Managing medications in clinically complex elders: "There's got to be a happy medium"

Impact of Pharmacist-Provided Medication Therapy Management on Healthcare Quality and Utilization in Recently Discharged Elderly Patients

BACKGROUND

The optimization of medication use during care transitions represents an opportunity to improve overall health-related outcomes. The utilization of clinical pharmacists during care transitions has demonstrated benefit, although the optimal method of integration during the care transition process remains unclear.

OBJECTIVE

To evaluate the impact of pharmacist-provided telephonic medication therapy management (MTM) on care quality in a care transitions program (CTP) for high-risk older adults.

METHODS

This prospective, randomized, controlled study was conducted from December 8, 2011, through October 25, 2012, in a primary care work group at a tertiary care academic medical center in the midwestern United States. High-risk elderly (aged ≥60 years) patients were randomized to a pharmacist-provided MTM program via telephone or to usual care within an existing outpatient CTP. The primary outcome was the quality of medication prescribing and utilization based on the Screening Tool to Alert Doctors to the Right Treatment (START) and the Screening Tool of Older Persons' Prescriptions (STOPP) scores. The secondary outcomes were medication utilization using a modified version of the Medication Appropriateness Index, hospital resource utilization within 30 days of discharge, and drug therapy problems.

RESULTS

Of 222 eligible high-risk patients, 25 were included in the study and were randomized to the pharmacist MTM intervention (N = 13) or to usual care (N = 12). No significant differences were found between the 2 groups in medications meeting the STOPP or START criteria. At 30-day follow-up, no significant differences were found between the 2 cohorts in medication utilization quality indicators or in hospital utilization. At 30-day follow-up, 3 (13.6%) patients had an emergency department visit or a hospital readmission since discharge. In all, 22 patients completed the study. Medication underuse was common, with 20 START criteria absent medications evident for all 25 patients at baseline, representing 15 (60%) patients with ≥1 missing medications. Overall, 55 drug therapy problems were identified at baseline, 24 (43.6%) of which remained unresolved at 30-day follow-up.

CONCLUSION

The use of a pharmacist-provided MTM program did not achieve a significant difference compared with usual care in an existing CTP; however, the findings demonstrated frequent utilization of inappropriate medications as well as medication underuse, and many drug therapy problems remained unresolved. The small size of the study may have limited the ability to detect a difference between the intervention and usual care groups.

A Comprehensive Look at Polypharmacy and Medication Screening Tools for the Older Cancer Patient

: Inappropriate medication use and polypharmacy are extremely common among older adults. Numerous studies have discussed the importance of a comprehensive medication assessment in the general geriatric population. However, only a handful of studies have evaluated inappropriate medication use in the geriatric oncology patient. Almost a dozen medication screening tools exist for the older adult. Each available tool has the potential to improve aspects of the care of older cancer patients, but no single tool has been developed for this population. We extensively reviewed the literature (MEDLINE, PubMed) to evaluate and summarize the most relevant medication screening tools for older patients with cancer. Findings of this review support the use of several screening tools concurrently for the elderly patient with cancer. A deprescribing tool should be developed and included in a comprehensive geriatric oncology assessment. Finally, prospective studies are needed to evaluate such a tool to determine its feasibility and impact in older patients with cancer.

IMPLICATIONS FOR PRACTICE

The prevalence of polypharmacy increases with advancing age. Older adults are more susceptible to adverse effects of medications. "Prescribing cascades" are common, whereas "deprescribing" remains uncommon; thus, older patients tend to accumulate medications over time. Older patients with cancer are at high risk for adverse drug events, in part because of the complexity and intensity of cancer treatment. Additionally, a cancer diagnosis often alters assessments of life expectancy, clinical status, and competing risk. Screening for polypharmacy and potentially inappropriate medications could reduce the risk for adverse drug events, enhance quality of life, and reduce health care spending for older cancer patients.

Self-Care Needs of Seniors With Chronic Medical Conditions for Living in Their Own Homes

Health care expenditure and the maintenance of seniors’ well-being and health are important issues in Taiwan because of increased longevity and the fact that 89% of seniors have at least one chronic disease. In this study, a face-to-face questionnaire survey was conducted with 400 senior patients, to elicit their self-care needs for living in their own homes. Results showed that seniors required care from relatives and friends and social resource and medical information. Moreover, each need was affected by their family relationships, economic stress, education, religion, and living conditions. Therefore, government policy should be directed at addressing the needs of society, providing information and medication to reduce unnecessary health care expenditure, and enhancing seniors’ autonomy and quality of life.

A Delphi process to address medication appropriateness for older persons with multiple chronic conditions

Background

Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.

Methods

Modified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.

Results

The panel reached consensus on a set of markers to identify problems with medication regimens, including patient/caregiver report of non-adherence, medication complexity, cognitive impairment, medications identified by expert opinion as inappropriate for older persons, excessively tight blood sugar and blood pressure control among persons with diabetes mellitus, patient/caregiver report of adverse medication effects or medications not achieving desired outcomes, and total number of medications. The panel also reached consensus on approaches to address these problems, including endorsement of strategies to discontinue medications with known benefit if necessary because of problems with feasibility or lack of alignment with patient goals.

Conclusions

The results of the Delphi process provide the basis for an algorithm to improve medication regimens among older persons with MCCs. The algorithm will require assessment not only of medications and diagnoses but also cognition and social support, and it will support discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do not align with goals.

The inability of older adults to recall their drugs and medical conditions

BACKGROUND/OBJECTIVES

Previous research has shown that many older adults without known cognitive impairment are unable to recall basic knowledge about their medical history. We sought to determine whether older adult patients in our own clinic population were able to recall their drug regimens and medical conditions from memory.

METHODS

Patients aged 65 years or older with no known cognitive impairment, dementia, or memory loss who were presenting for routine outpatient follow-up in our medical school neurology and general medicine clinics were recruited. Each patient was asked to recall the number and names of their presently prescribed drugs and their associated medical conditions. Each patient was also administered a Mini-Mental State Examination (MMSE) cognitive screening test (range 0-30).

