1
|
Clarkson L, Hart L, Lam AK, Khoo TK. Reducing inappropriate polypharmacy for older patients at specialist outpatient clinics: a systematic review. Curr Med Res Opin 2023; 39:545-554. [PMID: 36847597 DOI: 10.1080/03007995.2023.2185390] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Polypharmacy is associated with negative clinical consequences. The efficacy of deprescribing interventions within medical specialist outpatient clinics remains unclear. Here, we reviewed the research on the effectiveness of deprescribing interventions implemented within specialist outpatient clinics for patients ≥ 60 years. METHODS Systematic searches of key databases were undertaken for studies published between January 1990 and October 2021. The diverse nature of the study designs made it unsuitable for pooling for meta-analysis, thus, a narrative review was conducted and presented in both text and tabular formats. The primary outcome for review was that intervention resulted in a change in medication load (either total number of medications or appropriateness of medication). Secondary outcomes were the maintenance of deprescription and clinical benefits. Methodological quality of the publications was assessed using the revised Cochrane risk-of-bias tools. RESULTS Nineteen studies with a total of 10,914 participants were included for review. These included geriatric outpatient clinics, oncology/hematology clinics, hemodialysis clinics, and designated polypharmacy/multimorbidity clinics. Four randomized controlled trials (RCTs) reported statistically significant reductions in medication load with intervention; however, all studies had a high risk of bias. The inclusion of a pharmacist in outpatient clinics aims to increase deprescribing, however, the current evidence is mainly restricted to prospective and pilot studies. The data on secondary outcomes were very limited and highly variable. CONCLUSIONS Specialist outpatient clinics may provide valuable settings for implementing deprescribing interventions. The addition of a multidisciplinary team including a pharmacist and the use of validated medication assessment tools appear to be enablers. Further research is warranted.
Collapse
Affiliation(s)
- Louise Clarkson
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
| | - Laura Hart
- Lancet Neurology, London, London, United Kingdom
| | - Alfred K Lam
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
| | - Tien K Khoo
- School of Medicine & Dentistry, Menzies Health Institute Queensland, Griffith University, Queensland, Australia
- Northern New South Wales Local Health District, NSW Health, Australia
- Graduate School of Medicine, University of Wollongong, New South Wales, Australia
| |
Collapse
|
2
|
Kok W, Haverkort E, Algra Y, Mollema J, Hollaar V, Naumann E, de van der Schueren M, Jerković-Ćosić K. The association between polypharmacy and malnutrition(risk) in older people: A Systematic Review. Clin Nutr ESPEN 2022; 49:163-171. [DOI: 10.1016/j.clnesp.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/15/2022] [Accepted: 03/05/2022] [Indexed: 11/30/2022]
|
3
|
Cross AJ, George J, Woodward MC, Le VJ, Elliott RA. Deprescribing potentially inappropriate medications in memory clinic patients (DePIMM): A feasibility study. Res Social Adm Pharm 2020; 16:1392-1397. [DOI: 10.1016/j.sapharm.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 12/22/2022]
|
4
|
Parfitt G, Post D, Kalisch Ellett L, Lim R, Penington A, Corlis M, Roughead E. A cross-sectional assessment of the relationship between sedative medication and anticholinergic medication use and the movement behaviour of older adults living in residential aged care. PeerJ 2020; 8:e9605. [PMID: 32775054 PMCID: PMC7384436 DOI: 10.7717/peerj.9605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/04/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care. Materials and Methods Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants’ medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman’s Rho correlations were conducted, as the data were not normally distributed. Results Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA (p < .02). Conclusion The findings of this study showed a negative association between sedative load, due to medicines, and an individual’s movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances.
