RESEARCH ARTICLE Open Access

Family involvement in managingmedications of older patients acrosstransitions of care: a systematic reviewElizabeth Manias1* , Tracey Bucknall1,2 , Carmel Hughes3 , Christine Jorm4,5 and Robyn Woodward-Kron6

Abstract

Background: As older patients’ health care needs become more complex, they often experience challenges withmanaging medications across transitions of care. Families play a major role in older patients’ lives. To date, there hasbeen no review of the role of families in older people’s medication management at transitions of care. This systematicreview aimed to examine family involvement in managing older patients’ medications across transitions of care.

Methods: Five databases were searched for quantitative, qualitative and mixed methods empirical studies involvingfamilies of patients aged 65 years and older: Cumulative Index to Nursing and Allied Health Literature Complete, Medline,the Cochrane Central Register of Controlled Trials, PsycINFO, and EMBASE. All authors participated independently inconducting data selection, extraction and quality assessment using the Mixed Methods Appraisal Tool. A descriptivesynthesis and thematic analysis were undertaken of included papers.

Results: Twenty-three papers were included, comprising 17 qualitative studies, 5 quantitative studies and one mixedmethods study. Families participated in information giving and receiving, decision making, managing medicationcomplexity, and supportive interventions in regard to managing medications for older patients across transitions of care.However, health professionals tended not to acknowledge the medication activities performed by families. Whilefamilies actively engaged with older patients in strategies to ensure safe medication management, communicationabout medication plans of care across transitions tended to be haphazard and disorganised, and there was a lack ofshared decision making between families and health professionals. In managing medication complexity acrosstransitions of care, family members perceived a lack of tailoring of medication plans for patients’ needs, and believedthey had to display perseverance to have their views heard by health professionals.

Conclusions: Greater efforts are needed by health professionals in strengthening involvement of families in medicationmanagement at transitions of care, through designated family meetings, clinical bedside handovers, ward rounds, andadmission and discharge consultations. Future work is needed on evaluating targeted strategies relating to familymembers’ contribution to managing medications at transitions of care, with outcomes directed on family understandingof medication changes and their input in preventing and identifying medication-related problems.

Keywords: Transitions of care, Family, Medication management, Older patients, Family involvement, Hospitals, Home,Aged care facilities

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: emanias@deakin.edu.au1Centre for Quality and Patient Safety Research, School of Nursing andMidwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125,AustraliaFull list of author information is available at the end of the article

Manias et al. BMC Geriatrics (2019) 19:95 https://doi.org/10.1186/s12877-019-1102-6

BackgroundAs older patients’ needs develop increased complexity,they are more likely to have changes in their health thatrequire treatment with medications. When older patientsbecome acutely ill, hospitalisation may be required,which necessitates medication management across tran-sitions of care. ‘Transitions of care’ refers to the timeswhen patients transfer between settings of care, such ashospitals, home, rehabilitation care and long-term care,between locations or within the same location, includingadmission and discharge [1]. Medication errors are likelyto occur at transitions of care because of the potentialfor communication breakdown during activities such asbedside handovers, ward rounds, and admission and dis-charge consultations between health professionals, olderpatients and families [2]. Previous research has shownthat medication error rates associated with transitionsbetween hospitals, residential aged care facilities andhome vary between 19 and 80% [3, 4].Many medication management activities are carried

out by families of older patients. These activities include:assisting with administering medications, recognisingtherapeutic benefits and adverse effects of medications,and clarifying information for patients [5, 6]. To date,there has been no review of the role of families in olderpeople’s medication management at transitions of care.Therefore, the aim of this systematic review was toexamine family involvement in managing older patients’medications across transitions of care. A specific mnemonicfor systematic reviews, PICo, was used to develop theresearch question. The components for the research ques-tion according to PICo are population (families),phenomenon of interest (managing older patients’ medica-tions) and context (transitions of care) [7]. The researchquestion that guided the systematic review is: how are fam-ilies involved in managing older patients’ medicationsacross transitions of care?

MethodsA systemic review was undertaken of research studiesusing a best practice guide for conducting systematicreviews [8].

Eligibility criteriaInclusion criteria comprised research of any design –qualitative, quantitative and mixed methods – involvingfamilies of older patients aged 65 years and older. Familieswere defined as formal relations of older patients or othersignificant individuals who played an important role in theolder people’s lives. Research had to involve older peoplemoving between different settings. Papers were still con-sidered if medication management was not the centralfocus of the study but was identified within the findings.Papers not published in English were excluded.

Information sourcesThe literature search was conducted in the followingelectronic bibliographic databases from inception to endDecember 2017: The Cumulative Index to Nursing andAllied Health Literature (CINAHL) Complete (Elton B.Stephens Co Host (Ebscohost)), Medical LiteratureAnalysis and Retrieval System Online (MEDLINE) (Ebs-cohost), the Cochrane Central Register of ControlledTrials (CENTRAL) (The Cochrane Library), Psycho-logical Information Database (PsycINFO) (Ebscohost),and Excerpta Medica Database (EMBASE) (refer toAdditional file 1 for Medline search) [9]. Hand searchingof reference lists was also conducted for relevant studies.Cochrane systematic reviews were searched to locaterelevant papers. However, reviews themselves were notincluded in the final dataset. The grey literature was alsosearched using Google Scholar to locate other original,peer-reviewed research.

Search and study selectionThe following key terms, and variations thereof, weresearched as four separate groups of terms: (1) family,carers, caregivers, and relatives; (2) older patients, olderpeople, and older adults, geriatric, seniors, elderly; (3)medication, medicines, medication management andmedicines management; and (4) admission, discharge,transfer, transition, transitions of care, and transitionpoints. These terms were subsequently combined. Oneauthor completed the search with assistance from theuniversity research librarian, and all authors independ-ently determined the eligibility of retrieved papers forinclusion at the abstract and full text levels. The authorscomprised individuals with different perspectives anddiscipline expertise. It was therefore perceived there wasvalue in each author independently checking the litera-ture to minimise selection bias, and to improve the rigorof the study selection process. There were a number ofstudies identified at the initial search that investigatedfamily involvement at transitions of care. At the full textlevel, unless there was some mention in the results offamilies’ contribution in older patients’ medications, aparticular study was excluded.

Data extraction and evaluationInformation was extracted from each paper on the typeof study conducted, and the settings in which each studywas undertaken. Information was also noted on the datacollection processes used, and the patients and familieswho participated. To prepare the data for synthesis,qualitative and quantitative data located within the re-sults section of papers were extracted and incorporatedinto a spreadsheet.Each paper was independently assessed by two

reviewers using the Mixed Methods Appraisal Tool

Manias et al. BMC Geriatrics (2019) 19:95 Page 2 of 21

(MMAT), which provided a quality score for qualitative,quantitative and mixed-method studies [10]. Any dis-crepancies were discussed until consensus was reached.No studies were excluded because of the quality score.

Data synthesisData synthesis of qualitative data was achieved using athematic approach. These data were read and re-read toincrease familiarity and understanding with the content.Line-by-line coding was undertaken using words andphrases within and across studies. Words and phraseswere grouped together, which were clustered into cat-egories. These categories were further examined foridentification of themes and subthemes [11].In synthesising quantitative results, it was not possible

to undertake meta-analysis due to the heterogeneity ofoutcomes and variability in operational definitions.Therefore, a descriptive synthesis was conducted of themajor findings. These quantitative studies were alsoexamined to determine how the results fitted into thethemes and subthemes generated from qualitative data.All quantitative data that were transferred to a spread-sheet were subsequently re-written and transformed intonarrative forms to describe and explain the results.These rewritten narrative forms were read several timesand examined to determine how they could be identifiedas categories. These categories were compared andcontrasted with other categories to determine how theycould be grouped into already developed themes andsubthemes, or whether they could be grouped into newthemes and subthemes. All authors scrutinised the con-tent and structure of themes and subthemes, and the waysin which studies of different research designs were repre-sented and mapped within these themes and subthemes.By means of an example, the quantitative results of the

Towle et al. paper [12] were integrated into themes in thefollowing way. The results were rewritten in a descriptiveway to explain the impact of an evidence-based qualityimprovement initiative to enhance patient and family pre-paredness in care transition. The following details weredocumented. After implementation of the quality improve-ment initiative, health professionals interacted with pa-tients and families in goal-directed ways to conveyinformation. Subsequently, family members’ understandinghad improved of the patients’ medical condition, medica-tions prescribed, treatment plan and follow up care. Theseresults mapped onto the theme: Giving information andreceiving feedback, and the subtheme: health professionalsinforming families. The results also mapped onto thetheme: Managing medication complexity across transitionsof care and the subtheme: supporting family participationin interventions. Mixed methods studies were handledaccording to the approaches described for both qualitativeand quantitative data. Only information from the results

section of included studies was used for synthesis and noinformation was used from the discussion section.

