[Drug-drug interactions in the elderly : Which ones really matter?].
Bitter K,Schlender J F,Woltersdorf R
Pharmacotherapy in the elderly is challenging due to age-related physiological changes, high interindividual variability, and increasing frequency of multimorbidity. The resulting polypharmacy increases the risk of drug-drug interactions and requires an individual risk assessment. Some drug-drug interactions are documented to be associated with harm in older adults including intoxication, gastrointestinal bleeding, or falls. Therefore, they are considered to be of special importance in the elderly. Moreover, frequent risk factors and continuous physiological alterations in the elderly should be taken into account during risk assessment. This review exemplifies clinically relevant drug-drug interactions and risk factors in the elderly. In addition, assessment tools as well as prevention and management strategies for clinical practice are presented.
Pharmacology in the Geriatric Patient.
Welker Katherine Louise,Mycyk Mark B
Emergency medicine clinics of North America
The aging population of the United States creates pharmaceutical challenges for the practicing emergency physician. Polypharmacy, drug-drug and drug-disease interactions, and other pharmaceutical complications from the pathophysiologic changes associated with aging need to be recognized in order to optimize outcomes in the elderly. Effective strategies that improve patients outcomes include a better understanding of the physiologic and pharmacologic changes that occur with aging, integrated use of clinical emergency department pharmacists, and choosing nonpharmacologic treatment options when possible.
Benzodiazepine Misuse in the Elderly: Risk Factors, Consequences, and Management.
Airagnes Guillaume,Pelissolo Antoine,Lavallée Mélanie,Flament Martine,Limosin Frédéric
Current psychiatry reports
Benzodiazepine (BZD) inappropriate use (i.e., misuse and overuse) is a worldwide public health problem. Despite current knowledge about increased sensitivity to side effects in the elderly, that should lead to more caution, only a third of BZD prescriptions in this age group are considered appropriate. The most frequent inadequate situations are excessive duration and/or dosage of a medical prescription or self-medication, especially in a context where it would be contraindicated, e.g., long-acting BZD in the elderly. Polypharmacy and comorbidities are major risk factors. Consequences of BZD inappropriate use are falls, delirium and other cognitive dysfunction, acute respiratory failure, car accidents, dependence, and withdrawal symptoms. An emerging concern is a potentially increased risk of dementia. Contrary to most clinicians' belief, discontinuation of chronic BZD use in elderly patients is feasible, with adequate psychotherapeutic or pharmacological strategies, and can lead to long-term abstinence. Brief cognitive therapy mostly relies on psychoeducation and motivational enhancement and is particularly useful in this context. Further research is needed, notably in three areas: (1) assessing the impact of public health programs to prevent BZD inappropriate use in the elderly, (2) developing alternative strategies to treat anxiety and insomnia in elderly patients, and (3) exploring the association between chronic BZD use and dementia.
Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments.
Stewart Derek,Mair Alpana,Wilson Martin,Kardas Przemyslaw,Lewek Pawel,Alonso Albert,McIntosh Jennifer,MacLure Katie,
Expert opinion on drug safety
INTRODUCTION:Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, 'Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY', which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter's eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.
Polypharmacy and Medication Management in Older Adults.
Kim Jennifer,Parish Abby Luck
The Nursing clinics of North America
Polypharmacy in older adults is a global problem that has recently worsened. Approximately 30% of adults aged 65 years and older in developed countries take 5 or more medications. Although prescribed and over-the-counter medications may improve a wide range of health problems, they also may cause or contribute to harm, especially in older adults. Polypharmacy in older adults is associated with worsening of geriatric syndromes and adverse drug events. Given the risks and burdens of polypharmacy and potentially inappropriate medications, nurses must use patient-centered approaches and nonpharmacologic strategies to treat common symptoms and to optimize patient function and quality of life.
Clinical Pharmacology and the Risks of Polypharmacy in the Geriatric Patient.
Pesante-Pinto Jose Luis
Physical medicine and rehabilitation clinics of North America
Elderly people have several characteristics that make them unique. They have several factors such as environmental factors and demographic factors such as age, sex, socioeconomic level, and schooling, which contribute to these differences being accentuated. As one ages, these various organic and systemic features are accentuated. The pace varies between people, and organs and systems suffer from several normal and adverse changes that make them more or less susceptible to diseases and injuries, and the medications are responsible for many of these threats. This article raises awareness about these changes.
Prevalence of inappropriate medication use in residential long-term care facilities for the elderly: A systematic review.