RESULTS

Most patients were unable to recall their drug regimens or their medical conditions. Of 99 patients taking drugs, only 22% correctly named their drugs from memory, and only 34% correctly named their medical conditions associated with the drugs. Fewer than half (49%) correctly recalled the number of drugs they were taking. Poor recall performance was evident even in high-cognitive (MMSE>27) patients.

CONCLUSION

The accuracy of recall memory in older adults regarding their drugs and medical conditions may be poor, which has important implications towards medication reconciliation within meaningful-use doctrine. Clinicians treating older adults should be very cautious before relying on their patients' memories for accurate recall of their medical conditions, their drug regimens, and even the number of drugs they are taking.

An Update on Geriatric Medication Safety and Challenges Specific to the Care of Older Adults

The prescribing of drug therapies in older adults presents a number of safety challenges. The increased complexity of chronic care for older adults has led to polypharmacy and potentially inappropriate medication use, which can contribute to drug-induced diseases, adverse drug reactions, drug interactions, cognitive impairment, falls, hospitalization, and mortality. In this review, the authors discuss recent medication safety literature pertaining to the classes of medications commonly prescribed to older adults: anticholinergics, psychiatric medications, and antibiotics. Safety concerns associated with the use of these medications and the implications for long-term care practitioners are reviewed. The information provided can be used to inform and improve geriatric care delivered by practitioners across health care environments.

Inappropriate Medication Use Among Underserved Elderly African Americans

OBJECTIVE

The goal of this study is to identify correlates and the prevalence of potentially inappropriate medication (PIM) use among underserved elderly African Americans.

METHOD

This cross-sectional study recruited 400 elderly African Americans living in South Los Angeles, and used structured, face-to-face surveys. These elicited data pertaining to the type, frequency, dosage, and indications of all medications used by participants.

RESULTS

Seventy percent of participants engaged in PIM use and used at least one medication that was classified as "Avoid" (27%) and "Use Conditionally" (43%) through Beers Criteria. Significant correlations emerged between PIM use and the number of autonomic and central nervous system, neurological and psychotherapeutic medications, medication duplications, and drug-drug interactions.

DISCUSSION

Our findings point to the need for multidisciplinary team programs of health care providers that include primary and specialist physicians, pharmacists, nurses, and social workers. Together, they can improve health outcomes, enhance the quality of life, and reduce morbidity and mortality due to inappropriate medication use.

Improving the care of people with long-term conditions in primary care: protocol for the ENHANCE pilot trial

BACKGROUND

Long-term conditions (LTCs) are important determinants of quality of life and healthcare expenditure worldwide. Whilst multimorbidity is increasingly the norm in primary care, clinical guidelines and the delivery of care remain focused on single diseases, resulting in poorer clinical outcomes. Osteoarthritis, and anxiety and/or depression frequently co-occur with other LTCs, yet are seldom prioritized by the patient or clinician, resulting in higher levels of disability, poorer prognosis, and increased healthcare costs.

OBJECTIVE

To examine the feasibility and acceptability of an integrated approach to LTC management, tackling the under-diagnosis and under-management of osteoarthritis-related pain and anxiety and/or depression in older adults with other LTCs in primary care.

DESIGN

The ENHANCE study is a pilot stepped-wedge cluster randomized controlled trial to test the feasibility and acceptability of a nurse-led ENAHNCE LTC review consultation for identifying, assessing, and managing joint pain, and anxiety and/or depression in patients attending LTC reviews. Specific objectives (process evaluation and research outcomes) will be achieved through a theoretically informed mixed-methods approach using participant self-reported questionnaires, a medical record review, an ENHANCE EMIS template, qualitative interviews, and audio recordings of the ENHANCE LTC review.

DISCUSSION

Success of the pilot trial will be measured against the level of the primary care team engagement, assessment of training delivery, and degree of patient recruitment and retention. Patient satisfaction and treatment fidelity will also be explored. ISRCTN registry number: 12154418.

Routine deprescribing of chronic medications to combat polypharmacy

The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

Association between use of warfarin with common sulfonylureas and serious hypoglycemic events: retrospective cohort analysis

STUDY QUESTION

Is warfarin use associated with an increased risk of serious hypoglycemic events among older people treated with the sulfonylureas glipizide and glimepiride?

METHODS

This was a retrospective cohort analysis of pharmacy and medical claims from a 20% random sample of Medicare fee for service beneficiaries aged 65 years or older. It included 465,918 beneficiaries with diabetes who filled a prescription for glipizide or glimepiride between 2006 and 2011 (4,355,418 person quarters); 71,895 (15.4%) patients also filled a prescription for warfarin (416,479 person quarters with warfarin use). The main outcome measure was emergency department visit or hospital admission with a primary diagnosis of hypoglycemia in person quarters with concurrent fills of warfarin and glipizide/glimepiride compared with the rates in quarters with glipizide/glimepiride fills only, Multivariable logistic regression was used to adjust for individual characteristics. Secondary outcomes included fall related fracture and altered consciousness/mental status.

SUMMARY ANSWER AND LIMITATIONS

In quarters with glipizide/glimepiride use, hospital admissions or emergency department visits for hypoglycemia were more common in person quarters with concurrent warfarin use compared with quarters without warfarin use (294/416,479 v 1903/3,938,939; adjusted odds ratio 1.22, 95% confidence interval 1.05 to 1.42). The risk of hypoglycemia associated with concurrent use was higher among people using warfarin for the first time, as well as in those aged 65-74 years. Concurrent use of warfarin and glipizide/glimepiride was also associated with hospital admission or emergency department visit for fall related fractures (3919/416,479 v 20,759/3,938,939; adjusted odds ratio 1.47, 1.41 to 1.54) and altered consciousness/mental status (2490/416,479 v 14,414/3,938,939; adjusted odds ratio 1.22, 1.16 to 1.29). Unmeasured factors could be correlated with both warfarin use and serious hypoglycemic events, leading to confounding. The findings may not generalize beyond the elderly Medicare population.