ResultsIn all, 860 papers were identified through databasesearching. An additional two papers were added follow-ing a manual screen of full text papers. A total of 23papers were eligible for inclusion (Fig. 1).Qualitative exploratory designs comprised data collection

methods involving semi-structured interviews (n = 11),observations (n = 2), diaries and interviews (n = 2), andfocus groups and interviews (n = 2). Quantitative designsincluded two randomised controlled trials, one quasi-ex-perimental study, two cross-sectional survey studies, andone mixed method study comprising interviews and anelectronic medical record review. MMAT findings showedthat 15 studies obtained a score of 75%, which meant thatthree-quarters of the criteria were met, and 6 had a score of50%, which meant that half of the criteria were met(Table 1).Four themes were identified: giving information and

receiving feedback, participating in decision making,managing medication complexity across transitions ofcare, and supporting family participation in interven-tions (Table 2).

Giving information and receiving feedbackEighteen studies addressed the theme of giving informa-tion and receiving feedback [12–29]. There were twosubthemes relating to this theme: families conveying infor-mation to health professionals about patients’ medication-taking behaviour and activities, and health professionalsinforming families about medication changes.Families played a crucial role in information giving

during patient admission to hospital, when patients withdementia moved to long term care [16], for patientsreceiving palliative care [28] or in their last year of life[30] and when patients moved from hospital to home[13, 18, 21, 24, 25, 29]. Family members perceived thattheir role was as ‘knowledge keepers’ about patients’medications, particularly those with chronic conditions[16, 18]. Whilst some family members indicated thatthey understood how to administer medications, theywere less clear about how these medications worked andtheir potential adverse effects, especially for patientswho had experienced a recent critical event, such as astroke [26, 29].In patients who lacked cognitive capacity such as

those with dementia, hospital doctors indicated that itwas difficult for them to obtain and verify a completeand accurate list of current medications, and to ad-dress the discrepancies between the medication listand medications actually consumed by patients [17]. Inthese situations, hospital pharmacists perceived that

Manias et al. BMC Geriatrics (2019) 19:95 Page 3 of 21

verification of the medication list on admission wasdependent on family members. If family members werenot present, or they did not bring the patients’ medica-tions to the hospital on admission, hospital pharma-cists indicated that their responsibility was to attemptto contact general practitioners or community pharma-cists [17]. Family members perceived themselves as be-ing able to effectively provide medication informationat crucial times on behalf of patients, such as those ex-periencing delirium or those with confusion followinga femur fracture [18], and to clarify patients’ expecta-tions to health professionals, thereby leading toreduced patient anxiety [22].Some family members considered that misunder-

standings about medications related to their own lackof initiative rather than to the responsibility of healthprofessionals [24]. In contrast, other family membersindicated that they played the role of “conductors” (p.1197) of information for older patients in the last yearof life [30]. In this role, family members had a regularpresence, provided detailed knowledge about patients’medication-taking activities, and alerted health profes-sionals about potential medication errors [13, 30].

Keeping families informed about medication changeswas considered important. Family members stated theywere concerned about doctors notifying patients aboutmedication changes in situations where patients werecompromised due to alterations in their physical andpsychological status [13, 22]. Family members felt frus-trated if doctors did not convey medication changes tothem [13, 16, 23, 24], and family members valued infor-mation provided by pharmacists upon discharge fromhospital [13, 24] and by general practitioners in relayingmedication changes after discharge [13]. Conversely,family members reported that nurses were too busy toprovide medication information [17, 21, 24]. Familiesalso valued receiving written medication guides or medi-cation lists as practical ways of keeping them informed;however, these resources were not always available [24].Sometimes, community nurses provided information tothe ‘wrong’ family members, which then had to be redir-ected to others [29].

Participating in decision makingThis theme related to how families participated in deci-sion making with, or on behalf of, patients in managing

Fig. 1 Flowchart for determining included papers

Manias et al. BMC Geriatrics (2019) 19:95 Page 4 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

Allenet

al.2017[13]

Australia***

Design:Qualitative

exploratory.

Setting:

metropo

litan

public

health-carene

twork

Datacollection:interviews.

Transitio

npo

intsinvolved

:acute

wardsettingandrehabilitation

settingin

hospital,ho

me.

Med

icationmanagem

entprocess

involved

:adm

ission

instruction,

dischargeinstruction.

Patientsn=19.

78.9years(age

rang

e45–94

yearsforpatientsand

families).

Gen

der:no

tstated

.Family

n=7.

Gen

der:no

tstated

.

Caringrelatio

nships

with

health

profession

als:

-Nursesin

rehabilitationattend

edto

follow-up

phon

ecalls

tocheckon

dischargemanagem

ent.

-Lack

ofcontinuity

ofmed

icalpractitione

rsand

interactions

with

multip

lemed

icalpractitione

rs.

-Med

icalde

cision

makingabou

tdischarge

med

ications

with

outun

derstand

ingabou

tmed

ications

prescribed

byothe

rmed

ical

practitione

rs.

Seekinginform

ation:

-Ifpatientswas

tooun

welltoseek

inform

ation

durin

gtheiracuteillne

ss,fam

ilywantedto

have

med

icationinform

ationon

theirbe

half.

-Expe

ctationthat

doctorswou

ldsharemed

ication

inform

ationwith

them

durin

gtheho

spital

admission

.Thisdidno

talwaysoccur.

-Family

mem

berswerewellinformed

abou

tchange

sto

med

ications

inrehabilitationward

setting.

-Gen

eralpractitione

r(GP)

reliedon

accurate

and

timelydischargesummaryto

explainmed

ication

inform

ationto

family.

Colem

anet

al.2006[15]

UnitedStates**

Design:Rand

omised

controlledtrial.

Setting:

oneho

spital,eigh

tskilled

nursingfacilities,on

eho

mehe

alth

care

agen

cy.

Datacollection:ratesof

reho

spitalisationmeasuredat

30,90,

and180days.

Transitio

npo

intsinvolved

:commun

ity;skillednu

rsingfacility;

reho

spitalisation.

Med

icationmanagem

entprocesses

involved

:med

icationself-

managem

ent.

Interven

tion–four

pillars.

-Supp

ortpatientsandfamily

with

med

icationself-managem

ent,

med

icationreconciliation.

-Patient-cen

tred

record

toassist

with

site

transitio

ns.

-Timelyfollow-upwith

care.

-Supp

lypatientsandfamily

with

list

of“red

flags”forworsening

cond

ition

.

Patients:

n=379interven

tiongrou

p,n=371controlg

roup

.Age

forinterven

tiongrou

p:mean76.0years(SD7.1

years).

Age

forcontrolg

roup

:mean

76.4years(SD6.8years).

Gen

der:48%

femalefor

interven

tiongrou

p.52%

femaleforcontrol

grou

p.Med

icalcond

ition

:atleast1

of11

selected

acuteor

chroniccond

ition

s.Family

recruitedwith

patients:

n=no

tspecified

.Relatio

nshipwith

patient:not

specified

.

Outcomes:

Reho

spitalisationratesat

30days

–Interven

tiongrou

p=8.3%

Con

trol

grou

p=11.9%,p

=0.048.

Reho

spitalisationratesat

90days

–Interven

tiongrou

p=16.7%

Con

trol

grou

p=22.5%,p

=0.040.

Reho

spitalisationratesforthesamecond

ition

that

precipitatedtheinde

xho

spitalisationat

90days

–Interven

tiongrou

p=5.3%

Con

trol

grou

p=9.8%

,p=0.04.

Reho

spitalisationratesforthesamecond

ition

that

precipitatedtheinde

xho

spitalisationat

180days

-Interven

tionpatients:8.6%

Con

trol

patients:13.9%,p

=0.046.

Meanho

spitalcostsat

180days

-Interven

tionpatients:$2058

Con

trol

patients:$2546,log-transformed

p=0.049.

Colem

anet

al.2004[14]

UnitedStates***

Design:Quasiexpe

rimen

tal

stud

ywith

interven

tionand

controlg

roup

s.Setting:

onecommun

ity,

hospital.

Datacollection:ratesof

reho

spitalisationat

30,90and180

days;caretransitio

nmeasure

Transitio

npo

intsinvolved

:hospital,

commun

ityreside

ncefacility,ho

me.

Med

icationmanagem

entprocess

Patients:

n=158interven

tiongrou

p,n=1235

controlg

roup

from

administrativedata.

Age

forinterven

tiongrou

p:mean75.1years(SD6.4

Outcomes:

Reho

spitalisationat

30days

–Interven

tiongrou

pcomparedwith

controlg

roup

:0.52

(95%

confiden

ceinterval(CI)0.25,0.96)

Reho

spitalisationat

90days

–Interven

tiongrou

pcomparedwith

controlg

roup

:

Manias et al. BMC Geriatrics (2019) 19:95 Page 5 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

involved

:med

icationself-

managem

ent.

Interven

tion–four

pillars.

-Supp

ortpatientsandfamily

with

med

icationself-managem

ent,

med

icationreconciliation.

