C. A., Patterson, S. M., Kerse, N., Cardwell, C. R., Bradley, M. C., … Hughes, C. (2018). Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.cd008165.pub4

3. Why the source was chosen (what made it better than other choices).

I wanted to identify a source that discussed the general impact of polypharmacy on the risk of falls in the elderly. The source I chose specifies the scope of the problem of falls in the elderly (28%-35% of people over the age of 64 fall each year) and the relationship of falls to increasing age, frailty level, and living situation. The review included 13 articles from multiple countries and therefore is likely to be generalizable to elderly persons living in high-income countries.

Source:

Zia, A., Kamaruzzaman, S. B., & Tan, M. P. (2014). Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk. Postgraduate Medicine, 127(3), 330–337. doi: 10.1080/00325481.2014.996112

4. List at least three reasons why the source that was selected meets Wikipedia’s reliable medical sources (MEDRS) criteria.

The source I selected was published in a peer-reviewed, non-predatory journal with an impact factor greater than 2. The source is a review and therefore attempts to summarize the current accepted knowledge on the topic. The source was published within the last 5 years and can be considered recent.

5. How do you plan to use the source for improving the article?

As of now, the sentences describing polypharmacy and the associated risk of falls in the elderly have no citations. Therefore, the source selected will be used to improve the credibility of the articles by including citations that reference current accepted knowledge on the topic.

Assignment #3
Proposed changes

Polypharmacy is associated with an increased risk of falls in the elderly. Certain medications are well known to be associated with the risk of falls, including cardiovascular and psychoactive drugs. There is some evidence that the risk of falls increases cumulatively with the number of medications.

Rationale for proposed change

I plan to add a number of recent citations to the sentences establishing the association between polypharmacy and the risk of falls in the elderly. I will also slightly modify the sentence discussing medication types associated with fall risk in order to reflect the citations I have identified. Largely, the content of the sentences is not changed: the citations are meant to support the contained information and improve access to evidence about this topic.

After the first sentence, I added citations from the WHO and the Public Health Agency of Canada to establish the known association between fall risk and polypharmacy in the elderly. In the second sentence, I added citations from systematic reviews that showed increased risk of falls with certain types of medications including antihypertensives, sedatives and hypnotics, antidepressants, and benzodiazepines. After the third sentence, I added a citation to support the claim that the risk of falls increases with the number of medications. I also rewrote the sentence to reflect the conflicting evidence on this point: some studies did not find an association between the number of medications and risk of falls.

As mentioned above, there is currently some controversy as to whether the number of medications leads to an increased risk of falls in the elderly, or whether this increased risk is better independently attributed to certain types of medications. To reflect this lack of consensus, I included sources (systematic reviews) that discuss the current evidence on whether number of medications and/or type of medication are independently associated with risk of falls. From my literature search, it seems that it is generally known that certain types of medications can increase the risk of falls through side effects such as confusion, dizziness, etc. There is less consensus as to whether the actual number of medications (i.e. polypharmacy) contributes to fall risk. That is, is someone that takes 4 or more medications at increased risk due to the number of medications, the types of medications, or both?

Critique of Source

The source I described in Assignment 2 is a review article with some characteristics of a systematic review: a search strategy was employed and was explicitly stated in the article, and eligible articles were selected for abstract and full-text review based on eligibility criteria. However, no quality assessment or risk of bias assessment was completed. The review therefore provides an overview of the current evidence and seeks to summarize trends in the data characterizing the association between polypharmacy and falls. The lack of quality assessment is unfortunate; although, because this was not a systematic review it is not a limitation. Importantly, the review included articles published in English only, which could have potentially introduced bias into the selection of the studies into the review. The authors did not explore the effect of study design on the data collection by stratifying or subgroup analysis. No subgroup analyses were conducted. In addition to the selected articles, there is also discussion of data from systematic reviews and meta-analyses. Overall, this source is a narrative review of the current evidence on polypharmacy and falls in the elderly, and is a useful overview of the knowledge gaps and contemporary understanding of the association.

In terms of the impact of these issues on how I will use the source in my proposed changes, I have decided to cite the source as an accessible overview of the recent literature on the topic. In particular, I found the discussion surrounding the association between number of medications and fall risk to be especially insightful given the conflicting evidence on this issue. Of course, I have also prioritized the inclusion of multiple other sources to represent the scope of the current discussion and to direct readers to multiple sources of accessible information.

Feedback

1.Well done in assignment #2. I have nothing to add!

2. The proposed change is great and well thought out. You did a great job at explaining the rationale for the proposed changed and identifying the controversy. I think that your last sentence highlights the "general trending evidence" but also alludes to conflicting evidence. You critiqued your source very thoughtfully.

Agata Szlanta