WHAT THIS STUDY ADDS

A substantial positive association was seen between use of warfarin with glipizide/glimepiride and hospital admission/emergency department visits for hypoglycemia and related diagnoses, particularly in patients starting warfarin. The findings suggest the possibility of a significant drug interaction between these medications.

FUNDING, COMPETING INTERESTS, DATA SHARING

JAR and DPG receive support from the National Institute on Aging, the Commonwealth Fund, and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. ABJ receives support from the NIH Office of the Director. No additional data are available.

Epidemiology of Chronic Obstructive Pulmonary Disease (COPD) in Aging Populations

Current epidemiologic practice evaluates COPD based on self-reported symptoms of chronic bronchitis, self-reported physician-diagnosed COPD, spirometry confirmed airflow obstruction, or emphysema diagnosed by volumetric computed chest tomography (CT). Because the highest risk population for having COPD includes a predominance of middle-aged or older persons, aging related changes must also be considered, including: 1) increased multimorbidity, polypharmacy, and severe deconditioning, as these identify mechanisms that underlie respiratory symptoms and can impart a complex differential diagnosis; 2) increased airflow limitation, as this impacts the interpretation of spirometry confirmed airflow obstruction; and 3) "senile" emphysema, as this impacts the specificity of CT-diagnosed emphysema. Accordingly, in an era of rapidly aging populations worldwide, the use of epidemiologic criteria that do not rigorously consider aging related changes will result in increased misidentification of COPD and may, in turn, misinform public health policy and patient care.

How to Use the American Geriatrics Society 2015 Beers Criteria-A Guide for Patients, Clinicians, Health Systems, and Payors

The Beers Criteria are a valuable tool for clinical care and quality improvement but may be misinterpreted and implemented in ways that cause unintended harms. This article describes the intended role of the 2015 American Geriatrics Society (AGS) Beers Criteria and provides guidance on how patients, clinicians, health systems, and payors should use them. A key theme underlying these recommendations is to use common sense and clinical judgment in applying the 2015 AGS Beers Criteria and to remain mindful of nuances in the criteria. The criteria serve as a "warning light" to identify medications that have an unfavorable balance of benefits and harms in many older adults, particularly when compared with pharmacological and nonpharmacological alternatives. However, there are situations in which use of medications included in the criteria can be appropriate. As such, the 2015 AGS Beers Criteria work best not only when they identify potentially inappropriate medications, but also when they educate clinicians and patients about the reasons those medications are included and the situations in which their use may be more or less problematic. The criteria are designed to support, rather than supplant, good clinical judgment.

Prescription medication burden in patients with newly diagnosed diabetes: a SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) study

OBJECTIVE

To understand the burden of medication use for patients with newly diagnosed diabetes both before and after diabetes diagnosis and to identify subpopulations of patients with newly diagnosed diabetes who face a relatively high drug burden.

DESIGN

Retrospective cohort study.

SETTING

11 integrated health systems in the United States.

PARTICIPANTS

196,654 insured adults 20 years of age or older newly diagnosed with type 1 or type 2 diabetes from January 2005 through December 2009.

MAIN OUTCOME MEASURES

Number of unique therapeutic classes of drugs dispensed in the 12 months before and 12 months after diagnosis of diabetes in five categories: overall, antihypertensive agents, antihyperlipidemic agents, mental health agents, and antihyperglycemic agents (in the postdiagnosis period only).

RESULTS

The mean number of drug classes used by newly diagnosed patients with diabetes is high before diagnosis (5.0) and increases significantly afterward (6.6). Of this increase, 81% is due to antihyperglycemic initiation and increased use of medications to control hypertension and lipid levels. Multivariate analyses showed that overall drug burden after diabetes diagnosis was higher in women, older, white, and obese patients, as well as among those with higher glycosylated hemoglobin concentrations and comorbidity levels (significant for all comparisons). The overall number of drug classes used by newly diagnosed patients with diabetes after diagnosis decreased slightly but significantly between 2005 and 2009.

CONCLUSION

Patients newly diagnosed with diabetes face a substantially increased burden of medications used to control diabetes and other comorbidities. This study shows an increased focus on cardiovascular disease risk factor control after diagnosis of diabetes. However, total drug burden may be slightly decreasing over time.

Use of Renally Inappropriate Medications in Older Veterans: A National Study

OBJECTIVES

To determine how many ambulatory older adults with chronic kidney disease receive medications that are contraindicated or dosed excessively given their level of renal function.

DESIGN

Cross-sectional retrospective study.

SETTING

U.S. Department of Veterans Affairs (VA) clinics.

PARTICIPANTS

Individuals aged 65 and older with a creatinine clearance (CrCl) of 15 to 49 mL/min (N = 83,850; mean age 80; 96% male).

MEASUREMENTS

Forty medications that require dose adjustment or are contraindicated in people with impaired renal function were examined. Medication use and CrCl (calculated using the Cockroft-Gault equation) were assessed using VA pharmacy, laboratory, and other data sources as of October 2007.

RESULTS

Thirteen percent of older veterans with a CrCl of 30 to 49 mL/min and 32% of those with a CrCl of 15 to 29 mL/min received one or more drugs that were contraindicated or prescribed at an excessive dose given the individual's level of renal function. The strongest risk factor for renally inappropriate prescribing was number of medications used; the risk of receiving renally inappropriate medications was 5.5 times as high (95% confidence interval = 5.1-5.9) in older adults taking 10 or more medications as in those taking one to three medications. Ranitidine, allopurinol, and metformin together accounted for 76% of renally misprescribed medications in individuals with a CrCl of 30 to 49 mL/min. Glyburide, ranitidine, gemfibrozil, carvedilol, and allopurinol accounted for 47% of renally misprescribed drugs for individuals with a CrCl of 15 to 29 mL/min.

CONCLUSION

Inappropriate prescribing of renally cleared medications is common in ambulatory older veterans, with only a few medications accounting for most of these prescribing problems.

Measuring prevalence, reliability and variation in high-risk prescribing in general practice using multilevel modelling of observational data in a population database

Background

High-risk primary care prescribing is common and is known to vary considerably between practices, but the extent to which high-risk prescribing varies among individual general practitioners (GPs) is not known.