Collapse
Affiliation(s)
- Gaynor Parfitt
- Allied Health and Human Performance, Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
| | - Dannielle Post
- Allied Health and Human Performance, Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | | | - Megan Corlis
- Helping Hand Organisation, Adelaide, South Australia, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| |
Collapse
|
5
|
Miscio G, Paroni G, Bisceglia P, Gravina C, Urbano M, Lozupone M, Piccininni C, Prisciandaro M, Ciavarella G, Daniele A, Bellomo A, Panza F, Di Mauro L, Greco A, Seripa D. Pharmacogenetics in the clinical analysis laboratory: clinical practice, research, and drug development pipeline. Expert Opin Drug Metab Toxicol 2019; 15:751-765. [PMID: 31512953 DOI: 10.1080/17425255.2019.1658742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Over the last decade, the spread of next-generation sequencing technology along with the rising cost in health management in national health systems has led to widespread use/abuse of pharmacogenetic tests (PGx) in the practice of many clinical disciplines. However, given their clinical significance, it is important to standardize these tests for having an interaction with the clinical analysis laboratory (CAL), in which a PGx service can meet these requirements. Areas covered: A diagnostic test must meet the criteria of reproducibility and validity for its utility in the clinical routine. This present review mainly describes the utility of introducing PGx tests in the CAL routine to produce correct results useful for setting up personalized drug treatments. Expert opinion: With a PGx service, CALs can provide the right tool to help clinicians to make better choices about different categories of drugs and their dosage and to manage the economic impact both in hospital-based settings and in National Health Services, throughout electronic health records. Advances in PGx also allow a new approach for pharmaceutical companies in order to improve drug development and clinical trials. As a result, CALs can achieve a powerful source of epidemiological, clinical, and research findings from PGx tests.
Collapse
Affiliation(s)
- Giuseppe Miscio
- Clinical Laboratory Analysis and Transfusional Medicine, Laboratory and Transfusional Diagnostics, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Giulia Paroni
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Paola Bisceglia
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Carolina Gravina
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Maria Urbano
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Madia Lozupone
- Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience, and Sense Organs, University of Bari Aldo Moro , Bari , Italy
| | - Carla Piccininni
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia , Foggia , Italy
| | - Michele Prisciandaro
- Clinical Laboratory Analysis and Transfusional Medicine, Laboratory and Transfusional Diagnostics, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Grazia Ciavarella
- Clinical Laboratory Analysis and Transfusional Medicine, Laboratory and Transfusional Diagnostics, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Antonio Daniele
- Institute of Neurology, Catholic University of Sacred Heart , Rome , Italy.,Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
| | - Antonello Bellomo
- Psychiatric Unit, Department of Clinical and Experimental Medicine, University of Foggia , Foggia , Italy
| | - Francesco Panza
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy.,Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neuroscience, and Sense Organs, University of Bari Aldo Moro , Bari , Italy
| | - Lazzaro Di Mauro
- Clinical Laboratory Analysis and Transfusional Medicine, Laboratory and Transfusional Diagnostics, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Antonio Greco
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| | - Davide Seripa
- Research Laboratory, Complex Structure of Geriatrics, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo della Sofferenza , Foggia , Italy
| |
Collapse
|
6
|
Cross AJ, Le VJ, George J, Woodward MC, Elliott RA. Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients' medication management and assist with deprescribing. Res Social Adm Pharm 2019; 16:681-688. [PMID: 31405811 DOI: 10.1016/j.sapharm.2019.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/19/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Memory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams. OBJECTIVE To explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications. METHODS Quantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed. RESULTS Most patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted. CONCLUSION Patients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.
