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Background: Previous interventions have shown limited success in improving medication adherence in older adults, and this may be due to the lack of a theoretical underpinning., Objective: This review sought to determine the effectiveness of theory-based interventions aimed at improving medication adherence in older adults prescribed polypharmacy and to explore the extent to which psychological theory informed their development., Data Sources: Eight electronic databases were searched from inception to March 2015, and extensive hand-searching was conducted., Eligibility Criteria: Interventions delivered to older adults (populations with a mean/median age of ≥65 years) prescribed polypharmacy (four or more regular oral/non-oral medicines) were eligible. Studies had to report an underpinning theory and measure at least one adherence and one clinical/humanistic outcome., Review Methods: Data were extracted independently by two reviewers and included details of intervention content, delivery, providers, participants, outcomes and theories used. The theory coding scheme (TCS) was used to assess the extent of theory use., Results: Five studies cited theory as the basis for intervention development (social cognitive theory, health belief model, transtheoretical model, self-regulation model). The extent of theory use and intervention effectiveness in terms of adherence and clinical/humanistic outcomes varied across studies. No study made optimal use of theory as recommended in the TCS., Conclusions: The heterogeneity observed and inclusion of pilot designs mean conclusions regarding effectiveness of theory-based interventions targeting older adults prescribed polypharmacy could not be drawn. Further primary research involving theory as a central component of intervention development is required. The review findings will help inform the design of future theory-based adherence interventions., Competing Interests: Compliance with Ethical StandardsFundingThis work was supported by The Dunhill Medical Trust (Grant Number: R298/0513). The funding body was not involved in the design of the review, data collection, analysis and interpretation of findings or in writing the manuscript.Conflict of interestDeborah Patton, Carmel Hughes, Cathal Cadogan and Cristín Ryan have no conflicts of interest relevant to the content of this review.

The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of 'many' drugs and 'too many' drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients' clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients' safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving 'many' medicines. It is now recognised that the prescribing of 'many' medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients' clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term 'appropriate polypharmacy' in differentiating between the prescribing of 'many' drugs and 'too many' drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research.