-Patient-cen

tred

record

toassist

with

site

transitio

ns.

-Timelyfollow-upwith

care.

-Supp

lypatientsandfamily

with

list

of“red

flags”forworsening

cond

ition

.Interven

tioninvolved

:meetin

gswith

transitio

nscoach;commun

ication

tool

(personalised

med

icalrecord,

roleplays),follow

upph

onecalls.

years).

Age

forcontrolg

roup

:mean

78.5years(SD7.5years).

54%

femaleforinterven

tion

grou

p.55%

femaleforcontrol

grou

p.Med

icalcond

ition

:atleast

oneor

moreof

9med

ical

cond

ition

s.Family

recruitedwith

patients:

n=no

tspecified

.Relatio

nshipwith

patient:not

specified

.

0.57

(95%

CI0.25,0.72)

Reho

spitalisationat

180days

–Interven

tiongrou

pcomparedwith

controlg

roup

:0.57

(95%

CI0.36,0.92).

Interven

tiongrou

p-patientsrepo

rted

:highlevelo

fconfiden

cein

obtaininginform

ation,

commun

icatingwith

health

care

team

,and

unde

rstand

ingtheirmed

icationregimen

.Qualityof

care

transitio

nstaxono

my–

Interven

tiongrou

p:9.5%

ofpo

stho

spitaltransition

swerecomplicated

.Con

trol

grou

p:14.9%

oftransitio

ns,P

=0.35.

Crawford

etal.2015[16]

Australia***

Design:Qualitative,

exploratory.

Setting:

oneaged

rehabilitationandge

riatric

evaluatio

nandmanagem

ent

facility

Datacollection:

Semi-structuredinterviews.

Transitio

npo

intsinvolved

:acute

hospitalsettin

g,aged

rehabilitation

andge

riatricevaluatio

nand

managem

entfacility

Med

icationmanagem

entprocess

involved

:discharge

planning

.

Family

n=20.

Relatio

nshipwith

patient:

husbands,w

ives,d

augh

ters,

son,daug

hter-in

-law,close

frien

dsof

peop

lewith

demen

tia.

Them

es:

Adjustin

gto

new

rolefro

mcaregiverto

visitor–

-Difficulty

inrelinqu

ishing

role.

-Desire

tocontinue

tobe

involved

inde

cision

s.-Felton

goingrespon

sibilityto

commun

icate

med

icationne

eds.

-Beliefabou

tspecialised

know

ledg

eabou

trelative’s

care.

-Stayinginform

edhe

lped

caregiversto

cope

with

moveto

facility.

Deeks

etal.(2016)[17]

Australia**

Design:Qualitative,

exploratory.

Setting:

threeurbanprim

ary

andacutesites,on

erural

prim

aryandacutesite.

Datacollection:semi-structured

interviews.

Med

icationmanagem

entprocess

involved

:hospitaladm

ission

and

dischargeforpatientswith

demen

tia.

51participantscomprising

doctors,nu

rses,p

harm

acists,

occupatio

nalthe

rapists,

gene

ralp

ractition

ers,

Alzhe

imer’sAustraliastaff,

andfamily.

Family

n=no

tspecified

.Relatio

nshipwith

patient:not

specified

.

Them

es:

Med

icationreconciliation–

-Verifying

accurate

liston

admission

was

difficultif

family

mem

bersno

tpresen

tor

med

ications

not

brou

ghtto

hospital.

Lack

ofmod

ified

planning

forcare

transitio

ns–

-Lack

ofiden

tificationthat

patient

hadcogn

itive

prob

lemsas

they

moved

across

settings.

-Inadeq

uate

inform

ationabou

tmed

ication

change

sat

discharge.

-Carers’supp

ortforuseof

dose

administrationaids

bypatients,bu

tpo

tentialp

roblem

swith

errors.

Lack

ofassessmen

tof

patients’ability

touseaid.

-Desire

foron

ce-dailydo

sing

ifpaid

carerrequ

ired

tovisitat

homeafterdischarge.

Multip

leprescribers–

-Littleinform

ationshared

betw

eenprivateand

publicho

spitals.

-Treatm

entde

lays

betw

eenspecialistandge

neral

practitione

ras

commun

icationby

letter.

Reside

ntialage

dcare

facilities–

-Lack

ofaccurate

andcompleteinform

ationfro

m

Manias et al. BMC Geriatrics (2019) 19:95 Page 6 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

hospital.

Med

icationreview

sby

pharmacists–

-Patientswith

demen

tiatrustedandbu

iltrapp

ort

with

commun

ityph

armacistsandge

neral

practitione

rs.Patientsno

treceptiveto

home

med

icinereview

s.

Dyrstad

etal.(2015)[18]

Norway**

Design:Qualitative,

exploratory.

Setting:

twoho

spitals

Datacollection:ob

servations,

conversatio

ns,o

bservatio

nalfield

notes.

Transitio

npo

intsinvolved

:tw

oem

erge

ncyde

partmen

ts(EDs),

sevenho

spitalw

ards;including

admission

sfro

mho

mebasedcare

ornu

rsingho

mes,and

discharge.

Med

icationmanagem

entprocess

involved

:adm

ission

instruction,

dischargeinstruction.

Patientsn=41.

Age

:mean86.0years,rang

e73–97years.

Gen

der:46%

female.

Med

icalcond

ition

:an

orthop

aedicdiagno

sisor

chroniccond

ition

,and

poly-

pharmacy(>

5med

ications

daily).

Family

n=28.

Relatio

nshipwith

patient:

son,daug

hter,w

ife.

Health

profession

alsn=no

tspecified

.Disciplines

involved

:paramed

ics,nu

rses,d

octors.

Them

es:

Inform

ationdissem

inationandde

cision

-making–

-Nosche

duleddischargeplanning

meetin

gswith

patient

andfamily.

-Nurse

phon

edfamily

toinform

them

ofdo

ctors’

decision

s.Nextof

kinim

portantadvocates–

-In

ED,p

rovide

dvaluableinform

ationabou

tmed

ications

takenbe

fore

admission

.-Family

administeredmed

ications

inED

durin

gbu

sytim

es.

-In

wards,noroutines

toinvite

family

toparticipate

ondo

ctor’sroun

ds.

-Inform

edon

dayof

dischargeabou

twardroun

dde

cision

s.-Somefamilies

hadto

seek

inform

ationabou

tmed

icationde

cision

sat

discharge.

Geo

rgiadis&Corrig

an2017

[19]

UnitedKing

dom***

Design:Ph

enom

enolog

ical.

Setting:

threeho

spitals.

Datacollection:Interview,aud

iodiary,writtendiary.

Transitio

npo

intsinvolved

:clinical

settings

(not

describ

ed),ho

me.

Med

icationmanagem

entprocess

involved

:med

icationcoun

selling

atdischarge.

18participants

Patientsn=12.

Age

:65.9years(SD17.2

years).

Gen

der:Mixed

,not

stated

.Med

icalcond

ition

:not

men

tione

d.Patientswith

non-med

icalcomplex

cond

i-tio

ns,w

hich

wereno

tde

fined

.Family

n=6.

Relatio

nshipwith

patient:not

specified

.

Them

es:

Limitedinvolvem

entin

discharge-care

prep

arations

– -Prem

aturedischarges

meant

lack

ofplanning

inmed

icationcoun

selling

.-Une

xpectedandde

layeddischarges

meant

that

family

unableto

bepresen

t.Weakserviceinterface

–-Expe

cted

organisatio

nof

appo

intm

entsfor

outpatient

clinicor

homevisitsdidno

thapp

en.

Relianceon

family

formed

icationadministration.

-Family

arrang

edprim

aryclinicto

assess

med

ications.

Haged

oorn

etal.2017[20]

TheNethe

rland

s***

Design:Qualitative

exploratory.

Setting:

Four

gene

ral

hospitals,

Datacollection:no

n-participantob

-servations,aud

io-recording

sof

planne

ddiscussion

sforadmission

anddischargediscussion

sandfamily

meetin

gs.

Transitio

npo

intsinvolved

:adm

ission

toward,

13clinicalwards

comprising

neurolog

y,pu

lmon

ary,internal

med

icine,cardiology,g

eriatrics.

Discharge

from

ward.

Med

icationmanagem

entprocess

involved

:adm

inistration,mon

itorin

g.

Patientsn=62.

Age

:76years(SD7.2years).

Gen

der:48%

female.

Med

icalcond

ition

:22

patients(36%

)had

3or

more

chronicdiseases.

Family

n=107at

planne

ddiscussion

s.Relatio

nshipwith

patient:

husband,

wife,son

,daugh

ter.

Them

es:

Socialne

tworksupp

ort–

-Supp

ortby

family

caregiversassistingwith

ormon

itorin

gmed

icationintake

atho

me.Not

addressedby

nurses

inho

spitalassessm

ent

sessions.

Coo

rdinationof

care

–-Duringdischargediscussion

snu

rses

review

edho

memed

icationlistwith

patientsandfamily.