Collapse
Affiliation(s)
- Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Vivien J Le
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Michael C Woodward
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, Victoria, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Austin Health, Heidelberg, Victoria, Australia.
| |
Collapse
|
7
|
Kim K, Magness JW, Nelson R, Baron V, Brixner DI. Clinical Utility of Pharmacogenetic Testing and a Clinical Decision Support Tool to Enhance the Identification of Drug Therapy Problems Through Medication Therapy Management in Polypharmacy Patients. J Manag Care Spec Pharm 2019; 24:1250-1259. [PMID: 30479202 PMCID: PMC10397798 DOI: 10.18553/jmcp.2018.24.12.1250] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In polypharmacy patients, medication therapy management (MTM) services provide a comprehensive review of current medications and future treatment goals. Pharmacogenetics (PGx) may further optimize the identification of potential drug therapy problems (DTPs); however, the clinical utility of PGx information with a clinical decision support tool (CDST) in an MTM setting in identifying DTPs has not been systematically assessed. OBJECTIVE To assess the clinical utility of an MTM service enhanced by pharmacogenetic test results and a clinical decision support tool. METHODS This study was a post hoc analysis of the data obtained from an open-label, randomized, observational trial. Polypharmacy patients eligible for MTM service were randomly assigned to 3 intervention arms: standard MTM (SMTM), MTM incorporating CDST (CMTM), and CMTM further enhanced by PGx test results of CYP450 and VKORC1 enzymes (PGxMTM). Allocation for this post hoc analysis was based on patient adherence to the research protocol and completion of a PGx test. The number of DTPs per patient was compared across the 3 arms using analysis of variance. In addition, the frequency of serious DTPs as a categorical variable (grade 3 or above vs. lower grade) was compared across the 3 arms between PGx driven and non-PGx driven DTP recommendations. Statistical significance was tested using the chi-square test. The level of agreement between the DTP seriousness and the acceptance made by prescribers was presented as Cohen's kappa coefficient. RESULTS Numbers of patients after cohort reallocation based on completion of PGx testing were 104, 180, and 58 for the SMTM, CMTM, and PGxMTM arms, respectively. On average, 3.08 DTPs were identified for each patient, which was nearly identical across all 3 arms. Blinded clinical pharmacists considered seriousness (grade 3 or 4) in 31% of the PGx-related DTPs in comparison with 4.9% of the non-PGx DTPs (P < 0.001). The more serious (i.e., grade 3 or above) DTP recommendations were more likely to be accepted by prescribers with the odds ratios of 1.95 (P = 0.05) and 2.39 (P = 0.15), when the analysis was performed for all DTPs and DTPs from the PGxMTM arm only, respectively. CONCLUSIONS MTM enhanced by PGx testing and the clinical decision support tool did not increase the number of DTPs identified. However, PGx testing and the decision support software helps pharmacists determine more serious DTPs, and resulting subsequent recommendations were more readily accepted by a prescriber. Future study of the patient safety outcomes and overall health care costs associated with the utility of the decision support is warranted. DISCLOSURES No funding was received for conducting the post hoc analysis presented in this study. Magness is employed by Magellan Health, which received funding from Genelex for costs to administrate the medication management program. The open-label randomized trial was sponsored by Genelex (Clinicaltrials.gov ID number NCT02428660). PGx tests were provided and laboratory analysis was performed by Genelex. Valerie Baron is an employee of YouScript, which created the clinical decision support tool used in this study and formerly was part of Genelex. The other authors have nothing to disclose.
Collapse
Affiliation(s)
- Kibum Kim
- 1 Pharmacotherapy Outcomes Research Center and Department of Pathology, University of Utah, Salt Lake City
| | | | - Ryan Nelson
- 3 Pharmacotherapy Outcomes Research Center, University of Utah, Salt Lake City
| | | | - Diana I Brixner
- 5 Pharmacotherapy Outcomes Research Center and Department of Pharmacotherapy, University of Utah, Salt Lake City, and Program in Personalized Health Care, University Health, Salt Lake City, Utah
| |
Collapse
|
8
|
Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. A narrative review of problems with medicines use in people with dementia. Expert Opin Drug Saf 2018; 17:825-836. [DOI: 10.1080/14740338.2018.1497156] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tesfahun C. Eshetie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H. Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| |
Collapse
|
9
|
Murphy K, Coombes I, Moudgil V, Patterson S, Wheeler A. Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements. J Eval Clin Pract 2017; 23:1164-1172. [PMID: 28471043 DOI: 10.1111/jep.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVE The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme. METHODS This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand). RESULTS Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records. CONCLUSIONS Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.
