Introduction
According to the World Health Organisation [WHO] (2022a, 2022b), hearing impairment will affect one in four people globally by 2030, and one in five people in the UK (Hearing Link, 2023). The UK population is expected to increase to 69.2 million by 2030 (Office for National Statistics [ONS], 2020), with one in five people being over 65 years old. An estimated 18 million people in the UK, approximately one in three adults, will be affected by deafness, hearing loss, or tinnitus, and 1.2 million adults will have hearing loss severe enough to prevent understanding most conversational speech (Royal National Institute for Deaf People [RNID], 2024). This age group is also more likely to experience visual impairment, which is projected to affect 2.7 million people in the UK by 2030, rising to 4 million by 2050 (ONS, 2020). Additionally, nearly half a million people in the UK will have both sight and hearing loss (Venus-Balgobin, Reference Venus-Balgobin2023). Of these, 418,000 will be over the age of 70 (Care England, 2022). These demographic trends may lead to an increase in the prevalence of sensory impairment in the UK and worldwide.
For the purposes of this review, sensory impairment is used to describe visual and or hearing impairment or loss, whether present from birth or occurring later in life, ranging from a low level of loss to a more profound impairment. The term hard-of-hearing describes individuals with partial hearing loss who may use hearing aids and rely on a combination of auditory and visual communication.
Multimorbidity, the presence of two or more long term health conditions, has been estimated to affect up to 95% of the primary care population aged 65 years and older (Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012; Navickas et al., Reference Navickas, Petric, Feigl and Seychell2016; Yarnall et al., Reference Yarnall, Sayer, Clegg, Rockwood, Parker and Hindle2017). Compared with those with no long term health conditions, multimorbidity can affect an older person’s ability to access and use health care services, communicate with health care providers, and manage their medications (Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012; Yarnall et al., Reference Yarnall, Sayer, Clegg, Rockwood, Parker and Hindle2017; Smith et al., Reference Smith, Macaden, Kroll, Alhusein, Taylor, Killick, Stoddart and Watson2019; Cooper et al., Reference Cooper, Fuzesi, Jacob, Kamalakannan, Lennon, Macaden, Smith, Welsh, Broadfoot and Watson2023). Despite the increasing numbers of older people with multimorbidity, clinical practice guidelines and delivery of care are still built around single diseases, which can increase the risk of experiencing adverse drug events (Navickas et al., Reference Navickas, Petric, Feigl and Seychell2016; Yarnall et al., Reference Yarnall, Sayer, Clegg, Rockwood, Parker and Hindle2017). This highlights the need for evidence based guidelines that deliver a person centred approach, better care management, enhanced multidisciplinary teamwork, and support for patient education (Navickas et al., Reference Navickas, Petric, Feigl and Seychell2016). Such guidelines should consider the complexity and diversity of individual health needs, rather than focusing on individual diseases, made possible through the promotion of medicines optimization, deprescribing, and regular medication reviews (Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012; Picton and Wright Reference Picton and Wright2013; Navickas et al., Reference Navickas, Petric, Feigl and Seychell2016; Yarnall et al., Reference Yarnall, Sayer, Clegg, Rockwood, Parker and Hindle2017; Tarrant et al., Reference Tarrant, Lewis and Armstrong2023).
The prevalence of multimorbidity increases substantially with age (Navickas et al., Reference Navickas, Petric, Feigl and Seychell2016). Older people with multimorbidity and sensory impairment may struggle to manage the multiple medications prescribed to them, leading to difficulties with treatment adherence (Alhusein et al., Reference Alhusein, Macaden, Smith, Stoddart, Taylor, Killick, Kroll and Watson2018). Potentially inappropriate prescribing can introduce the risk of medication related adverse events, hospital admissions, falls, depression, and mortality (Riordan Reference Riordan, Byrne, Fleming, Kearney, Galvin and Sinnott2017; Yarnall et al., Reference Yarnall, Sayer, Clegg, Rockwood, Parker and Hindle2017; Alhusein et al., Reference Alhusein, Killick, Macaden, Smith, Stoddart, Taylor, Kroll and Watson2019). Evidence shows that older people with sensory impairment experience multiple challenges with all aspects of their medicine journey, from the consultation when a medicine is prescribed, to ordering, obtaining, storing medicine, and its administration and disposal (Smith et al., Reference Smith, Macaden, Kroll, Alhusein, Taylor, Killick, Stoddart and Watson2019).