-Family

askedspecificqu

estio

nsabou

tchange

sin

thepatients’ho

memed

ications.

Manias et al. BMC Geriatrics (2019) 19:95 Page 7 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

Hvalvik&Reierson

,2015[21]

Norway***

Design:Ph

enom

enolog

ical

herm

eneutic

design

.Setting:

hospital.

Datacollection:in-dep

thinterviews.

Transitio

npo

intsinvolved

:hospital,

mun

icipalrehabilitation,short-term

care

facility,ho

me.

Med

icationmanagem

entprocess

involved

:discharge

planning

,self-

managem

entat

home.

Family

n=11.

Relatio

nshipwith

patient:

son,spou

se,d

augh

ter.

Them

es:

Balancingvulnerability

andstreng

th–

-Endu

ringem

otionalstresswith

discharge.

-Family

expe

cted

tobe

involved

indischarge,bu

twereno

tinclud

ed.

-Worry

abou

tbe

ingdischarged

tooearly

andlack

ofmed

icationinform

ation.

-Lack

ofcommun

icationabou

tmed

ications

durin

gstay.

-Senseof

respon

sibilityin

managingmed

ications.

-Lack

ofcommun

icationbe

tweenho

spitaland

commun

ityservices.Prescrip

tionof

med

ications

that

shou

ldhave

been

ceased

dueto

adverse

effectsor

allergies.

Cop

ingwith

analteredeveryday

life–

-Dealingwith

change

sto

family

routines.

-Anticipatingpo

ssibleprob

lemsifpatients

discharged

early.

-Com

preh

ensive

unde

rstand

ingabou

tolde

rpe

rson

’svulnerability,and

fragility.

Jeffs

etal.2017Canada***

Design:Qualitative

exploratory.

Setting:

orthop

edicinpatient

units

intw

oacutecare

hospitalsandon

eorthop

edic

unitat

acomplex

continuing

care

rehabilitationho

spital.

Datacollection:semi-structured

interviews.

Med

icationmanagem

entprocess

involved

:careinvolvingtransfer

from

anacutecare

hospitaltoa

rehabilitationho

spital.

Patientsn=13.

Age

:82.9years(rang

e:68–91

years).

Gen

der:69%

female.

Med

icalcond

ition

:non

-electivepatientswho

had

fallenor

sustaine

dafracture

thou

ghan

accide

nt.

Family

n=9.

Relatio

nshipwith

patient:

child,spo

use,partne

r,sibling.

Health

profession

alsn=50.

Them

es:

Watching–

-Alertto

med

icationadministrationandchange

sin

patients’status.

-Patients’lack

ofun

derstand

ingabou

tmed

ication

change

s.Beingan

activecare

provider

–-Respon

sibilityforprovidingcare

that

health

care

providerspe

rform

ed.

-Adm

inisterin

gmed

icationwas

easier

forfamily

todo

than

thenu

rses,asnu

rses

expe

rienced

challeng

eswith

thepatient

taking

med

ication.

-Lack

ofen

gage

men

tby

health

care

providers

abou

tinvolvingfamily.

Advocating–

-Beingsupp

ortiveof

patients’ne

edssuch

aschanging

med

icationtim

esto

suitpatients’

routines.

Navigatingthehe

alth

care

system

–-Askingqu

estio

nsandcoordinatin

gfollow-upcare.

-Arranging

appo

intm

entswith

vario

usmem

bersof

interdisciplinaryteam

.-Lack

ofavailabilityof

health

care

providersto

ask

questio

nsabou

ttransitio

nsplan.

King

etal.2013[23]

United

States***

Design:Qualitativestud

yusinggrou

nded

dimen

sion

alAnalysis.

Setting:

fiveno

n-profit

Datacollection:focusgrou

pand

individu

alinterviews

Transitio

npo

intsinvolved

:skilled

nursingfacilities,ho

spital.

Health

profession

alsn=27.

Disciplines

involved

:nurses.

Them

es:

Reconciling

hospitalinformation-

-Seekingmed

icationde

tails

from

families

was

prob

lematicas

sometim

esno

tadeq

uately

Manias et al. BMC Geriatrics (2019) 19:95 Page 8 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

religious

andgo

vernmen

tskilled

nursingfacilities(SNF)

Med

icationmanagem

entprocess

involved

:hospitald

ischarge

.inform

edabou

tfamily

mem

berscontactde

tails.

-Askingfamilies

abou

tmed

icationde

tails

createda

poor

firstim

pression

ofSN

Fstaff.

Con

sequ

encesof

poor-qualitydischargecommun

i-catio

n–

-Carede

lays

andim

plem

entatio

nof

aninapprop

riate

med

icationplan.

-Inaccurate

hospitalinformationprod

uced

family

dissatisfaction.

-MadetheSN

Fappe

arun

organised.

Knight

etal.2013[24]

United

King

dom**

Design:Qualitative

exploratory.

Setting:

participants’hom

e

Datacollection:semi-structuredin-

terviews,med

icationdiary.

Transitio

npo

intsinvolved

:hospital,

home

Med

icationmanagem

entprocess

involved

:discharge

process.

Patientsn=7.

Age

:>75

years.

Gen

der:43%

female.

Med

icalcond

ition

:not

stated

.Family

n=12.

Relatio

nshipwith

patient:

wife,husband

.

Them

es:

Discharge

inge

neral–

-Long

delays

tilld

ischarge

orabrupt

notification

abou

tdischarge.

Obtaining

med

icationfordischarge-

-Waitin

gformed

ications

tobe

prep

ared

atho

spital

pharmacy.

Inform

ationregardingdischargemed

ication–

-Carer

beliefthat

itwas

theirrespon

sibilityto

check

unde

rstand

ingon

individu

almed

icines.

-Carer

satisfactionabou

tinform

ationprovided

but

notde

tailed.

-Med

icationchange

sin

hospitaln

otconveyed

tocarers.

-Inadeq

uate

explanations

ofne

wmed

icines

and

associated

risks

forthepatient.

Med

icationlists–

-Lack

ofwrittengu

ideavailableor

hadne

ver

received

alist.

Com

mun

icationabou

tmed

icationin

hospitaland

followingdischarge–

-Carersde

tected

med

icationom

ission

saftercareful

exam

ination.

-Neede

dto

feelbe

tter

prep

ared

with

med

ications

post-discharge

.

Lowsonet

al.2012United

King

dom***

Design:Qualitative

exploratory.

Setting:

participants’hom

e

Datacollection:semi-structured

interviews.

Transitio

npo

intsinvolved

:hospital,

home.

Med

icationmanagem

entprocess

involved

:med

icationinform

ationat

admission

.

Patientsn=27.

Age

:mean=79.0years(SD

4.25

years).

Gen

der:52%

female.

Med

icalcond

ition

:heart

failure

orcancer

inthelast

year

oflife.

Family

n=12.

Relatio

nshipwith

patient:

wife,husband

,daugh

ter,

sister,neigh

bour,friend

.

Them

es:

Con

ductors–

-Strong

contrib

utions

tomaintaining

good

care

throug

hout

illne

sstrajectory.

-Detailedknow

ledg

eabou

tmed

ications.

-Alerted

health

profession

alsabou

tpo

tential

med

icationerrors.

Second

fiddle–

-Followingho

spitaladm

ission

,abilityto

workwith

health

profession

alsto

influen

cede

cision

svastly

redu

ced.

-Carersinvested

effortin

maintaining

continuity

ofrelatio

nship.

Manias et al. BMC Geriatrics (2019) 19:95 Page 9 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

-Advocated

onpatients’be

halfto

affect

bene

ficial

change

.

Nazarathet

al.2001United

King

dom***

Design:Rand

omised

controlledtrial.

Setting:

threege

neral

hospitals,one

long

-stay

hospital

Datacollection:

Transitio

npo

intsinvolved

:gen

eral

hospitalw

ards,hom

e.Med

icationmanagem

entprocess

involved

:discharge

inform

ation.

Interven

tion:(fo

rinterven

tion

stud

ies)Discharge

plansde

velope

dby

pharmacists,hom

evisitby

commun

ityph

armacist,coun

selling

patientsandfamily

onapprop

riate

dosesandpu

rpose.

Con

trol

grou

p:dischargeletter

toge

neralp

ractition

er.

Patients:

n=181interven

tiongrou

p,n=181controlg

roup

.Age

forinterven

tiongrou

p:mean84

years(SD5.2years).

Age

forcontrolg

roup

:mean

84years(SD5.4years).

Gen

der:

62%

femaleforinterven

tion

grou

p.66%

femaleforcontrol

grou

p.Med

icalcond

ition

:had

ameanof

threechronic

cond

ition

s.Family

(n=no

tspecified

)Includ

edin

interven

tionbu

tno

tstated

.

Outcomes:

Hospitalreadm

ission

at3mon

ths–

Interven

tiongrou

p:64

(39%

)Con

trol

grou

p:69

(39.2%

),p>0.05.