Storms Hannelore,Marquet Kristel,Aertgeerts Bert,Claes Neree
The European journal of general practice
BACKGROUND:Multi-morbidity and polypharmacy of the elderly population enhances the probability of elderly in residential long-term care facilities experiencing inappropriate medication use. OBJECTIVES:The aim is to systematically review literature to assess the prevalence of inappropriate medication use in residential long-term care facilities for the elderly. METHODS:Databases (MEDLINE, EMBASE) were searched for literature from 2004 to 2016 to identify studies examining inappropriate medication use in residential long-term care facilities for the elderly. Studies were eligible when relying on Beers criteria, STOPP, START, PRISCUS list, ACOVE, BEDNURS or MAI instruments. Inappropriate medication use was defined by the criteria of these seven instruments. RESULTS:Twenty-one studies met inclusion criteria. Seventeen studies relied on a version of Beers criteria with prevalence ranging between 18.5% and 82.6% (median 46.5%) residents experiencing inappropriate medication use. A smaller range, from 21.3% to 63.0% (median 35.1%), was reported when considering solely the 10 studies that used Beers criteria updated in 2003. Prevalence varied from 23.7% to 79.8% (median 61.1%) in seven studies relying on STOPP. START and ACOVE were relied on in respectively four (prevalence: 30.5-74.0%) and two studies (prevalence: 28.9-58.0%); PRISCUS, BEDNURS and MAI were all used in one study each. CONCLUSIONS:Beers criteria of 2003 and STOPP were most frequently used to determine inappropriate medication use in residential long-term care facilities. Prevalence of inappropriate medication use strongly varied, despite similarities in research design and assessment with identical instrument(s).
[Drug therapy for older people : Choosing wisely].
Zeitschrift fur Gerontologie und Geriatrie
Elderly people are the most rapidly growing sector of our society. Due to their multimorbidity they are exposed to a multitude of medications, which are accompanied by chances and risks. The problem of inappropriate medication in the elderly is exacerbated by the fact that only a holistic view can help these patients and that this is predominantly the responsibility of the general practitioner. The closely measured paid contact time is often insufficient to optimize complex medications. Clinically successfully tested aids in the form of lists give reason for hope: in particular, the positive/negative assessment of limitations of the elderly with respect to drugs by the STOPP/START criteria and the FORTA classification are clinically successful aids. Purely negative lists, such as the Beers or PRISCUS lists, have been disappointing in clinical application because they do not consider the needs, prognostic and particularly symptomatic importance and weighting of the diagnosis of patients. Further implementation of these aids to decision making should help to improve the problem of care of elderly patients in the field of drug treatment, even in IT systems.
Drug eruptions in the mature patient.
Wolf Ronni,Marinović Branka
Clinics in dermatology
The world's population is now ageing at an unprecedented rate. Declining fertility and improved health and longevity have generated rising numbers and proportions of the older population in most parts of the world. With advancing age, however, comes an increasing incidence of disease (comorbidity or multimorbidity), an increasing use of medications (polypharmacy), and consequently an increase in adverse drug reactions (ADRs). Age-related changes in pharmacodynamics and pharmacokinetics (eg, volumes of drug distribution, metabolism and clearance, altered drug responsiveness and toxicity) and greater vulnerability to ADRs are other reasons for the higher incidence of ADRs in the elderly compared with young adults. Because the clinical patterns of ADRs are very similar for all age groups, including the elderly, the present review will deal mainly with statistics and numbers, rather than the clinical and/or disease patterns.
Medication management in older adults.
Kim Luke D,Koncilja Kenneth,Nielsen Craig
Cleveland Clinic journal of medicine
Managing medications is a major part of providing care to older adults. Polypharmacy is common in the elderly and is fraught with risks. A careful and systematic approach is needed for managing drug therapy in these patients, recognizing the patient's specific goals.
Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases.
Pérez-Jover Virtudes,Mira José J,Carratala-Munuera Concepción,Gil-Guillen Vicente F,Basora Josep,López-Pineda Adriana,Orozco-Beltrán Domingo
International journal of environmental research and public health
The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors.
Medications & Polypharmacy Influence on Recurrent Fallers in Community: a Systematic Review.
Ming Yu,Zecevic Aleksandra
Canadian geriatrics journal : CGJ
The purpose of this systematic review is to summarize information about the impact different classes of medications and polypharmacy have on recurrent falls, defined as two or more falls in a 12-month period, in community-dwelling older adults. After adjustment for confounders such as age, gender, weight or depression symptoms, the reviewed studies suggested that older adults who use antidepressants, sedatives or hypnotics and anti-epileptics were more likely to experience recurrent falls than non-users. Polypharmacy (use of four or more prescription medications daily) caused 1.5-2 times higher possibility of recurrent falls in older adults. As a high-risk group, recurrent fallers require meaningful intervention. Medications are believed to be a modifiable risk factor in falls prevention; hence, special consideration should be taken to balance the benefit and harm in initiating, continuing or increasing certain classes of medications in elderly recurrent fallers.