Older people with visual impairment face substantial challenges in their medicines management such as, identifying individual medicines, especially when their shape, size, or colour changes and/or have difficulty reading medication labels and information sheets (Alhusein et al., Reference Alhusein, Killick, Macaden, Smith, Stoddart, Taylor, Kroll and Watson2019; Cooper et al., Reference Cooper, Fuzesi, Jacob, Kamalakannan, Lennon, Macaden, Smith, Welsh, Broadfoot and Watson2023). Older people may be unable to use assistive devices such as multi compartment devices, for example, dosette boxes, which are unsuitable for complex medication regimens, or live alone with no support, which may increase the risk of inappropriate medicines use, such as missed doses or unintentional overdose (Alhusein et al., Reference Alhusein, Killick, Macaden, Smith, Stoddart, Taylor, Kroll and Watson2019; Cooper et al., Reference Cooper, Fuzesi, Jacob, Kamalakannan, Lennon, Macaden, Smith, Welsh, Broadfoot and Watson2023). These challenges might reduce the benefits and increase harms from medicines. Many types of health professionals are permitted to prescribe, including doctors and non-medical prescribers. The latter have been introduced in many countries to meet the increasing demand and need for healthcare (Edwards et al., Reference Edwards, Coward and Carey2022). The extent to which prescribers are trained and/or modify their prescribing behaviour for older people with sensory impairment is unknown.
Aim
The aim of this review was to explore whether and how practitioners modify their prescribing behaviour for older people (≥ 65 years) with sensory impairment in primary care settings and the evidence sources available to inform prescribing for these specific patient populations.
The specific objectives were to:
1. Explore whether and how independent prescribers modify their prescribing behaviours for older people (65 years and over) with sensory impairment in primary care;
2. Identify potential factors that may influence prescribing behaviours, including barriers and facilitators to modifying prescribing for older people with sensory impairment;
3. Identify guidelines that may support evidence based prescribing for the safe and effective use of medicines by these specific patient populations; and
4. Identify information and resources that could influence prescribing for older people with sensory impairment.
Methods
The review was conducted to reflect the Joanna Briggs Institute [JBI] (Peters et al., Reference Peters, Godfrey, McInerney, Munn, Tricco, Khalil, Aromataris and Munn2020) methodology for scoping reviews and is reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for scoping reviews (PRISMA ScR) (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks and Hempel2018; Page et al., Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann, Mulrow, Shamseer, Tetzlaff, Akl, Brennan and Chou2021). The review protocol was registered with the Open Science Framework [OSF], registration number: osf.io/zy5we (Morrison et al., Reference Morrison, Asante, Lennon and Watson2023).
Eligibility criteria
The population, concept, context (PCC) framework was used to define the inclusion/exclusion criteria (Table 1) (Munn et al., Reference Munn, Peters, Stern, Tufanaru, McArthur and Aromataris2018).
Table 1. Inclusion and exclusion criteria (Munn et al., Reference Munn, Peters, Stern, Tufanaru, McArthur and Aromataris2018)
Information sources
Sources searched included the following electronic databases: MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL). Both qualitative and quantitative studies were sought. Editorials and opinion articles were excluded.
Grey literature
A wide range of grey literature sources were searched (Appendix 1) including local, national, and international organisations’ websites, health related and scientific organisations, professional organisation websites, and other information sources. Google and Google Scholar were also searched.
Search strategy
The search strategy comprised keywords and subject headings contained in the titles and abstracts and was developed in consultation with institutional subject Librarian. The MEDLINE search strategy is presented in Appendix 2. The strategy was adapted for each of the five electronic databases. All databases were searched for the period January 2012 to 14 April 2023. The review was not limited by language or geographical region. One study was published in German. Non-English language studies were translated using Google translate.