Hospitalreadm

ission

at6mon

ths–

Interven

tiongrou

p:38

(27.9%

)Con

trol

grou

p:43

(28.4%

),p>0.05

Nodifferences

betw

eengrou

ps:Patients’ge

neral

well-b

eing

,satisfactionwith

theserviceand

know

ledg

eof

andadhe

renceto

prescribed

med

ica-

tion(p>0.05).

Neiterm

anet

al.2015[25]

Canada**

Design:Qualitative

exploratory.

Setting:

participants’hom

e

Datacollection:interviews

Transitio

npo

intsinvolved

:hospital,

home

Med

icationmanagem

entprocess

involved

:med

icationmanagem

ent

atho

me

Patientsn=17.

Age

:70–89

years,mean=79

years.

Gen

der:41%

female.

Med

icalcond

ition

:diverse

chronicillne

sses.

Family

n=19.

Relatio

nshipwith

patient:

husband,

wife,m

othe

r,father,

daug

hter,son

,daugh

ter-in-

law,son

-in-law.

Them

es:

Dealingwith

med

icalconfusion–

-Po

st-discharge

med

icationmanagem

entwas

diffi-

cultbe

causeof

med

icationchange

s.Facilitatorsforrecovery:socialcapitaland

social

supp

ort-

-Family

mem

bersmadesure

that

med

ications

sche

duleswerefollowed

.-Family

was

overwhe

lmed

andexhausteddu

eto

constant

need

tocoordinate

care

anden

sure

patients’ne

edsmet.

Targeted

nursepractitione

rinitiative-

-Somecaregiversdidno

tfully

unde

rstand

the

nursepractitione

r(NP)

rolebu

treliedon

NPs

tooverseethemanagem

entof

med

ications.

Palagyietal.2016[26]

Australia***

Design:Qualitative

exploratory.

Setting:

threelong

-term

care

facilities

Datacollection:Focusgrou

psand

interviews

Transitio

npo

intsinvolved

:lon

g-term

care

facilities,ho

spital,commun

itycare.

Med

icationmanagem

entprocess

involved

:dep

rescrib

ingmed

ications.

Patientsn=25.

Age

:mean=87.6years,rang

e75–100.

Gen

der:77%

female.

Med

icalcond

ition

:not

stated

.Family

n=16.

Relatio

nshipwith

patient:not

men

tione

d.Health

profession

alsn=27.

Disciplines

involved

:gen

eral

practitione

rs,lon

g-term

care

facilitiesstaff.

Them

es:

Pitfallsof

coordinatedcare

--Lack

ofreview

ofacutemed

icationaftercond

ition

was

treated.

Neg

otiatin

gacomplex

system

--Family

concerne

dthat

compu

lsorytw

o-year

resi-

dentialm

edicationmanagem

entreview

sche

dule

was

toolong

.Manychange

soccurin

twoyears.

Med

icationknow

ledg

e-

-Family

wereun

familiar

with

specificmed

ication

indicatio

ns.-

Minim

alrecogn

ition

ofadversedrug

reactio

ns.

WhatevertheGPsays

goes

-

Manias et al. BMC Geriatrics (2019) 19:95 Page 10 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

-Com

pletetrustin

thecare

andde

cision

sof

the

GP.

-Num

berof

specialistsinvolved

inreside

nts’care.

Needforrealistic

expe

ctations-

-Relatives

view

edlong

-term

care

facilitiesas

active

providersof

med

icalcare.G

Psregarded

itas

apal-

liativecare

environm

ent.

Ploe

get

al.2017[31]

Canada***

Design:Interpretive

descrip

tive.

Setting:

participants’hom

e

Datacollection:semi-structured

interviews.

Transitio

npo

intsinvolved

:hom

e,prim

arycare

settings,hospital.

Med

icationmanagem

entprocess

involved

:managingmed

ications

for

multip

lecomorbidities.

Patientsn=41.

Age

:17%

aged

85yearsand

over.

Gen

der:44%

female.

Med

icalcond

ition

:three

ormorechroniccond

ition

s.Family

n=47.

Relatio

nshipwith

patient:

wife,husband

,grand

father,

mothe

r-in-law,friend

s.Health

profession

alsn=42.

Disciplines

involved

:registered

nurse,registered

/licen

sedpracticalnu

rse,

person

alsupp

ortworker/

healthcare

aide

Them

es:

Expe

rienceof

managingmultip

lechronic

cond

ition

s-

-Em

otionally

draining

.Organisingpills

andappo

intm

ents-

-Managingchange

sto

med

ications

that

frequ

ently

occurred

afteran

acutecare

hospitalization.

-Abrup

tdischarge,with

outinpu

tfro

mcaregivers

abou

tpreferen

ces.

-Organisingappo

intm

entsto

discussbloo

dresults

andscansaffectingmed

ications.

Beingsplit

–-Receivingservices

from

multip

leproviderswho

focuson

asing

ledisease

-Lack

ofcommun

icationbe

tweenfamily

doctor

andspecialists.

Doing

whatthedo

ctor

says

--Family

believedde

cision

makingwas

physician-

directed

.Provide

rspe

rceivedtheirapproach

in-

volved

shared

decision

-making.

Pope

joy2011

[32]

United

States***

Design:Qualitative

exploratory.

Setting:

tertiary

care

hospital

Datacollection:semi-structured

interviews.

Transitio

npo

intsinvolved

:hospital,

home,reside

ntialage

dcare

facility.

Med

icationmanagem

entprocess

involved

:Discharge

planning

.

Patientsn=13.

Age

:mean=84

years,rang

e=72–89years.

Gen

der:62%

female.

Med

icalcond

ition

:no

cogn

itive

impairm

ent,at

least

pre-clinicallyfrail.

Family

n=12.

Relatio

nshipwith

patient:

spou

ses.

Health

profession

alsn=7.

Disciplines

involved

:registered

nurses,social

workers.

Them

es:

Chang

ingthedischargeplan

--Patientsandcaregiverswereadam

antabou

tgo

ingho

me(not

toreside

ntialcare).

-Health

profession

alswereworriedwhe

nfamily

hadtrou

bleun

derstand

ingabou

tmed

ications.

-Family

weresometim

esoldwith

health

prob

lems

them

selves,and

haddifficulties

coping

with

and

remem

berin

gto

offerpatients’med

ications

atho

me.

Tjiaet

al.2014[27]

United

States***

Design:qu

alitative

exploratory.

Setting:

Threeho

spice

agen

cies.

Datacollection:semi-structured

interviews

Transitio

npo

intsinvolved

:hospice,

outpatient

oncology,p

rimarycare

settings.

Med

icationmanagem

entprocess

involved

:med

icationprescribing

Patientsn=18.

Age

:mean=80

years(SD10

years).

Gen

der:42%

female.

Med

icalcond

ition

:advanced

cancer.

Family

n=8.

Them

es:

Med

icationcoordinatio

nandcommun

ication-

-Families

werekeen

tohave

compreh

ensive

med

icationreview

sup

ontransitio

nto

hospice

that

assessed

ongo

inguseof

long

standing

med

ications

forcomorbidillne

ss.

-Family

werereceptiveto

redu

cing

harm

fuland

Manias et al. BMC Geriatrics (2019) 19:95 Page 11 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

across

transitio

ns.

Relatio

nshipwith

patient:not

stated

.Health

profession

alsn=17.

Disciplines

involved

:nurses,

physicians.

non-essentialm

edications.

Towleet

al.2012[12]

Sing

apore*

Design:Prospe

ctive

observational,cross-sectional.

Setting:

onetertiary

hospital

Datacollection:survey

questio

nnaire

Transitio

npo

intsinvolved

:hospital,

home.

Med

icationmanagem

entprocess

involved

:Discharge

process.

Interven

tion:(fo

rinterven

tion

stud

ies)BO

OST

(BetterOutcomefor

Older

adultsthroug

hSafe

Transitio

ns);an

eviden

ce-based

qual-

ityim

provem

entinitiativeto

en-

hancecare

transitio

nin

improving

patient/fam

ilyprep

ared

ness

for

discharge.

Patientsn=40.

Age

:not

stated

.Gen

der:no

tstated

.Med

icalcond

ition

:>1

chroniccond

ition

.Family

n=no

tstated

.Relatio

nshipwith

patient:not

stated

.

Outcomes:

Patient

andcaregiverun

derstand

ingof

med

ical

cond

ition

--Im

provem

entby

70%.

Patient

andcaregiverun

derstand

ingof

med

ications-

-Im

provem

entby

67%.

Patient

andcaregiverun

derstand

ingof

treatm

ent

plan

--Im

provem

entby

81%.Patient

andcaregiver

unde

rstand

ingof

follow-up-

-Im

provem

entby

41%.

Trollor1997

[28]

Australia****

Design:Cross-sectio

nal.

Setting:

Com

mun

itypalliative

care

service.

Datacollection:qu

estio

nnaire.