Objectives

To create prescribing safety indicators usable in existing electronic clinical data and to examine (1) variation in high-risk prescribing between patients, GPs and practices including reliability of measurement and (2) changes over time in high-risk prescribing prevalence and variation between practices.

Design

Descriptive analysis and multilevel logistic regression modelling of routine data.

Setting

UK general practice using routine electronic medical record data.

Participants

(1) For analysis of variation and reliability, 398 GPs and 26,539 patients in 38 Scottish practices. (2) For analysis of change in high-risk prescribing, ≈ 300,000 patients particularly vulnerable to adverse drug effects registered with 190 Scottish practices.

Main outcome measures

For the analysis of variation between practices and between GPs, five indicators of high-risk non-steroidal anti-inflammatory drug (NSAID) prescribing. For the analysis of change in high-risk prescribing, 19 previously validated indicators.

Results

Measurement of high-risk prescribing at GP level was feasible only for newly initiated drugs and for drugs similar to NSAIDs which are usually initiated by GPs. There was moderate variation between practices in total high-risk NSAID prescribing [intraclass correlation coefficient (ICC) 0.034], but this indicator was highly reliable (> 0.8 for all practices) at distinguishing between practices because of the large number of patients being measured. There was moderate variation in initiation of high-risk NSAID prescribing between practices (ICC 0.055) and larger variation between GPs (ICC 0.166), but measurement did not reliably distinguish between practices and had reliability > 0.7 for only half of the GPs in the study. Between quarter (Q)2 2004 and Q1 2009, the percentage of patients exposed to high-risk prescribing measured by 17 indicators that could be examined over the whole period fell from 8.5% to 5.2%, which was largely driven by reductions in high-risk NSAID and antiplatelet use. Variation between practices increased for five indicators and decreased for five, with no relationship between change in the rate of high-risk prescribing and change in variation between practices.

Conclusions

High-risk prescribing is common and varies moderately between practices. High-risk prescribing at GP level cannot be easily measured routinely because of the difficulties in accurately identifying which GP actually prescribed the drug and because drug initiation is often a shared responsibility with specialists. For NSAID initiation, there was approximately three times greater variation between GPs than between practices. Most GPs with above average high-risk prescribing worked in practices which were not themselves above average. The observed reductions in high-risk prescribing between 2004 and 2009 were largely driven by falls in NSAID and antiplatelet prescribing, and there was no relationship between change in rate and change in variation between practices. These results are consistent with improvement interventions in all practices being more appropriate than interventions targeted on practices or GPs with higher than average high-risk prescribing. There is a need for research to understand why high-risk prescribing varies and to design and evaluate interventions to reduce it.

Funding

Funding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.

Characteristics of medication schedules used by elderly ambulatory patients

PURPOSE

We investigated the prevalence and quality of medication schedules of elderly ambulatory patients and assessed factors associated with the availability of a medication schedule. In particular, we evaluated whether sending out a blank medication schedule template would increase the chances to use such a document.

METHODS

Data originate from the ESTHER study, a cohort study conducted in Saarland, Germany, in which trained study physicians performed home visits. They scanned all medication schedules, recorded the participants' medication, and performed thorough geriatric assessments. As part of the intervention, a blank medication schedule template along with a brochure was mailed to half of the participants (intervention group) 4 weeks prior to the home visits.

RESULTS

In total, 553 of 2470 participants (22.4 %) had a medication schedule. Almost two thirds of the schedules were issued by health care professionals (n = 353, 63.8 %). These schedules offered a higher quality, although important information such as over-the-counter (OTC) medication was regularly missing. Self-reported adherence was higher in participants who used self-issued medication schedules; however, self-reported medication adherence in patients with any medication schedule was poorer compared to those patients not using a schedule. Factors associated with the availability of a medication schedule were male sex, a higher number of medicines to take, and a more complex drug regimen. The intervention did not increase the number of patients having a medication schedule.

CONCLUSION

Only a minority of elderly ambulatory patients had a medication schedule at home. Sending out a brochure along with a blank medication schedule template did not increase the prevalence of medication schedules.

The EU(7)-PIM list: a list of potentially inappropriate medications for older people consented by experts from seven European countries

Purpose

The aim of the study was to develop a European list of potentially inappropriate medications (PIM) for older people, which can be used for the analysis and comparison of prescribing patterns across European countries and for clinical practice.

Methods

A preliminary PIM list was developed, based on the German PRISCUS list of potentially inappropriate medications and other PIM lists from the USA, Canada and France. Thirty experts on geriatric prescribing from Estonia, Finland, France, the Netherlands, Spain and Sweden participated; eight experts performed a structured expansion of the list, suggesting further medications; twenty-seven experts participated in a two-round Delphi survey assessing the appropriateness of drugs and suggesting dose adjustments and therapeutic alternatives. Finally, twelve experts completed a brief final survey to decide upon issues requiring further consensus.

Results

Experts reached a consensus that 282 chemical substances or drug classes from 34 therapeutic groups are PIM for older people; some PIM are restricted to a certain dose or duration of use. The PIM list contains suggestions for dose adjustments and therapeutic alternatives.

Conclusions

The European Union (EU)(7)-PIM list is a screening tool, developed with participation of experts from seven European countries, that allows identification and comparison of PIM prescribing patterns for older people across European countries. It can also be used as a guide in clinical practice, although it does not substitute the decision-making process of individualised prescribing for older people. Further research is needed to investigate the feasibility and applicability and, finally, the clinical benefits of the newly developed list.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-015-1860-9) contains supplementary material, which is available to authorized users.

Does the Elderly's Number of Prescribed Medications across Months Matter? National Cohort versus Single-Center Cohort

OBJECTIVES

To investigate the monthly number of prescribed medication (NPM) patterns among different elderly populations and the factors associated with monthly NPM changes.