Collapse
Affiliation(s)
- Kate Murphy
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Ian Coombes
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Vikas Moudgil
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Susan Patterson
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Amanda Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| |
Collapse
|
10
|
Cross AJ, George J, Woodward MC, Ames D, Brodaty H, Wolfe R, Connors MH, Elliott RA. Potentially Inappropriate Medication, Anticholinergic Burden, and Mortality in People Attending Memory Clinics. J Alzheimers Dis 2017; 60:349-358. [DOI: 10.3233/jad-170265] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amanda J. Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Michael C. Woodward
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, VIC, Australia
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia
- University of Melbourne Academic Unit for Psychiatry of Old Age, St George’s Hospital, Kew, VIC, Australia
| | - Henry Brodaty
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Michael H. Connors
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rohan A. Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
| |
Collapse
|
11
|
Sousa SRAE, Shoemaker SJ, do Nascimento MMG, Costa MS, Ramalho de Oliveira D. Development and validation of a logic model for comprehensive medication management services. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2017; 26:250-257. [DOI: 10.1111/ijpp.12392] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/04/2017] [Indexed: 11/30/2022]
Abstract
Abstract
Objectives
To develop and validate a theoretical logic model for comprehensive medication management (CMM) services.
Methods
The components of a logic model were constructed after a literature review and interviews with 4 CMM professionals. To validate the logic model, a panel of 17 CMM experts participated in three online Delphi method rounds to achieve consensus on the model. The consensus between the experts on each component of the logic model was evaluated using the Content Validity Index and Inter-rater Agreement in each of the rounds.
Key findings
A logic model for CMM services containing 51 items was constructed and validated. Both the items of each component of the model and the linkage between the main components were agreed upon among the experts.
Conclusions
A logic model for CMM services was developed and validated. It is an innovative tool that, if used as a theoretical framework for the implementation of CMM, can ensure greater reproducibility of CMM services in different scenarios of practice and levels of care.
Collapse
Affiliation(s)
- Samuel R A e Sousa
- School of Pharmacy, Federal University of Minas Gerais (FAFAR/UFMG), Belo Horizonte, Minas Gerais, Brazil
| | | | - Mariana M G do Nascimento
- School of Pharmacy, Federal University of Minas Gerais (FAFAR/UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Marianne S Costa
- School of Pharmacy, Federal University of Minas Gerais (FAFAR/UFMG), Belo Horizonte, Minas Gerais, Brazil
| | | |
Collapse
|
12
|
Kjeldsen LJ, Nielsen TRH, Olesen C. Investigating the Relative Significance of Drug-Related Problem Categories. PHARMACY 2017; 5:E31. [PMID: 28970443 PMCID: PMC5597156 DOI: 10.3390/pharmacy5020031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/24/2017] [Accepted: 06/06/2017] [Indexed: 11/17/2022] Open
Abstract
The aim of the review was to investigate whether an assessment of clinical significance can be related to specific drug-related problems (DRPs) and hence may assist in prioritizing individual categories of DRP categorization systems. The literature search using Google Scholar was performed for the period 1990 to 2013 and comprised primary research studies of clinical pharmacy interventions including DRP and clinical significance assessments. Two reviewers assessed the titles, abstracts, and full-text papers individually, and inclusion was determined by consensus. A total of 27 unique publications were included in the review. They had been conducted in 14 different countries and reported a large range of DRPs (71-5948). Five existing DRP categorisation systems were frequently used, and two methods employed to assess clinical significance were frequently reported. The present review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories "ADR" and possibly "Drug interaction" were often associated with an assessed high clinical significance, albeit they were infrequently identified in the studies. Hence, clinical significance assessments do not seem to be useful in prioritizing individual DRPs in the DRP categorization systems. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs.