Transitio

npo

intsinvolved

:palliative

care

services,hom

e,prim

arycare

services.

Med

icationmanagem

entprocess

involved

:sym

ptom

managem

ent.

Patientsn=26.

Age

:not

stated

.Gen

der:31%

female.

Med

icalcond

ition

:patients

with

palliativecare

need

s.Family

n=26.

Relatio

nshipwith

patient:

wives,d

augh

ters,husband

s.

Them

es:

-13

outof

26family

mem

berswerein

charge

ofpatients’med

ication.

-Ro

lein

dealingwith

gene

ralp

ractition

ersand

palliativecare

specialists,toadministermed

ication

forpain,sleep

ingdifficulty

andloss

ofappe

tite

weremostchalleng

ing.

White

etal.2015[29]

United

States***

Design:Qualitative

exploratory.

Setting:

Twoho

spitals.

Datacollection:semi-structured

interviews.

Transitio

npo

intsinvolved

:hospital,

home.

Med

icationmanagem

entprocess

involved

:Discharge

planning

.

Patientsn=20.

Age

:mean=77

years(SD8.8

years).

Gen

der:47%

female.

Med

icalcond

ition

:stroke

survivors.

Family

n=9.

Relatio

nshipwith

patient:

husband,

wife,son

,daugh

ter.

Them

es:

Prep

aringto

goho

meafterthestroke

--Im

portance

ofhe

alth

profession

alsun

derstand

ing

family’sne

edsfollowingdischargeso

that

specific

situationcouldbe

addressed.

-Wrong

family

mem

bertargeted

forproviding

inform

ation.

Com

plexity

ofmed

icationmanagem

ent-

-somefamily

wereconfiden

tabou

ttheir

know

ledg

e.-Somefamily

lacked

unde

rstand

ingabou

tthe

purposeof

med

ication.

-Usuallyfamily

mem

berwho

managed

med

ications.

-Difficultiesin

managingmed

ications

forpatients

with

swallowingprob

lems.Rand

omde

cision

sabou

twhich

med

ications

shou

ldbe

crushe

d.

Manias et al. BMC Geriatrics (2019) 19:95 Page 12 of 21

Table

1Characteristicsof

includ

edpape

rsexam

iningfamily

involvem

entformanagingmed

ications

ofolde

rpatientsacross

transitio

nsof

care

(N=23)(Con

tinued)

Autho

r,year,cou

ntry,M

MAT

result

Designandsetting

Descriptio

nof

stud

yParticipants

KeyFind

ings

White

etal.2014[33]

United

States**

Design:Mixed

metho

ds.

Setting:

Twoho

spitals.

Datacollection:semi-structuredin-

terviews,electron

icmed

icalrecord

review

.Transitio

npo

intsinvolved

:hospital,

home.

Med

icationmanagem

entprocess

involved

:Discharge

planning

.

Patientsn=310.

Age

:mean=76

years(SD9.8

years).

Gen

der:Not

stated

.Med

icalcond

ition

:stroke

survivors.

Family

n=20

combine

dwith

patients.

Relatio

nshipwith

patient:not

stated

.

Them

es:

With

inon

emon

thof

discharge,10%

were

readmitted

and25%

with

in6mon

ths.

Reason

sforreadmission

wererecurren

tstroke/

transien

tischaemicattack

(19%

),pn

eumon

iaand

urinarytractinfection(19%

),sw

allowingprob

lems

andde

hydration(9%),andcardiaccauses

(7%).

-Needforgu

idance

onwhatto

expe

ctat

home.

-Needfollow-upin

commun

ityabou

tearly

iden

tifi-

catio

nof

prob

lems.

-Com

plexity

ofmed

icationmanagem

ent

sometim

esledto

lack

ofun

derstand

ing.

Note:

Thesymbo

ls*,**,***

and****

referto

scores

of25

,50,

75an

d10

0%respectiv

elyob

tained

ontheMixed

Metho

dsApp

raisal

Tool

(MMAT)

Manias et al. BMC Geriatrics (2019) 19:95 Page 13 of 21

Table

2Synthe

sisedthem

esfro

minclud

edstud

ies

Them

esandsubthe

mes

Stud

ieswith

thefirstnamed

author

andyear

Allen

2017

Colem

an.

2006

Colem

an2004

Crawford

2015

Deeks.

2016

Dyrstad

2015

Geo

rgiadis

2017

Haged

oorn

2017

Hvalvik

2015

Jeffs

2017

King

2013

Knight

2013

Givinginform

ationandreceivingfeed

back

Families

conveyinginform

ationto

health

profession

als

XX

XX

XX

X

Health

profession

alsinform

ingfamilies

XX

XX

XX

XX

XX

X

Participatingin

decision

making

Med

icationde

cision

soccurringon

admission

X

Med

icationde

cision

soccurringtransfersanddischarge

XX

XX

XX

XX

Med

icationde

cision

soccurringafterdischarge

XX

X

Characteristicsof

health

profession

alsandfamilies

XX

Managingmed

icationcomplexity

across

transitio

nsof

care

Challeng

esin

managingmed

icationcomplexity

from

hospitaladm

ission

todischarge

X

Difficultiesaffectingmed

icationcomplexity

inthe

commun

ityandaged

care

facilities

XX

XX

X

Possibilitiesforindividu

alised

tailoredcare

XX

Supp

ortin

gfamily

participationin

interven

tions

XX

Manias et al. BMC Geriatrics (2019) 19:95 Page 14 of 21

Them

esandsubthe

mes

Stud

ieswith

thefirstnamed

author

andyear

Lowson

2012

Nazarath

2001

Neiterm

an2015

Palagyi

2016

Ploe

g2017

Pope

joy

2011

Tjia

2014

Towle

2012

Trollor

1997

White

2015

White

2014

Givinginform

ationandreceivingfeed

back

Families

conveyinginform

ationto

health

profession

als

XX

XX

X

Health

profession

alsinform

ingfamilies

XX

XX

Participatingin

decision

making

Med

icationde

cision

soccurringon

admission

Med

icationde

cision

soccurringtransfersanddischarge

XX

Med

icationde

cision

soccurringafterdischarge

XX

X

Characteristicsof

health

profession

alsandfamilies

XX

X

Managingmed

icationcomplexity

across

transitio

nsof

care

Challeng

esin

managingmed

icationcomplexity

from

hospital

admission

todischarge

XX

Difficultiesaffectingmed

icationcomplexity

inthecommun

ityand

aged

care

facilities

XX

XX

XX

X

Possibilitiesforindividu

alised

tailoredcare

XX

Supp

ortin

gfamily

participationin

interven

tions

XX

Manias et al. BMC Geriatrics (2019) 19:95 Page 15 of 21

medications across transitions of care. Fourteen studiesexamined this theme [13, 16–21, 23–26, 30–32]. Foursubthemes underpinned this theme: medication decisionsoccurring on admission to hospital, those occurringduring transfers and at discharge, those that happenedafter discharge home and to aged care facilities, and char-acteristics of health professionals and family members infostering participation in decision making.In one participant observation study in emergency

departments, family members made decisions aboutadministering medications [18]. They determined thespecific times to give medications to patients. This oc-curred at busy times while patients waited to be trans-ferred to other settings. An example included a daughterproviding anti-epileptic medications to her motherbecause of understaffing and heavy nursing workloads inthe emergency department [18].Many challenges impeded family participation in deci-

sion making during transfers and at discharge. Unex-pected or delayed transfers and discharges due to staffconstraints of doctors, nurses and pharmacists resulting ininsufficient time and planning, led to limited opportunitiesfor families to participate in medication decisions [19, 20,24, 25, 31]. Family members believed that some healthprofessionals, such as community nurses or specialists fo-cused on treating a single condition, that health profes-sionals did not listen to them, and that healthprofessionals organised discharge medications without un-derstanding about patients’ concerns and the home situ-ation that could impact on their treatment regimen [13,16, 31]. There was lack of family participation in medica-tion decisions in diverse communication encounters, in-cluding informal bedside conversations, ward rounds, anddischarge consultations [17–19]. The absence of struc-tured routines for family communication meant that fam-ily members were not present at times when goals of carewere discussed [18]. For example, family members com-plained about nurses contacting them by phone to informthem about medication decisions on the day of discharge,with these decisions having been made much earlier dur-ing the patients’ hospital stay. Family members preferredthat doctors and nurses had a routine of contacting themabout participating on the doctors’ rounds relating toplanning for discharge. [18].Planning activities for patient transfer or discharge

often lacked an individualised approach, as shown by theabsence of dedicated sessions to discuss goals of treat-ment [17, 19]. Some assertive family members ques-tioned nurses about how patients would use medicationsto deal with worsening symptoms, such as difficulties inbreathing or increasing confusion [20], and the effects ofchanged medications at the time of discharge [17].Nevertheless, opportunities for their involvement tendedto be more apparent if nurses organised specific family