Source of evidence selection
The search results were uploaded into Rayyan systematic review software (Ouzzani et al., Reference Ouzzani, Hammady, Fedorowicz and Elmagarmid2016) and duplicates removed. Titles and abstracts were screened by one author Brenda Morrison (BM) with duplicate, independent screening undertaken on a 10% random sample by another individual Eugene Asante (EA). Studies deemed relevant were included in the full text review. Duplicate, independent screening of the full text articles was undertaken (BM, EA). Disagreements were resolved by a third reviewer Margaret Watson (MW). The reference lists of all included studies were screened for additional studies.
Results
A total of 3,590 records were identified through database searching and 10 full text articles were retrieved after screening. Grey literature identified a further 61 records. On examination of all full text articles, none fulfilled the inclusion criteria for this review (Figure 1). Hand searching of reference lists did not identify additional relevant studies.
Figure 1. The preferred reporting items for systematic reviews and meta analysis extension for scoping reviews (PRISMA ScR) flow diagram (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley, Weeks and Hempel2018; Page et al., Reference Page, McKenzie, Bossuyt, Boutron, Hoffmann, Mulrow, Shamseer, Tetzlaff, Akl, Brennan and Chou2021).
Although no studies met the inclusion criteria, the literature highlights growing interest in ageing, sensory impairment, and healthcare delivery, with studies addressing communication strategies (McKee et al., Reference Mckee, Moreland, Atcherson and Zazove2015; Stevens et al., Reference Stevens, Dubno, Wallhagen and Tucci2019), medication adherence (Smith & Bailey, Reference Smith and Bailey2014; Waterman et al., Reference Waterman, Evans, Gray, Henson and Harper2013), access barriers (Lesch et al., Reference Lesch, Burcher, Wharton, Chapple and Chapple2019), and sensory environments (Drahota et al., Reference Drahota, Ward, Mackenzie, Stores, Higgins, Gal and Dean2012). Some emphasize the need for tailored treatment and integrated care for older adults with sensory impairment (Dietlein et al., Reference Dietlein, Rosentreter and Lappas2016; Jaiswal et al., Reference Jaiswal, Gupta, Paramasivam, Santhakumaran, Holzhey, Dupont and Wittich2023). However, many focus on broader populations or hospital-based settings, which fall outside the scope of this review. To maintain relevance to prescribing in primary care for older adults (≥65 years), studies not addressing prescribing practices, decision-making, or relevant resources were excluded. Transferable insights, particularly around communication and adherence, may still inform future research and practice.
Discussion
This review did not identify any studies or resources that met the inclusion criteria, which highlighted a notable gap, despite the prevalence of age related sensory impairment.
Several resources were identified that are relevant to more generic aspects of prescribing and for older people, in particular. For example, in the UK, the Royal Pharmaceutical Society has practice guidance for medicines optimization (Picton and Wright, Reference Picton and Wright2013), defined as a person centred approach to safe and effective medicines use. Medicines optimization builds upon four principles: understanding the patient experience; evidence based choice of medicines; ensuring medicines use is as safe as possible; and making medicines optimization part of routine practice (Picton and Wright, Reference Picton and Wright2013). Prescribers may be able to support older people with sensory impairment by following these principles and adopting strategies to support their medicines use, to ensure that people get the right choice of medicines, at the right time, and are engaged in the process by their healthcare professional.
Additional tools and guidelines were identified including the Medicines for Older People, part of the National Service Framework for Older People (England) (Department of Health [DoH], England, 2001), and the STOPP/START criteria (O’Mahony et al., Reference O’Mahony, O’Sullivan, Byrne, O’Connor, Ryan and Gallagher2014). The STOPP/START criteria is a set of guidelines to help identify and avoid potentially inappropriate prescribing and potential prescribing omissions in older people. The Beers Criteria (Samuel, Reference Samuel2023) is a list of guidelines published by the American Geriatrics Society [AGS] to help improve the safety of prescribing medications for older people. It identifies medications that should be used with caution in older people, especially those with certain health conditions. All the above tools aim to help avoid inappropriate prescribing and reduce the risk of polypharmacy and adverse drug events in older people.