Collapse
Affiliation(s)
- Lene Juel Kjeldsen
- The Danish Research Unit for Hospital Pharmacy, Amgros I/S, 2100 Copenhagen, Denmark.
| | | | - Charlotte Olesen
- The Hospital Pharmacy, Central Denmark Region, 8000 Aarhus, Denmark.
| |
Collapse
|
13
|
Cross AJ, George J, Woodward MC, Ames D, Brodaty H, Ilomäki J, Elliott RA. Potentially Inappropriate Medications and Anticholinergic Burden in Older People Attending Memory Clinics in Australia. Drugs Aging 2015; 33:37-44. [DOI: 10.1007/s40266-015-0332-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
14
|
Chau SH, Jansen APD, van de Ven PM, Hoogland P, Elders PJM, Hugtenburg JG. Clinical medication reviews in elderly patients with polypharmacy: a cross-sectional study on drug-related problems in the Netherlands. Int J Clin Pharm 2015; 38:46-53. [PMID: 26597955 PMCID: PMC4733134 DOI: 10.1007/s11096-015-0199-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 09/21/2015] [Indexed: 11/30/2022]
Abstract
Background Knowledge of drug-related problems (DRPs) identified in the medication of home-dwelling elderly patients with polypharmacy has been based predominantly on medication reviews conducted in research settings rather than in daily practice. Objective To evaluate the prevalence of DRPs identified by means of a clinical medication review (CMR) and the implementation rate of proposed interventions in a large group of older patients with polypharmacy in the daily practice of community pharmacies. Setting 318 Dutch community pharmacies. Method A cross-sectional study based on CMR-data of 3807 older patients (≥65 years) with polypharmacy (≥5 drugs) completed between January and August 2012. Data were extracted from community pharmacists’ databases and entailed: year of birth, gender, dispensing data, number and nature of identified DRPs, consultations performed, proposed and implemented interventions. Main outcome measure Prevalence of DRPs, drug classes involved in overtreatment and undertreatment, and proposed and implemented interventions. Results A median of two DRPs (interquartile range 1–4; mean 3.0) was identified per patient. The DRP-categories overtreatment (25.5 %) and undertreatment (15.9 %) were found most frequently. 46.2 % of the proposed interventions to solve DRPs were implemented as proposed, in 22.4 % of cases, the intervention differed from the proposal. In 31.3 % of cases no intervention was implemented. Conclusion By conducting a CMR community pharmacists identified a median of two DRPs in older patients with polypharmacy. Overtreatment and undertreatment accounted for 41.4 % of the DRPs identified. In dealing with DRPs, pharmacists proposed a variety of interventions of which the majority (69.9 %) was either implemented or led to alternative interventions. A set of explicit criteria should be applied during a CMR to solve and prevent DRPs.