METHODS

This retrospective cohort study was conducted using the databases obtained from National Health Insurance Research Databases and a 2000-bed academic medical center in Taiwan (i.e., single-center cohort). We compared the monthly NPMs, demographic characteristics, disease states, and health care contacts among the National Health Insurance elderly cohorts in 2006 and 2007, and for those elderly in the national and single-center cohorts who had outpatient visits from November to October in 2006 to 2007 and 2007 to 2008, respectively. Generalized estimating equation analyses of repeated measures were performed for monthly NPMs.

RESULTS

The average monthly NPMs among the National Health Insurance elderly cohort was 2.33 in 2006 and 4.39 in 2007, respectively. After controlling for other factors, the increment in the proportion of monthly NPMs among the older elderly patients, in certain months and for those patients with hypertension and dyslipidemia, was statistically significant among the single-center cohort but was not observed in the national elderly cohort. The proportional changes decreased significantly among patients who made visits to emergency rooms and who were hospitalized during a 1-year period.

CONCLUSIONS

There was an incremental trend of monthly NPMs among the national cohort from 2006 to 2007. Although acute exacerbations and hospitalization might be the protecting factors of increasing monthly NPMs, more attention should be paid toward high-utilization patients with specific diseases during certain months for different elderly cohorts.

Recruiting older people at nutritional risk for clinical trials: what have we learned?

Background

The difficulty of recruiting older people to clinical trials is well described, but there is limited information about effective ways to screen and recruit older people into trials, and the reasons for their reluctance to enrol. This paper examines recruitment efforts for a community-based health intervention study that targeted older adults.

Methods

One year randomized control trial. Undernourished men and women, aged ≥ 65 years and living independently in the community were recruited in three Australian states. Participants were allocated to either oral testosterone undecanoate and high calorie oral nutritional supplement or placebo medication and low calorie oral nutritional supplementation. Hospital admissions, functional status, nutritional health, muscle strength, and other variables were assessed.

Results

4023 potential participants were identified and 767 were screened by a variety of methods: hospital note screening, referrals from geriatric health services, advertising and media segments/appearances. 53 participants (7% of total screened) were recruited. The majority of potentially eligible participants declined participation in the trial after reading the information sheet. Media was the more successful method of recruiting, whereas contacting people identified by screening a large number of hospital records was not successful in recruiting any participants.

Conclusion

Recruitment of frail and older participants is difficult and multiple strategies are required to facilitate participation.

Trial registration

Australian Clinical Trial Registry: ACTRN 12610000356066 date registered 4/5/2010

The rising tide of polypharmacy and drug-drug interactions: population database analysis 1995-2010

BACKGROUND

The escalating use of prescribed drugs has increasingly raised concerns about polypharmacy. This study aims to examine changes in rates of polypharmacy and potentially serious drug-drug interactions in a stable geographical population between 1995 and 2010.

METHODS

This is a repeated cross-sectional analysis of community-dispensed prescribing data for all 310,000 adults resident in the Tayside region of Scotland in 1995 and 2010. The number of drug classes dispensed and the number of potentially serious drug-drug interactions (DDIs) in the previous 84 days were calculated, and age-sex standardised rates in 1995 and 2010 compared. Patient characteristics associated with receipt of ≥ 10 drugs and with the presence of one or more DDIs were examined using multilevel logistic regression to account for clustering of patients within primary care practices.

RESULTS

Between 1995 and 2010, the proportion of adults dispensed ≥ 5 drugs doubled to 20.8%, and the proportion dispensed ≥ 10 tripled to 5.8%. Receipt of ≥ 10 drugs was strongly associated with increasing age (20-29 years, 0.3%; ≥ 80 years, 24.0%; adjusted OR, 118.3; 95% CI, 99.5-140.7) but was also independently more common in people living in more deprived areas (adjusted OR most vs. least deprived quintile, 2.36; 95% CI, 2.22-2.51), and in people resident in a care home (adjusted OR, 2.88; 95% CI, 2.65-3.13). The proportion with potentially serious drug-drug interactions more than doubled to 13% of adults in 2010, and the number of drugs dispensed was the characteristic most strongly associated with this (10.9% if dispensed 2-4 drugs vs. 80.8% if dispensed ≥ 15 drugs; adjusted OR, 26.8; 95% CI 24.5-29.3).

CONCLUSIONS

Drug regimens are increasingly complex and potentially harmful, and people with polypharmacy need regular review and prescribing optimisation. Research is needed to better understand the impact of multiple interacting drugs as used in real-world practice and to evaluate the effect of medicine optimisation interventions on quality of life and mortality.

What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process

Polypharmacy and inappropriate medication use among older adults contribute to adverse drug reactions, falls, cognitive impairment, noncompliance, hospitalization and mortality. While deprescribing - tapering, reducing or stopping a medication - is feasible and relatively safe, clinicians find it difficult to carry out. Deprescribing guidelines would facilitate this process. The aim of this paper is to identify and prioritize medication classes where evidence-based deprescribing guidelines would be of benefit to clinicians. A modified Delphi approach included a literature review to identify potentially inappropriate medications for the elderly, an expert panel to develop survey content and three survey rounds to seek consensus on priorities. Panel participants included three pharmacists, two family physicians and one social scientist. Sixty-five Canadian geriatrics experts (36 pharmacists, 19 physicians and 10 nurse practitioners) participated in the survey. Twenty-nine drugs/drug classes were included in the first survey with 14 reaching the required (≥ 70%) level of consensus, and 2 new drug classes added from qualitative comments. Fifty-three participants completed round two, and 47 participants completed round three. The final five priorities were benzodiazepines, atypical antipsychotics, statins, tricyclic antidepressants, and proton pump inhibitors; nine other drug classes were also identified as being in need of evidence-based deprescribing guidelines. The Delphi consensus process identified five priority drug classes for which expert clinicians felt guidance is needed for deprescribing. The classes of drugs that emerged strongly from the rankings dealt with mental health, cardiovascular, gastroenterological, and neurological conditions. The results suggest that deprescribing and overtreatment occurs through the full spectrum of primary care, and that evidence-based deprescribing guidelines are a priority in the care of the elderly.