meetings where family members could ask questions[20]. In patients with dementia who had changingdemands for managing behavioural and psychologicalsymptoms, transitioning between various environmentswas common [16]. Their families believed that theyplayed a vital role in making decisions at home; however,their roles blurred and shifted between being an activecaregiver and a passive bystander as patients transferredfrom home, to acute care, rehabilitation and geriatricevaluation and management units, and back to home[16]. Family member sought to be called by healthprofessionals to enable pre-planning to organise a timeto discuss about medications.Lack of involvement during transitions contributed to

safety concerns about medications [19, 20, 24, 25, 31]. Fam-ilies were given little time to plan for assisting with medica-tion administration at home [20] and they were confusedabout the changes made, which meant they did not knowwhat to do when patients went home [24, 25, 31]. Familymembers commented that they did not feel involved indecisions because they received inadequate explanations formedication changes [24, 31]. Family members’ lack of par-ticipation sometimes led to increased risk, such asprescribing medications for patients where allergies existedand were not clarified [31].Following discharge, family members participated in

decisions by assisting with, and monitoring medication in-take for, patients at home. In examining patients’ medica-tion regimens, community nurses rarely discussed thepatients’ home situation [20]. At home, family membersperceived themselves as advocating for patients’ needs, bychanging medication times to suit patients’ individualisedroutines [22], and by reminding health professionals aboutthe medication schedules followed at home [25]. Forpatients discharged home after receiving palliative careservices, 13 out of 26 family members indicated that theytook charge of patients’ medications at home, to managesymptoms such as pain, sleeping difficulty and loss of ap-petite [28]. Conversely, for residents situated in long-termcare facilities, care workers tended to exclude familymembers from decision making. In these environments,some family members experienced difficulties in relin-quishing their carer role and wanted to retain their role indecisions [16]. Family members of patients discharged toaged care facilities were frustrated about their lack of in-clusion in decisions made at the acute care hospitals fromwhere the patients were transferred. They observed agedcare nurses making multiple requests to the acute carehospitals, seeking clarification of unclear discharge ordersfor patients discharged to aged care services [23]. Further-more, family members felt uncomfortable in questioninggeneral practitioners about the medication plans theyprepared for individuals situated in residential aged carefacilities [26].

Manias et al. BMC Geriatrics (2019) 19:95 Page 16 of 21

Interpersonal characteristics of health professionalsand family members affected how and whether deci-sion making took place. Family members commentedthat if nurses and doctors exuded a positive attitudeand explained their role, this approach facilitated fam-ily participation [13]. Some health professionals wereperceived to lack empathy, with an inability to ac-tively listen to family concerns about medications.Pharmacists and doctors believed it was their role toconsider the complexities of managing older patients’multiple medications. However, these health profes-sionals felt challenged in addressing the risk-benefitconcerns in following individual guidelines and tryingto tailor medication regimens for older patients withseveral health conditions [31]. Family members oftenfelt a sense of responsibility for managing patients’medications [21]. Patients delegated this responsibilityto family members because they did not want to beperceived as bothersome and complaining to clinicalstaff [30]. Health professionals sometimes changedtheir belief that family members would be able tocope with managing patients’ medications when theysought information from family members [32].

Managing medication complexity across transitions ofcareThere were 14 studies that focused on managing medi-cation complexity across transitions of care [13, 17, 19,21–26, 29–33]. Medication complexity referred to rap-idly changing dose and frequency orders, medicationsprescribed to treat several co-existing conditions, andcomplicated administration and storage requirements.Three subthemes related to this theme: challenges inmanaging medication complexity from hospital admis-sion to discharge, difficulties affecting medication com-plexity in the community and aged care facilities, andpossibilities for individualised tailored care for managingmedications.In managing medication complexity from hospital ad-

mission to discharge, families experienced difficulties inunderstanding how the health system operated in hospi-tals [21], while at the same time, they felt responsible forsupporting patients’ complex needs. Families describedplaying a “second fiddle” role (p. 1197) during hospital ad-mission of patients living with heart failure or lung cancerin their final year of life, where families felt subordinate todoctors and the hospital system [30]. Families consideredthat health professionals perceived them as outsiders, andthey had to be assertive to have their views heard [22].Hospital discharge meetings were organised in an

attempt to help patients and families to understand pa-tients’ complex treatment regimens [13, 19, 22]. However,families perceived that discharge activities were not tai-lored to patients’ complex needs. Quick discharge

processes were organised for patients with multiplechronic conditions [31] and planning was not modified totake account of patients with cognitive problems [17].Family members also had a poor first impression of

skilled nursing facilities (a form of aged care facility inthe United States), when health providers asked themabout medications prescribed after patients’ transferfrom hospital to these facilities. Instead, family mem-bers believed that health professionals in hospitalsshould provide clarification about these prescriptions atthe point of transfer [23]. In this particular circum-stance, family members felt it was wrong that they wereexpected to provide this clarification.Several studies reported difficulties in administering

complex medication regimens in the community andaged care facilities [17, 21, 25, 32]. For pharmacists offer-ing dose administration aids to patients at discharge,there was often insufficient screening to determine theappropriateness of using these aids at home. Olderpatients needed to have a reasonable degree of cognitionin order to work out the timing of doses, and to pushout medications from the aids [17]. Interviews withnurses working in a skilled nursing facility identifiedpoor communication and inappropriate medicationplans as patients moved from the hospital to the facility.Nurses believed that health professionals in hospitals didnot utilise families effectively to obtain informationduring transfers. Complicated medication changes at dis-charge created disruptions to daily routines at home forpatients and families [25] and since families were unableto understand the rationale for some changes, they didnot remember to remind patients about when to con-sume these medications [32]. Families preferred patientsto have once-daily doses of medications, especially forthose patients with multiple medications as paid carersoften only visited patients once a day. However, thispreference was not usually considered by prescribers[17]. Families also found themselves frequently remind-ing home nurses about medication orders that thesenurses should have stopped due to a patient’s history ofallergies or adverse events because of medications lead-ing to vomiting and confusion [21].For patients needing home palliative care services,

families were challenged in dealing with unresolvedsymptoms of pain, sleeplessness and loss of appetite,along with the diagnosis of cancer. As these patients’symptoms worsened, constant changes had to be madeto medication orders, thereby adding difficulties forfamilies [28]. Similarly, families wanted patients to havea compulsory medication review by hospice nurses inhospice environments to assess ongoing need for medi-cations used for long-standing conditions. However,hospice nurses perceived doctors were reluctant to dis-continue medications in these patients, and that these

Manias et al. BMC Geriatrics (2019) 19:95 Page 17 of 21

doctors lacked confidence in making medication assess-ments [27]. Furthermore, for older people moving intoAustralian residential aged care facilities, familiesbelieved that 2 years was too long to wait for a plannedformal medication review [26]. There was also concernabout acute conditions being treated for months afterconditions had subsided, including antihistamines andantibiotics [26]. At the same time, families were uncer-tain about what medications that doctors should pre-scribe following a patient’s stroke compared to whatthey prescribed prior to a stroke, and when patients hadmultiple comorbidities, such as hypertension andParkinson’s disease [29, 33]. Families also had to contendwith multiple prescribers who managed patients’ condi-tions [17, 31]. Prescribers often focused on single diseasestates and therefore did not always consider the effectsof their prescriptions on other chronic conditions ormedications being taken [21].Medication changes created the challenge of new

side-effects requiring additional monitoring, which weresometimes not adequately conveyed to family members[31]. For example, in the study by White et al. [29]involving patients following a stroke with impaired swal-lowing, families did not receive clear information fromdoctors about which medications could be crushed.Several studies considered possibilities for individua-

lised tailored care, which was more likely when healthprofessionals delayed patient discharge to provide moretime for coordinating medication regimens [19, 21, 30,31]. Proactive approaches used between family members,such as maintaining regular contact with each other,enabled continuity of care for patients with heart failureor cancer in the last year of life [30]. Such approachesenabled greater family understanding of how medicationchanges occurred as patients’ condition altered [21, 31].However, there was little focus of how patients’ demo-graphic characteristics such as those from disadvantagedor vulnerable backgrounds could affect tailored care formanaging medication regimens.