Categorization and association analysis of risk factors for adverse drug events.
Zhou Lina,Rupa Anamika Paul
European journal of clinical pharmacology
PURPOSE:Adverse drug events (ADE) are among the leading causes of morbidity and hospitalization. This review analyzes risk factors for ADE, particularly their categorizations and association patterns, the prevalence, severity, and preventability of ADE, and method characteristics of reviewed studies. METHODS:Literature search was conducted via PubMed, Science Direct, CINAHL, and MEDLINE. A review was conducted of research articles that reported original data about specific risk factors for ADE since 2000. Data analyses were performed using Excel and R. RESULTS:We summarized 211 risk factors for ADE, and grouped them into five main categories: patient-, disease-, medication-, health service-, and genetics-related. Among them, medication- and disease-related risk factors were most frequently studied. We further classified risk factors within each main category into subtypes. Among them, polypharmacy, age, gender, central nervous system agents, comorbidity, service utilization, inappropriate use/change use of drugs, cardiovascular agents, and anti-infectives were most studied subtypes. An association analysis of risk factors uncovered many interesting patterns. The median prevalence, preventability, and severity rate of reported ADE was 19.5% (0.29%~86.2%), 36.2% (2.63%~91%), and 16% (0.01%~47.4%), respectively. CONCLUSIONS:This review introduced new categories and subtypes of risk factors for ADE. The broad and in-depth coverage of risk factors and their association patterns elucidate the complexity of risk factor analysis. Managing risk factors for ADE is crucial for improving patient safety, particularly for the elderly, comorbid, and polypharmacy patients. Some under-explored risk factors such as genetics, mental health and wellness, education, lifestyle, and physical environment invite future research.
[Assessment of medication prescribing in a geriatric follow-up care and rehabilitation].
Laloui Kenza,Razafimbelo Hoby,Claude Goby-Ribemont Annie,Rabus Marie-Thérèse,Rwabihama Jean-Paul
The aim of the study was to analyse the prescriptions and identify the factors associated with inappropriate prescribing (IP) and polypharmacy. Polypharmacy and IP concerned 80% of the 54 patients included in the study upon admission, and 78% upon discharge without a statistically significant reduction. A critical analysis of prescriptions would help to reduce inappropriate prescribing and polypharmacy in elderly patients.
Challenges and innovations of drug delivery in older age.
Khan Muhammad Suleman,Roberts Michael S
Advanced drug delivery reviews
Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.
Pharmacokinetics and drug metabolism of antibiotics in the elderly.
Expert opinion on drug metabolism & toxicology
INTRODUCTION:The number of elderly people is increasing worldwide. The elderly may be at increased risk of bacterial infections compared with younger adults. Dosing adaptation of antibiotics in this population may be difficult due to changes in body composition, decline of renal function and/or drug-drug interactions. Lack of dose adaptation may cause unintentional overdosing with the risk of severe adverse effects. Areas covered: This review is based on a PubMed search of the literature published in English language and concerns pharmacokinetic (PK) studies of antibiotics in the elderly performed between 1971 and 2017. Expert opinion: Appropriateness of drug prescription in the elderly is a major commitment of the health care systems worldwide. This should push more and more clinicians to adjust the dosage of renally cleared antibiotics in relation to renal function estimates. The situation may become even more complex in frail elderly patients who are receiving polypharmacy due to drug-drug interactions. Development of new antibiotics should include within clinical trials adequate representation of patients aged ≥75 years to determine age-based dosing. Population PK could be helpful in increasing the knowledge of clinical factors influencing the need for dosing adaptation of the currently available antibiotics in the elderly.
[Appropriate Use of Medicine and Polypharmacy in Older Patients].