Development of a medication monitoring attitude measure using a mixed methods item development process

Objectives

Medication monitoring is important for safe and effective medication use; however, no attitudinal measure exists for a health care provider's medication monitoring attitude. The objectives of this study were to (1) create a measure of a community pharmacist medication monitoring attitude; (2) test concurrent validity using a validated measure of medication monitoring behaviours; and (3) report community pharmacist attitudes towards medication monitoring.

Methods

A mixed methods item development process was employed to generate Likert-type items from qualitative interviews. Following item review and piloting, a four-contact survey, including 20 6-point Likert-type items and the four-item Behavioral Pharmaceutical Care Scale monitoring domain, was mailed to 599 randomly sampled US community pharmacists from the state of Iowa. Exploratory factor analysis, Pearson's correlation and descriptive statistics were used to address study objectives.

Key findings

There were 254 (42.4%) returned and usable surveys. Factor analysis yielded two domains, a seven-item, positively worded internal (α = 0.819) and an eight-item, negatively worded external domain (α = 0.811). Both domains were positively correlated with the monitoring domain of the Behavioral Pharmaceutical Care Scale supporting convergent validity. Overall, respondents had a positive internal monitoring attitude with a mean of 4.62 (0.68), although many practiced in an environment less conducive to monitoring, as evident by a mean of 3.13 (0.88). Pharmacists were more oriented towards medication side effect and effectiveness monitoring than nonadherence monitoring.

Conclusions

The mixed methods item development process created a reliable and valid measure of a pharmacist's medication monitoring attitude. While pharmacists had an overall positive medication monitoring attitude, improvements are needed to bolster adherence monitoring and make pharmacy environments more conducive to monitoring.

Appropriate prescribing and important drug interactions in older adults

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

Design and delivery of a tailored intervention to implement recommendations for multimorbid patients receiving polypharmacy into primary care practices

Introduction. Managing polypharmacy is particularly demanding for general practitioners as coordinators of care. Recently, a German guideline for polypharmacy in primary care has been published. This paper describes the content and delivery of a tailored intervention, which aims at improving the implementation of guideline recommendations for polypharmacy into practice, considering individual barriers. Materials and Methods. Firstly, barriers for implementation and the corresponding strategies to address them have been identified. On this basis, an intervention consisting of a workshop for health care professionals and educational materials for patients has been developed. The workshop focused on knowledge, awareness, and skills. The educational materials included a tablet computer. Practice teams will elaborate individual concepts of how to implement the recommendations into their practice. The workshop has been evaluated by the participants by means of a questionnaire. Results. During the workshop 41 possible sources of medication errors and 41 strategies to improve medication management have been identified. Participants evaluated the workshop overall positively, certifying its relevancy to practice. Discussion. The concept of the workshop seemed appropriate to impart knowledge about medication management to the participants. It will have to be evaluated, if the intervention finally resulted in an improved implementation of the guideline recommendations.

Factors associated with medication warning acceptance for hospitalized adults

BACKGROUND

Computerized provider order entry (CPOE) systems can warn clinicians ordering medications about potential allergic or adverse reactions, duplicate therapy, and interactions with other medications. Clinicians frequently override these warnings. Understanding the factors associated with warning acceptance should guide revisions to these systems.

OBJECTIVE

Increase understanding of the factors associated with medication warning acceptance.

DESIGN

Retrospective study of all single-medication warnings generated in a CPOE system from October 2009 through April 2010.

SETTING

Academic medical center.

PATIENTS

All adult non-intensive care unit patients hospitalized during the study period.

RESULTS

A total of 40,391 medication orders generated a single-medication warning during the 7-month study period. Of these warnings, 47% were duplicate warnings, 47% interaction warnings, 6% allergy warnings, 0.1% adverse reaction warnings, and 9.8% were repeated for the same patient, medication, and provider. Only 4% of warnings were accepted. In multivariate analysis, warning acceptance was positively associated with male patient gender, admission to a service other than internal medicine, caregiver status other than resident, parenteral medications, lower numbers of warnings, and allergy or adverse reaction warning types. Older patient age, longer length of stay, inclusion on the Institute for Safe Medication Practice's List of High Alert Medications, and interaction warning type were all negatively associated with warning acceptance.

CONCLUSIONS

Medication warnings are rarely accepted. Acceptance is more likely when the warning is infrequently encountered, and least likely when it is potentially most important. Warning systems should be redesigned to increase their effectiveness for the sickest patients, the least experienced physicians, and the medications with the greatest potential to cause harm.

The diagnosis and management of mild cognitive impairment: a clinical review

IMPORTANCE

Cognitive decline is a common and feared aspect of aging. Mild cognitive impairment (MCI) is defined as the symptomatic predementia stage on the continuum of cognitive decline, characterized by objective impairment in cognition that is not severe enough to require help with usual activities of daily living.

OBJECTIVE

To present evidence on the diagnosis, treatment, and prognosis of MCI and to provide physicians with an evidence-based framework for caring for older patients with MCI and their caregivers.

EVIDENCE ACQUISITION

We searched PubMed for English-language articles in peer-reviewed journals and the Cochrane Library database from inception through July 2014. Relevant references from retrieved articles were also evaluated.

FINDINGS

The prevalence of MCI in adults aged 65 years and older is 10% to 20%; risk increases with age and men appear to be at higher risk than women. In older patients with MCI, clinicians should consider depression, polypharmacy, and uncontrolled cardiovascular risk factors, all of which may increase risk for cognitive impairment and other negative outcomes. Currently, no medications have proven effective for MCI; treatments and interventions should be aimed at reducing cardiovascular risk factors and prevention of stroke. Aerobic exercise, mental activity, and social engagement may help decrease risk of further cognitive decline. Although patients with MCI are at greater risk for developing dementia compared with the general population, there is currently substantial variation in risk estimates (from <5% to 20% annual conversion rates), depending on the population studied. Current research targets improving early detection and treatment of MCI, particularly in patients at high risk for progression to dementia.