Supporting family participation in interventionsFour studies focused on supporting family participation,together with that of patients, in interventions aimed atimproving patients’ experiences at transitions of care[12, 14, 15, 34]. In two papers by Coleman and col-leagues [14, 15], an intervention was delivered by anadvanced practice nurse to patients and families thatincluded medication self-management, a patient-centredrecord, primary care and specialist follow-up, and know-ledge of warning signs or symptoms that indicated aworsening condition. This intervention was designed toenhance patient and family self-management skillsacross transitions of care. To provide support with medi-cation self-management, the advanced practice nurse

reviewed each medication with the patient, as well as thefamily member if available, to ensure that the patientunderstood its purpose, instructions, and potential ad-verse effects. Aside from identifying that family memberswere involved as recipients of the intervention, nodetails were provided of how they perceived these inter-ventions, how they were specifically involved as a separ-ate or collaborative entity to patients, and how theirinvolvement influenced outcomes. In both studies, therewere significant reductions in rehospitalisation rates andcosts after discharge from the initial hospitalisation (p <0.05). No outcomes relating to medication errors werereported.In the intervention study by Nazarath et al. [34], dis-

charge plans were developed by hospital pharmacists,home visits occurred with community pharmacists, andcounselling took place with patients and family onappropriate doses and purpose of medications. No differ-ences were found between control and interventiongroups in terms of readmission at 3 months and 6months, or in patients’ well-being, satisfaction with theservice, and knowledge of and adherence to prescribedmedications (p > 0.05). There was no specific investiga-tion of how family involvement may have influenced theclinical outcomes.In Towle et al.’s [12] prospective observational study,

the focus was on evaluating the effectiveness of BOOST(Better Outcome for Older adults through Safe Transi-tions) in improving transition from hospital to home.After delivery of the intervention, comprising a bundleof evidence-based tools on discharge processes, the au-thors reported patients’ and families’ improved under-standings of medications by 67%, of the treatment planby 81%, and follow-up by 41%. No details were providedof the families’ specific contributions in achieving theseoutcomes.

DiscussionFour major themes were identified in this systematicreview: information giving and receiving, participation indecision making, managing medication complexity, andfamily participation in supportive interventions. In thestudies identified, families’ involvement in medicationmanagement tended to be subsumed in various aspectsof patients’ care. It was therefore sometimes difficult toidentify discrete details about the family perspective onmedication management.Information giving was a key area of family involve-

ment, which tended to occur in restricted ways. Healthprofessionals acknowledged family members as keysources of information about the medications that olderpeople were prescribed. However, the process of elicitinginformation from family members largely focused on pa-tient admission to hospital [18, 20]. There was also some

Manias et al. BMC Geriatrics (2019) 19:95 Page 18 of 21

indication of information seeking from family membersfor older patients with dementia who moved from acutecare settings to long term care [16] and of older patientsat their last year of life from hospital to home [30]. Noevidence was found with regard to information seekingfrom family members as older patients moved betweenvarious settings within hospitals. As health professionalsmainly sought information from families on patient ad-mission, this creates the possibility of medication dis-crepancies at future transitions of care. Informationgiving needs to occur in diverse environments, includingwhen older patients move to home or to residential agedcare facilities.Receiving information by family members from health

professionals was a relatively disorganised and haphaz-ard process [17–19]. There was little evidence of familiesreceiving information from health professionals if olderpatients moved between different acute care settingswithin hospitals, or when movements occurred fromacute care to subacute care or long-term care settings.Information receipt that focused on the time of dis-charge from hospital to home, sometimes created amanagement burden as health professionals attemptedto provide medication counselling and education at asingle time point. Medication errors were therefore apossibility following discharge. Rather than focusing in-formation receiving at discharge, it may be more effect-ive if this activity occurs throughout the patients’hospital stay. Similarly, efforts in information giving andreceiving could be reorganised such that different ap-proaches are available to deal with differing levels of pa-tient and family understanding.Participation in decision making demonstrated that

families communicated with patients about strategies touse when taking medications as they moved from oneenvironment to another. In some environments wherehealth professionals were affected by time constraints,understaffing, and heavy workloads, there was some-times little opportunity for health professionals to attendto older patients’ medication needs [18]. In these situa-tions, families were recipients rather than active partici-pants of decisions [35]. Greater attention should beplaced on enabling shared decision making duringplanned communication encounters including familymeetings, bedside handovers, ward rounds, and admis-sion and discharge consultations.In managing medication complexity across transitions

of care, family members perceived a lack of tailoring ofmedication plans for patients’ needs, and believed theyhad to display perseverance to have their views heard. Instudies that dealt with medication complexity, there wasinsufficient demographic information to indicate whetherfamilies had disadvantaged or vulnerable circumstances,such as being of non-English speaking backgrounds, low

socioeconomic groups, or low health literacy. Improvingunderstanding about medication complexity at transitionsof care requires fundamental changes in the way thathealth professionals and families interact with each other.Some past work has focused on the use of patientteach-back to address misinterpretations about the medi-cation regimen [36, 37]. As an extension of that process,family teach-back could be an effective means of identify-ing key information whereby family members use theirown words to explain to health professionals what theyknow about patients’ medications. Individuals can thencollectively verify understandings, address misconceptionsand improve family and health professional comprehen-sion [38].Four interventions were identified as being directed to

patients and families; however, the specific contributionof families was not clearly distinguished [12, 14, 15, 34].Improvements in family understanding about medica-tions were identified in one intervention study [12] whilein another, no improvements were found in medicationknowledge or understanding [34]. The remaining twostudies had no information about medication manage-ment outcomes [14, 15]. While families were named asrecipients of interventions, there was insufficient clarityabout the extent of their involvement, and of how theirinvolvement affected outcomes achieved. No detailswere provided about compliance with interventions, ordifficulties encountered with family involvement. To ad-dress gaps in past work, targeted strategies need to focusmore specifically on family members’ active contributionto managing medications at transitions of care, with out-comes directed on family understanding of medicationchanges and their input in preventing and identifyingmedication-related problems.There are limitations associated with the systematic

review. Since the review only included papers publishedin English, it is possible that those published in otherlanguages may have provided further insights on thetopic. As most papers did not specifically focus on theobjective of this systematic review, it was sometimes dif-ficult to extract the required information. There was alsono attempt to exclude papers on the basis of quality.There were a number of methodological issues relating

to the included studies. In terms of strengths, of thestudies included in the review, 65% had obtained aMMAT score of 75%, thereby indicating the majority ofthe studies were relatively well-conducted. Interviewstudies showed that the data were rich, comprehensive,and revealed clear insights into the contextual challengesaffecting older patients across transitions of care. In rela-tion to methodological limitations, transitions of caretended to be examined at only particular time points,namely, movements of patients during admission to ordischarge from hospital. Given that the focus of the work

Manias et al. BMC Geriatrics (2019) 19:95 Page 19 of 21

involves family involvement, it is interesting that only twostudies comprised qualitative observational designs.The systematic review indicates the need for further re-

search. Future studies should focus on examining families’contribution and involvement in managing older patients’medications across transitions of care. Most past workgenerally only addressed family involvement in general as-pects of patient movement across transitions of care.Greater consideration needs to be given to family involve-ment in the continuum of patient journey at differentcontexts of care, from admission to hospital, through totransfers across wards and across hospitals, and dischargehome or to residential aged care facilities.

ConclusionsFamilies play an important role in supporting older pa-tients in managing their medications as these patientsmove across different settings. Nevertheless, there is lackof acknowledgement from health professionals of the activ-ities performed by families before, during and followingthese movements. While families actively engage witholder patients in strategies to ensure medication safety, fur-ther work is needed on measuring the effectiveness onthese strategies on medication outcomes, facilitatingshared decision making between families and healthprofessionals, and clarifying medication plans of careacross transitions.

Additional file

Additional file 1: Search History/Alerts Medline (Ebscohost) [9]. Searchhistory for Medline. (DOCX 54 kb)

AbbreviationsBOOST: Better Outcome for Older adults through Safe Transitions;CENTRAL: Cochrane Central Register of Controlled Trials; CINAHL: CumulativeIndex to Nursing and Allied Health Literature; Ebscohost: Elton B. StephensCo Host; EMBASE: Excerpta Medica Database; MEDLINE: Medical LiteratureAnalysis and Retrieval System Online; MMAT: Mixed Methods Appraisal Tool;PICo: population, phenomenon of interest and context;PsycINFO: Psychological Information Database

AcknowledgementsNot applicable.

FundingAustralian Research Council, Discovery Grant Scheme, DP170100308. The fundingbody had no role the design of the systematic review and collection of papers,analysis and interpretation of papers, and in writing the manuscript.

Availability of data and materialsDatabase search strategies available as a supplementary file.

Authors’ contributionsAll authors: conception and design; EM, TB: provision of study materials; EM, TB:collection and assembly of data; All authors: data analysis and interpretation; Allauthors: manuscript writing and editing; All authors: final approval ofmanuscript.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1Centre for Quality and Patient Safety Research, School of Nursing andMidwifery, Deakin University, 221 Burwood Highway, Burwood, VIC 3125,Australia. 2Alfred Health, Commercial Road, Prahran, VIC 3181, Australia.3School of Pharmacy, Queen’s University Belfast, University Road, Belfast,Northern Ireland BT7 1NN, UK. 4Sydney Medical School, The University ofSydney, Edward Ford Building A27, Fisher Road, Camperdown, NSW 2050,Australia. 5NSW Regional Health Partners, 72 Watt St, Newcastle, NSW 2300,Australia. 6School of Medicine, The University of Melbourne, Grattan Street,Parkville, VIC 3052, Australia.

Received: 1 November 2018 Accepted: 8 March 2019

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