Quality and recommendations of guidelines for multimorbidity and polypharmacy in older adults: A systematic review

Global population aging exacerbates the challenges of multimorbidity and polypharmacy in older adults. Clinical practice guidelines are essential for addressing these issues. This systematic review aims to evaluate the quality of existing guidelines and synthesize their recommendations based on the Ariadne principles, to inform future guideline development and clinical practice.

We searched nine databases and five guideline repositories (e.g., PubMed, Web of Science, Cochrane Library, CNKI, WHO) up to August 2025. Guidelines and consensus documents focusing on multimorbidity or polypharmacy in older adults, published in English or Chinese, were included. Each guideline was evaluated using four validated tools: AGREE II (methodological quality), RIGHT (reporting completeness), AGREE-REX (recommendation credibility and applicability), and GLIA (implementation feasibility). Recommendations were categorized and synthesized according to the Ariadne principles, with independent screening and data extraction and consensus resolution of discrepancies.

The multidimensional appraisal of the 21 included guidelines revealed consistent weaknesses. According to AGREE II, the domains of Scope and Purpose (81.9 %) and Clarity of Presentation (61.1 %) demonstrated the highest median scores, whereas Rigor of Development (16.7 %) and Applicability (8.3 %) scored the lowest. Based on the RIGHT checklist, overall reporting completeness was 43.2 %, with the Evidence (0.0 %) and Quality Assurance (0.0 %) domains being particularly underreported. AGREE-REX evaluation indicated limited implementability at the individual recommendation level (12.5 %), and GLIA, while suggesting moderate implementability at the guideline level (65.4 %), identified frequent barriers in the domains of Measurable Outcomes (100.0 %) and Innovation Requirements (66.7 %). Thematically, most guidelines addressed interaction assessment (n = 15, 71.4 %), but far fewer incorporated patient preferences (n = 9, 42.9 %) or monitoring strategies (n = 9, 42.9 %). Only three guidelines (14.3 %) fully adhered to all five steps of Ariadne principles.

Current guidelines for older adults with multimorbidity or polypharmacy exhibit substantial weaknesses in methodological rigor, reporting completeness, and implementation feasibility. Synthesis based on the Ariadne principles revealed an imbalanced pattern of recommendations, with a predominant focus on medication safety rather than patient-centered and longitudinal care management. Future guideline development should strengthen methodological processes, systematically integrate patient perspectives, and co-design practical implementation strategies to better support personalized care for an aging population.