Collapse
Affiliation(s)
- Sek Hung Chau
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Aaltje P D Jansen
- The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Petra Hoogland
- Department of Pharmaceutical Affairs, Service Apotheek Beheer B.V., Enter, The Netherlands
| | - Petra J M Elders
- The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.,Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Jacqueline G Hugtenburg
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,The EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Summer Meranius M, Engstrom G. Experience of self-management of medications among older people with multimorbidity. J Clin Nurs 2015; 24:2757-64. [DOI: 10.1111/jocn.12868] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - Gabriella Engstrom
- Christine E. Lynn College of Nursing; Charles E. Schmidt College of Medicine Florida Atlantic University; Boca Raton FL USA
| |
Collapse
|
16
|
Meranius MS, Hammar LM. How does the healthcare system affect medication self-management among older adults with multimorbidity? Scand J Caring Sci 2015; 30:91-8. [DOI: 10.1111/scs.12225] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/14/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | - Lena Marmstål Hammar
- School of Health, Care and Social Welfare; Mälardalen University; Västerås Sweden
| |
Collapse
|
17
|
Affiliation(s)
- Rohan A Elliott
- Austin Health, Centre for Medicine Use and Safety; Monash University; Parkville Victoria
| |
Collapse
|
18
|
Elliott RA, C. Booth J. Problems with medicine use in older Australians: a review of recent literature. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2014. [DOI: 10.1002/jppr.1041] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Rohan A. Elliott
- Pharmacy Department; Austin Health; Heidelberg Victoria Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria Australia
| | - Jane C. Booth
- Pharmacy Department; Austin Health; Heidelberg Victoria Australia
| |
Collapse
|
19
|
Jean-Bart E, Faure R, Omrani S, Guilli T, Roubaud C, Krolak-Salmon P, Mouchoux C. [Role of clinical pharmacist in the therapeutical optimization in geriatric outpatient hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2014; 72:184-93. [PMID: 24780834 DOI: 10.1016/j.pharma.2013.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/14/2013] [Accepted: 12/19/2013] [Indexed: 10/25/2022]
Abstract
SETTING Cares in outpatient hospital for elderly patients is a period of interest for multidisciplinary reassessment and pharmaceutical care of the prescription. The objective is to present the implementation of the pharmaceutical care activity at the outpatient hospital. METHODS Between August and October 2011, elderly patients hospitalized in the outpatient hospital for a brief appraisal had a pharmaceutical care. The clinician introduced pharmaceutical reviews in the synthesis letter for general practitioner. An analysis of the activity was carried out over 3 months. RESULTS A pharmaceutical care had been realized for 67 patients, mean age of 81.7 years. Among medical related problems identified, 39.6% were for potentially unnecessary medication. A stop was proposed for 44% of pharmaceutical interventions. A total of 91 pharmaceutical interventions and 13 recommendations were made and 34% of patients had potentially inappropriate medication. CONCLUSION According to the objective to reduce the therapeutics contributing to the iatrogenesis, this approach allowed us to undertake a multidisciplinary collaboration oriented toward the relay between hospital and city cares.
Collapse
Affiliation(s)
- E Jean-Bart
- Pharmacie, hôpital des Charpennes, hospices civils de Lyon, 27, rue Gabriel-Péri, 69100 Villeurbanne, France.
| | - R Faure
- Pharmacie, hôpital des Charpennes, hospices civils de Lyon, 27, rue Gabriel-Péri, 69100 Villeurbanne, France
| | - S Omrani
- Pharmacie, hôpital des Charpennes, hospices civils de Lyon, 27, rue Gabriel-Péri, 69100 Villeurbanne, France
| | - T Guilli
- Pharmacie, hôpital des Charpennes, hospices civils de Lyon, 27, rue Gabriel-Péri, 69100 Villeurbanne, France
| | - C Roubaud
- Centre mémoire, recherche et ressource de Lyon, hôpital des Charpennes, hospices civils de Lyon, 69100 Villeurbanne,France
| | - P Krolak-Salmon
- Centre mémoire, recherche et ressource de Lyon, hôpital des Charpennes, hospices civils de Lyon, 69100 Villeurbanne,France; Université Claude-Bernard Lyon-1, 69373 Lyon, France; Inserm, U1028, CNRS, UMR5292, centre de recherche en neurosciences, 69500 Bron, France; Centre de recherche clinique « vieillissement, cerveau, fragilité », hôpital des Charpennes, hospices civils de Lyon, 69100 Villeurbanne, France
| | - C Mouchoux