Healthcare professionals who work with older people with sensory impairment, and who prescribe medicines, may need more training and education on how to help these specific patient populations to use their medicines safely and effectively. The lack of resources identified by this review could indicate a general lack of awareness of the needs of older people with sensory impairment in relation to their medicines. A free, online course was developed by some of the authors of this review to raise awareness of the challenges experienced by older people with their medicines, however, it does not focus specifically on prescribing (Future Learn, 2022).
Older people with sensory impairment, particularly those with hearing loss, might also benefit from longer healthcare consultations to address communication barriers (Stevens et al., Reference Stevens, Dubno, Wallhagen and Tucci2019), which often receive less attention and/or fewer adaptations compared with those for the visually impaired in healthcare settings (Reed et al., Reference Reed, Assi, Pedersen, Alshabasy, Deemer, Deal, Willink and Swenor2020). Evidence suggests that the perspectives and experiences of deaf people, who have a distinct culture, language, and communication needs, should be recognised, and accommodated in relation to medicines use and prescribing practices (McKee et al., Reference Mckee, Moreland, Atcherson and Zazove2015; Lesch et al., 2018; Stevens et al., Reference Stevens, Dubno, Wallhagen and Tucci2019).
Longer consultations might enable prescribers to explore supportive ways to tailor medication regimen for their older patients with sensory impairment. For example, they could explore patient preference for type of formulations and route of administration and involve the patient and their carers in shared decision-making. Simplified regimens can improve adherence and are beneficial for individuals with additional impaired motor and/or cognitive function (Smith and Bailey, Reference Smith and Bailey2014; Dietlein 2015). There is empirical evidence that the use of fixed combination preparations can simplify dosing regimens with no loss of therapeutic effect (Waterman 2013; Smith and Bailey, Reference Smith and Bailey2014; Dietlein 2015). Whilst there is limited empirical evidence of the effect of technologies and devices to support medication management by older people with sensory impairment, this is a vast range of low to high technology products and strategies that could be used to support their medication management (Cooper et al., Reference Cooper, Fuzesi, Jacob, Kamalakannan, Lennon, Macaden, Smith, Welsh, Broadfoot and Watson2023). Prescribers may not be fully aware of the range of devices and options available to help support their patients.
Strengths and limitations
Standard scoping review methods were used and the study is reported in compliance with the PRISMA ScR checklist. A broad range of databases and other sources were searched. Searches were not limited by geography or language, yet despite the inclusive nature of the review, no studies or resources fulfilled the selection criteria. Whilst the review returned no included studies or resources, this is unlikely to be due to a limited search strategy or protocol, but may reflect a lack of available data on this topic.
The narrow inclusion criteria, focused specifically on prescribing in primary care for older people with sensory impairment, may have contributed to the absence of eligible studies. This highlights a notable evidence gap in the literature. While related studies offer insights into communication, adherence, and care environments, they often target broader populations or settings outside the review’s scope. Despite the lack of eligible studies, the review highlights the need for focused research in this area. Future studies may benefit from using broader inclusion criteria or alternative methods to gather relevant evidence.
Conclusions
There is a paucity of guidance or other resources to support and inform prescribing for older people with sensory impairment. This review highlights a potential need for the development of resources, for example, evidence based guidelines, to support the safe and effective use of medicines for these specific patient populations. There may be a need for greater understanding of prescribers’ capacity, opportunity, and motivation to modify their prescribing, and their willingness to use prescribing resources to optimize medicines use and improve health outcomes for older people with sensory impairment.
Acknowledgements
The authors thank Ms Elaine Blair, (University of Strathclyde Library) for her assistance with the development of the search strategy.
Funding statement
This work was supported by the Vivensa Foundation [grant number PDM2202/29]. The funder had no role in the review process.
Competing interests
The Author(s) declare(s) that they have no conflict of interest to disclose.
Ethical standards
This study did not require ethical approval.
Appendix 1 Resources searched to identify potential studies from January 2012 to April 2023
Appendix 2 Search Strategy
Data base: Ovid MEDLINE(R) ALL <January 1, 2012 to April 14, 2023>
Open access