CONCLUSIONS AND RELEVANCE

Cognitive decline and MCI have important implications for patients and their families and will require that primary care clinicians be skilled in identifying and managing this common disorder as the number of older adults increases in coming decades. Current evidence supports aerobic exercise, mental activity, and cardiovascular risk factor control in patients with MCI.

Satisfaction With Medication Therapy Management Services at a University Ambulatory Care Clinic

A survey was issued to patients enrolled in the Medication Therapy Management Clinic (MTMC) at University of Illinois Hospital and Health Sciences (June 2011-January 2012) in order to assess satisfaction with pharmacy services provided by pharmacists. A 23-item survey was offered to 65 patients in the MTMC program before or after clinic visits. Since there is a paucity of data indicating the level of satisfaction with MTM services provided by pharmacists, this survey may contribute to the process of building a greater collaboration between the pharmacist and patient. Sixty-two of 65 patients completed the survey; satisfaction with MTMC pharmacists was demonstrated to be significantly positively correlated with overall satisfaction with the MTMC. Patient satisfaction is not significantly different according to age, gender, ethnicity, or number of disease states. Satisfaction with the pillbox service is not significantly different between younger and older patients. It was also noted that patients taking a greater number of medications had higher levels of satisfaction. Most patients indicated that they were satisfied with the MTMC pharmacists and services; further study linking patient satisfaction with MTM services to improved patient outcomes may allow our MTMC to serve as a model for other pharmacist-managed MTMCs serving similar patient populations.

Utilization of potentially inappropriate medications in elderly patients in a tertiary care teaching hospital in India

Aim:

To evaluate the use of potentially inappropriate medicines in elderly inpatients in a tertiary care teaching hospital.

Materials and Methods:

Retrospective analysis was performed for cases of elderly patients admitted between January 2010 and December 2010. Data on age, gender, diagnosis, duration of hospital stay, treatment, and outcome were collected. Prescriptions were assessed for the use of potentially inappropriate medications in geriatric patients by using American Geriatric Society Beer's criteria (2012) and PRISCUS list (2010).

Results:

A total of 676 geriatric patients (52.12% females) were admitted in the medicine ward. The average age of geriatric patients was 72.69 years. According to Beer's criteria, at least one inappropriate medicine was prescribed in 590 (87.3%) patients. Metoclopramide (54.3%), alprazolam (9%), diazepam (8%), digoxin > 0.125 mg/day (5%), and diclofenac (3.7%) were the commonly used inappropriate medications. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in heart and renal failure patients was the commonly identified drug–disease interaction. According to PRISCUS list, at least one inappropriate medication was prescribed in 210 (31.06%) patients.

Conclusion:

Use of inappropriate medicines is highly prevalent in elderly patients.

Prescribing quality in older veterans: a multifocal approach

BACKGROUND AND OBJECTIVE

Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults.

DESIGN AND PARTICIPANTS

Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans Affairs (VA) pharmacies in 2007.

MAIN MEASURES

Using VA pharmacy data linked with encounter, laboratory and other data, we assessed five types of prescribing problems.

KEY RESULTS

Among 462,405 patients age 65 and older, mean age was 75 years, 98 % were male, and patients were prescribed a median of five medications. Half of patients (50 %) had one or more prescribing problems, including 12 % taking one or more medications at an inappropriately high dose, 30 % with drug-drug interactions, 3 % with drug-disease interactions, and 26 % taking one or more Beers criteria drugs. In addition, 16 % were taking a high-risk drug (warfarin, insulin, and/or digoxin). On multivariable analysis, age was not strongly associated with four of the five types of prescribing issues assessed (relative risk < 1.3 across age groups), and comorbid burden conferred substantially increased risk only for drug-disease interactions and use of high-risk drugs. In contrast, the number of drugs used was consistently the strongest predictor of prescribing problems. Patients in the highest quartile of medication use had 6.6-fold to12.5-fold greater risk of each type of prescribing problem compared to patients in the lowest quartile (P < 0.001 for each).

CONCLUSIONS

The number of medications used is by far the strongest risk factor for each of five types of prescribing problems. Efforts to improve prescribing should especially target patients taking multiple medications.

Rationalizing prescribing for older patients with multimorbidity: considering time to benefit

Given the growing number of older adults with multimorbidity who are prescribed multiple medications, clinicians need to prioritize which medications are most likely to benefit and least likely to harm an individual patient. The concept of time to benefit (TTB) is increasingly discussed in addition to other measures of drug effectiveness in order to understand and contextualize the benefits and harms of a therapy to an individual patient. However, how to glean this information from available evidence is not well established. The lack of such information for clinicians highlights a critical need in the design and reporting of clinical trials to provide information most relevant to decision making for older adults with multimorbidity. We define TTB as the time until a statistically significant benefit is observed in trials of people taking a therapy compared to a control group not taking the therapy. Similarly, time to harm (TTH) is the time until a statistically significant adverse effect is seen in a trial for the treatment group compared to the control group. To determine both TTB and TTH, it is critical that we also clearly define the benefit or harm under consideration. Well-defined benefits or harms are clinically meaningful, measurable outcomes that are desired (or shunned) by patients. In this conceptual review, we illustrate concepts of TTB in randomized controlled trials (RCTs) of statins for the primary prevention of cardiovascular disease. Using published results, we estimate probable TTB for statins with the future goal of using such information to improve prescribing decisions for individual patients. Knowing the relative TTBs and TTHs associated with a patient's medications could be immensely useful to a clinician in decision making for their older patients with multimorbidity. We describe the challenges in defining and determining TTB and TTH, and discuss possible ways of analyzing and reporting trial results that would add more information about this aspect of drug effectiveness to the clinician's evidence base.

Views of general practitioners on the use of STOPP&START in primary care: a qualitative study

BACKGROUND AND OBJECTIVE

STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria aim at detecting potentially inappropriate prescribing in older people. The objective was to explore general practitioners' (GPs) perceptions regarding the use of the STOPP&START tool in their practice.

DESIGN

We conducted three focus groups which were conveniently sampled. Vignettes with clinical cases were provided for discussion as well as a full version of the STOPP&START tool. Knowledge, strengths and weaknesses of the tool and its implementation were discussed. Two researchers independently performed content analysis, classifying quotes and creating new categories for emerging themes.