- Pharmacie, hôpital des Charpennes, hospices civils de Lyon, 27, rue Gabriel-Péri, 69100 Villeurbanne, France; Université Claude-Bernard Lyon-1, 69373 Lyon, France; Inserm, U1028, CNRS, UMR5292, centre de recherche en neurosciences, 69500 Bron, France; Centre de recherche clinique « vieillissement, cerveau, fragilité », hôpital des Charpennes, hospices civils de Lyon, 69100 Villeurbanne, France
| |
Collapse
|
20
|
Tan ECK, Stewart K, Elliott RA, George J. Pharmacist consultations in general practice clinics: the Pharmacists in Practice Study (PIPS). Res Social Adm Pharm 2013; 10:623-32. [PMID: 24095088 DOI: 10.1016/j.sapharm.2013.08.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 08/28/2013] [Accepted: 08/29/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medication-related problems (MRPs) are a concern in primary care settings. Pharmacists based in the community or community pharmacies are able to identify, resolve and prevent MRPs; however, the lack of a formal partnership with physicians and poor access to patients' medical records are limitations. In Australia, delivery of pharmacist services within general practice clinics is rare. OBJECTIVES To evaluate the effectiveness of consultations by pharmacists based within primary care medical practices. METHODS A prospective, before-after intervention study was conducted at two primary health care (general practice) clinics in Melbourne, Australia. Participants were clinic patients who had risk-factors for MRPs (e.g. polypharmacy). Patients received a consultation with the pharmacist in a private consulting room at the clinic or in their home. The pharmacist reviewed the patient's medication regimen and adherence, with full access to their medical record, provided patient education, and produced a report for the general practitioner. The primary outcome was the number of MRPs identified by the pharmacist, and the number that remained unresolved 6 months after the pharmacist consultation. Secondary outcomes included medication adherence, health service use, and patient satisfaction. RESULTS Eighty-two patients were recruited and 62 (75.6%) completed the study. The median number of MRPs per patient identified by the practice pharmacist was 2 (interquartile range [IQR] 1, 4). Six months after review, this fell to 0 (IQR 0, 1), P < 0.001. The proportion of patients who were adherent to their medications improved significantly, according to both the Morisky (44.1% versus 62.7%, P = 0.023) and the Tool for Adherence Behaviour Screening (TABS) (35.6% versus 57.6%, P = 0.019) scales. There was no significant effect on health service use. Patients were highly satisfied with the pharmacist consultations. CONCLUSIONS Consultations undertaken by pharmacists located within primary health care clinics were effective in identifying and resolving MRPs. The consultations were well received by patients and were associated with improvements in medication adherence.
Collapse
Affiliation(s)
- Edwin C K Tan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia
| | - Kay Stewart
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia
| | - Rohan A Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia; Pharmacy Department, Austin Health, Studley Rd., Heidelberg, VIC 3084, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, VIC 3052, Australia.
| |
Collapse
|
21
|
Stankunas M, Soares JFJ, Viitasara E, Melchiorre MG, Sundin Ö, Torres-Gonzales F, Stankuniene A, Avery M, Ioannidi-Kapolou E, Barros H, Lindert J. Factors associated with refraining from buying prescribed medications among older people in Europe. Australas J Ageing 2013; 33:E25-30. [PMID: 24521077 DOI: 10.1111/ajag.12075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To evaluate the associations between refraining from buying prescribed medications and selected factors among older persons. METHODS A total of 4467 people aged 60-84 years from seven European countries answered a questionnaire (response rate 45.2%). Refraining from buying prescribed medications was measured with the question: 'Have you ever refrained from buying prescribed medication and care?' RESULTS About 11.9% of older people refrained from buying prescribed medications. The multiple regression analysis showed that ages 60-64 (odds ratio (OR) = 2.08; 95% confidence interval (95%CI): 1.38-3.13) and 65-69 (OR = 1.73; 95%CI: 1.16-2.57) years, experience of financial strain (OR = 1.59; 95%CI: 1.27-2.01), as well as exposure to abuse (OR = 1.64; 95%CI: 1.31-2.06) when taking into account country of participant were independently associated with refraining from buying medications, while an opposite association was observed for being male (OR = 0.72; 95%CI: 0.58-0.91). CONCLUSIONS The study found that refraining from buying prescription medications is a problem among older people and identified a number of factors associated with this.
Collapse
Affiliation(s)
- Mindaugas Stankunas
- School of Public Health, Griffith University, Gold Coast, Queensland, Australia; Department of Health Management, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Tamblyn R, Poissant L, Huang A, Winslade N, Rochefort CM, Moraga T, Doran P. Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records. J Am Med Inform Assoc 2013; 21:391-8. [PMID: 23956015 PMCID: PMC3994851 DOI: 10.1136/amiajnl-2013-001704] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Errors in community medication histories increase the risk of adverse events. The objectives of this study were to estimate the extent to which access to community-based pharmacy records provided more information about prescription drug use than conventional medication histories. Materials and methods A prospective cohort of patients with public drug insurance who visited the emergency departments (ED) in two teaching hospitals in Montreal, Quebec was recruited. Drug lists recorded in the patients’ ED charts were compared with pharmacy records of dispensed medications retrieved from the public drug insurer. Patient and drug-related predictors of discrepancies were estimated using general estimating equation multivariate logistic regression. Results 613 patients participated in the study (mean age 63.1 years, 59.2% women). Pharmacy records identified 41.5% more prescribed medications than were noted in the ED chart. Concordance was highest for anticoagulants, cardiovascular drugs and diuretics. Omissions in the ED chart were more common for drugs that may be taken episodically. Patients with more than 12 medications (OR 2.92, 95% CI 1.71 to 4.97) and more than one pharmacy (OR 3.85, 95% CI 1.80 to 6.59) were more likely to have omissions in the ED chart. Discussion The development of health information exchanges could improve the efficiency and accuracy of information about community medication histories if they enable automated access to dispensed medication records from community pharmacies, particularly for the most vulnerable populations with multiple morbidities. Conclusions Pharmacy records identified a substantial number of medications that were not in the ED chart. There is potential for greater safety and efficiency with automated access to pharmacy records.
Collapse
Affiliation(s)
- Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | | | | | | | | | | | | |
Collapse
|
23
|
Pharmacist-Led Medication Review to Identify Medication-Related Problems in Older People Referred to an Aged Care Assessment Team. Drugs Aging 2012; 29:593-605. [PMID: 22715865 DOI: 10.1007/bf03262276] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
24
|
|
25
|
Lee CY, George J, Elliott RA, Stewart K. Exploring stakeholder perspectives on medication review services for older residents in retirement villages. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2012; 20:249-58. [DOI: 10.1111/j.2042-7174.2012.00189.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Objective
To explore stakeholder perspectives on a government-subsidised Home Medicines Review (HMR) service and factors affecting the uptake of HMRs for older residents of retirement villages in Australia.
Methods
Thirty-two in-depth interviews and four focus groups were undertaken with a purposive sample of 32 residents of retirement villages, 10 pharmacists, nine general practitioners (GPs) and a general practice nurse. Data were transcribed verbatim and analysed using the framework approach.
Key findings
Three major themes were identified: participants' perceptions of the HMR service, barriers to the uptake of HMRs and strategies for increasing the uptake of HMR. Residents had positive, negative or mixed perceptions, whereas health professionals were generally positive about the benefits of the service. Barriers to the uptake of HMRs were related to GPs, pharmacists, patients and the healthcare system. A strategy recommended by multiple stakeholders for increasing the uptake of HMRs was to use a multi-faceted intervention targeting residents and their health professionals.
Conclusions
Multiple barriers to the uptake of HMRs and multiple strategies for increasing the uptake of HMRs were identified. These findings could inform the design of interventions to improve uptake of HMRs by residents and health professionals, in turn leading to better medicine use and safety.
Collapse
Affiliation(s)
- Cik Yin Lee
- Centre for Medicine Use and Safety, Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | | | | | | |
Collapse
|
26
|
Abstract
Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.
Collapse
Affiliation(s)
- Roschelle Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt Pleasant, Michigan 48859, USA.
| |
Collapse
|