RESULTS

Discussions highlighted incentives (e.g. systematic procedure for medication review) and barriers (e.g. time-consuming application) influencing the use of STOPP&START in primary care. Usefulness, comprehensiveness, and relevance of the tool were also questioned. Another important category emerging from the content analysis was the projected use of the tool. The GPs imagined key elements for the implementation in daily practice: computerized clinical decision support system, education, and multidisciplinary collaborations, especially at care transitions and in nursing homes.

CONCLUSION

Despite variables views on the usefulness, comprehensiveness, and relevance of STOPP&START, GPs suggest the implementation of this tool in primary care within computerized clinical decision support systems, through education, and used as part of multidisciplinary collaborations.

Potential drug interactions and chemotoxicity in older patients with cancer receiving chemotherapy

PURPOSE

Increased risk of drug interactions due to polypharmacy and aging-related changes in physiology among older patients with cancer is further augmented during chemotherapy. No previous studies examined potential drug interactions (PDIs) from polypharmacy and their association with chemotherapy tolerance in older patients with cancer.

METHODS

This study is a retrospective medical chart review of 244 patients aged 70+ years who received chemotherapy for solid or hematological malignancies. PDI among all drugs, supplements, and herbals taken with the first chemotherapy cycle were screened for using the Drug Interaction Facts software, which classifies PDIs into five levels of clinical significance with level 1 being the highest. Descriptive and correlative statistics were used to describe rates of PDI. The association between PDI and severe chemotoxicity was tested with logistic regressions adjusted for baseline covariates.

RESULTS

A total of 769 PDIs were identified in 75.4% patients. Of the 82 level 1 PDIs identified among these, 32 PDIs involved chemotherapeutics. A large proportion of the identified PDIs were of minor clinical significance. The risk of severe non-hematological toxicity almost doubled with each level 1 PDI (OR=1.94, 95% CI: 1.22-3.09), and tripled with each level 1 PDI involving chemotherapeutics (OR=3.08, 95% CI: 1.33-7.12). No association between PDI and hematological toxicity was found.

CONCLUSIONS

In this convenience sample of older patients with cancer receiving chemotherapy we found notable rates of PDI and a substantial adjusted impact of PDI on risk of non-hematological toxicity. These findings warrant further research to optimize chemotherapy outcomes.

Unmet needs and research challenges for late-life mood disorders

Mood disorders are common and often under-recognised in older people whereby, together with the general ageing of the population, they are becoming a significant and growing public health problem worldwide. However, the need to address the problem of late life mood disorders in a real-world setting is met with a surprising lack of strong evidence in this field. Randomised clinical trials which focus on elderly mood disorders are not very common and the majority of them focus on pharmacological treatment of major depression. The aim of this study was to review first the main unmet needs and research challenges in late-life mood disorders as a basis to then review the state of the art evidence resulting from randomised clinical trials and the main critical aspects of their implementation. Comorbidity as well as polypharmacy, cognitive decline, unpredictable placebo response, and uncertainty on optimal duration of trials are some of the challenges the investigator has to address. Moreover, some methodological limitations of randomised clinical trials reduce the applicability of the results of such studies to common clinical practices and have encouraged some authors to investigate the existence of possible alternative research designs such as pragmatic randomised clinical trials.

Confirming delivery: understanding the role of the hospitalized patient in medication administration safety

The purpose of our study was to gain an understanding of current patient involvement in medication administration safety from the perspectives of both patients and nursing staff members. Administering medication is taken for granted and therefore suited to the development of theory to enhance its understanding. We conducted a constructivist, grounded theory study involving 24 patients and 26 nursing staff members and found that patients had the role of confirming delivery in the administration of medication. Confirming delivery was characterized by three interdependent subprocesses: engaging in the medication administration process, being "half out of it" (patient mental status), and perceiving time. We believe that ours is one of the first qualitative studies on the role of hospitalized patients in administering medication. Medication administration and nursing care systems, as well as patient mental status, impose limitations on patient involvement in safe medication administration.

[Comorbidity in medical guidelines: comparison of the current state, epidemiologic models and expert opinion]

INTRODUCTION

Medical guidelines focusing on monomorbidities can be associated with adverse events in multimorbid patients. This study investigates how comorbidities are actually particularised in a set of German guidelines. In addition, it evaluates whether two epidemiologic approaches (disease combinations or clusters of comorbidities) can be used to systematically integrate multimorbidity in guideline development.

METHODS

Based on a matrix of 30 comorbidities, mentioning of comorbidities in 8 current German guidelines (diabetes mellitus, hypertension, heart failure, coronary heart disease, chronic obstructive lung disease/asthma, coxarthrosis, low back pain, osteoporosis) was investigated. These so called index diseases were selected on the basis of the hypothetical case of a multimorbid patient published by Cynthia Boyd and colleagues in 2005. Mentioning of comorbidities in the guidelines was compared to the epidemiologic approaches of disease combinations and clusters of comorbidities. In addition, using the comorbidity matrix, 36 physicians involved in everyday care of multimorbid patients assessed whether an explicit recommendation for the listed comorbidities would be helpful.

RESULTS

Mentioning of comorbidities was very heterogeneous across the guidelines investigated, ranging from 0 to more than 10. The proportion of the comorbidities that were considered relevant by the survey participants ranged from 0 % to 62 % with a focus on cardiovascular and metabolic diseases. When using disease combinations, only 0 to 3 of the "relevant" comorbidities were identified. Using the cluster model may be helpful in identifying whether a particular comorbidity is thematically close to the index disease or whether it is associated with an interacting thematic area.

CONCLUSIONS

Methodological support is needed for addressing comorbidities in guidelines in a more consistent way. The currently existing epidemiologic approaches should not be used in their current form without being further developed and re-evaluated. Expert opinion of physicians involved in the care of multimorbid patients should be systematically included in methodological refinement studies.

An interdisciplinary memory clinic: a novel practice setting for pharmacists in primary care

Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care-based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care-based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists' activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.