Yakugaku zasshi : Journal of the Pharmaceutical Society of Japan
In Japan, the population aged 65 years and older exceeds 28% of the total population. Since the birth rate is also declining, aging of the population is likely to continue. According to a patient survey conducted by the Ministry of Health, Labour and Welfare in 2014, the number of outpatients aged ≥65 years was higher by approximately 1.8 million since the previous survey in 2011. Drug therapy for the elderly is, thus, a matter of rapidly growing importance. The older generation has poorer physiological functions than younger adults. Therefore they are more likely to experience variable efficacy of drugs administered. The incidence of adverse effects is known higher in elderly people, and multidrug regimens are often unavoidable, especially when patients have more than one disease. In elderly patients, chronic lifestyle-related diseases are usually associated with geriatric syndrome. Given these circumstances, the potential area to be covered by pharmacists is very broad, and they should be involved in drug treatment of elderly people from hospital to home. We therefore propose the establishment of a new scientific field of geriatric pharmacology. We will consider novel approaches to geriatric pharmacotherapy from the viewpoints of basic science and clinical practice, deliberating the role that pharmacists should play in the provision of polypharmacy in older patients.
Epilepsy in the elderly: Unique challenges in an increasingly prevalent population.
Lezaic Nastasija,Roussy Josée,Masson Hélène,Jetté Nathalie,Keezer Mark Robert
Epilepsy & behavior : E&B
Elderly individuals (aged at least 60 or 65 years) represent a rapidly growing segment of the population. The incidence and prevalence of epilepsy is higher in this age group than in any other. Diagnosing epilepsy in the elderly can be challenging because the causes and clinical manifestations of seizures often differ as compared with younger individuals. Particular differential diagnoses, such as syncope and amyloid spells, are commonly encountered in the elderly population. A diagnosis of epilepsy has important implications in the older adult, many of which already present a variety of concomitant complex medical problems, such as cognitive impairment, comorbid cerebrovascular disease, and frailty. The treatment of epilepsy in the elderly is complicated by a variety of factors related to aging, including physiological changes, medical comorbidities, and polypharmacy. In this narrative review, we will address the descriptive epidemiology, clinical presentation, differential diagnosis, diagnostic evaluation, treatment, and prognosis of epilepsy in the elderly individual.
Oral Anticoagulation in the Elderly and Frail.
Bauersachs Rupert M,Herold Joerg
The proportion of elderly patients will increase substantially over the next decades, and both atrial fibrillation (AF) and venous thromboembolism (VTE) are more common in the elderly. Age is a risk factor not only for stroke and thromboembolism but also for bleeding, particularly in frail patients, in whom numerous pathophysiological changes occur that alter drug kinetics and toxicity of standard doses of oral anticoagulants (OACs). AF trials showed that the relative benefits of direct OACs (DOACs) also applied to elderly patients, and due to their higher risk this translates into a higher absolute risk reduction compared with vitamin K antagonists, suggesting that DOACs are the better choice. All DOACs-at varying extent-are eliminated via the kidney and it is crucial to evaluate renal function at initiation and during follow-up, especially for dabigatran. The fear of falls is a common reason against OAC. However, there is still a benefit with OAC, particularly with DOACs given the lower risk of intracranial hemorrhage. Polypharmacy represents a common challenge, nevertheless DOACs and warfarin were classified as beneficial. Nonetheless, attempts should be undertaken to reduce comedication, and drug-drug interactions should be assessed. Coadministration of platelet inhibitors increases bleeding risk and should be avoided. In conclusion, elderly and frail patients requiring anticoagulation for AF or VTE are at higher risk of adverse outcomes, but also have a higher absolute benefit from OAC. Important practical aspects to improve efficacy and safety in this challenging population are summarized in this overview.
Failure to Reach a Consensus in Polypharmacy Definition: An Obstacle to Measuring Risks and Impacts-Results of a Literature Review.
Taghy Najwa,Cambon Linda,Cohen Jean-Marie,Dussart Claude
Therapeutics and clinical risk management
Introduction:The risk of polypharmacy is on the rise in most industrialized countries, threatening to burden their health systems. Although many definitions exist and numerous concepts are found in literature as synonyms, the phenomenon of polypharmacy remains poorly defined. The aim of this literature review is to provide an overview of available definitions of polypharmacy, to analyse their convergences and divergences and to discuss the consequences on the assessment of the problem. Methods:A literature review was conducted to identify all published systematic reviews on definitions of polypharmacy available via Scopus and Pubmed databases. The Assessment of Multiple Systematic Reviews (AMSTAR) tool was used to appraise the methodological quality of the selected reviews. Available definitions and other characteristics were extracted; summarised in a table and analysed. Results:Six systematic reviews were identified. They were published between 2000 and 2018. Three focussed on definitions of polypharmacy in the elderly; two in the general population and one in children. The strategy adopted in reviews is more rigorous in the most recent ones. However, they remain, at best, partially exhaustive. The definitions found in the literature used two main approaches, either (i) quantitative, applying varying thresholds and types of polypharmacy based on the number of medications being taken by the patient (ii) qualitative, based on the clinical indications and effects of a given drug regimen, with a growing number of characteristics to describe polypharmacy. The term "inappropriate" is increasingly associated with polypharmacy especially in studies that aimed to use this definition to identify possible solutions for healthcare providers in the field related to aging. Conclusion:This review confirms a high variability and an evolution in the approaches defining "polypharmacy" in the absence of a consensus following standardized criteria. That makes it very difficult to estimate and measure the outcomes associated with this phenomenon.
Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly.
Ajam Tarek,Cumpian Tabitha L,Tilkens Blair L,Jahangir Imaan A,Frost Jared,Ceretto Cheryl,Jahangir Arshad
Expert review of clinical pharmacology
INTRODUCTION:Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population. AREAS COVERED:We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database. EXPERT OPINION:NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.
Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences.
Curtin Denis,Gallagher Paul F,O'Mahony Denis
Therapeutic advances in drug safety
Polypharmacy and prescribing of potentially inappropriate medications (PIMs) are the key elements of inappropriate medication use (IMU) in older multimorbid people. IMU is associated with a range of negative healthcare consequences including adverse drug events and unplanned hospitalizations. Furthermore, prescribing guidelines are commonly derived from randomized controlled clinical trials which have specifically excluded older adults with multimorbidity. Consequently, indiscriminate application of single disease pharmacotherapy guidelines to older multimorbid patients can lead to increased risk of drug-drug interactions, drug-disease interactions and poor drug adherence. Both polypharmacy and PIMs are highly prevalent in older people and strategies to improve the quality and safety of prescribing, largely through avoidance of IMU, are needed. In the last 30 years, numerous explicit PIM criteria-based tools have been developed to assist physicians with medication management in clinically complex multimorbid older people. Very few of these PIM criteria sets have been tested as an intervention compared with standard pharmaceutical care in well-designed clinical trials. In this review, we describe the most widely used sets of explicit PIM criteria to address inappropriate polypharmacy with particular focus on STOPP/START criteria and FORTA criteria which have been associated with positive patient-related outcomes when used as interventions in recent randomized controlled trials.
Rational deprescribing in the elderly.
Williams Scott,Miller Genevieve,Khoury Rita,Grossberg George T
Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists
BACKGROUND:Polypharmacy, defined as being prescribed 5 or more medications, has been shown to be associated with a decline in mental and physical functioning in elderly patients. Despite this, elderly patients are currently being prescribed a median of 7 medications, which often causes more harm than benefit, and emphasizes the importance of deprescribing. METHODS:Five classes of potentially inappropriate medications for the elderly population, especially for the aging brain, are discussed, including anticholinergics, benzodiazepines, antipsychotics, opioids, and proton pump inhibitors. Recommendations regarding these medications were collected from the 2015 Beer's Criteria, the Screening Tool of Older Person's Prescriptions (STOPP) criteria, the Screening Tool to Alert doctors to the Right Treatment (START) criteria, and the Fit fOR The Aged (FORTA) list. The PubMed database was also searched for the most recent evidence regarding prescription patterns, adverse effects, and recommendations regarding discontinuation of these medications in older adults. RESULTS:Anticholinergics, benzodiazepines, antipsychotics, and opioids were all found to have significant adverse effects in the elderly population. All of the discussed medication classes have been shown to be successfully deprescribable. CONCLUSIONS:Polypharmacy increases the risk of adverse drug reactions and hospitalizations in geriatric patients. Rational deprescribing of anticholinergics, benzodiazepines, antipsychotics, opioids, and proton pump inhibitors in selected patients may be a good first step to reducing this risk.
Psychopharmacological Treatment in Older People: Avoiding Drug Interactions and Polypharmacy.
Kratz Torsten,Diefenbacher Albert
Deutsches Arzteblatt international
BACKGROUND:As the elderly population increases, so, too, does the number of multimorbid patients and the risk of polypharmacy. The consequences include drug interactions, undesired side effects of medication, health impairment, and the need for hospital- ization. 5-10% of hospital admissions among the elderly are attributable to undesired side effects of medication. METHODS:This review is based on publications retrieved by a selective search in PubMed and the Cochrane Library that employed the search terms "drug interaction," "undesired side effect," "polypharmacy," "pharmacokinetics," and "pharmacody- namics." RESULTS:Elderly patients are particularly at risk of polypharmacy, both because of the prevalence of multimorbidity in old age and because of physicians' uncritical implementation of guidelines. The more drugs a person takes, the greater the risk of drug interactions and undesired side effects. Age-associated changes in pharmacokinetics and pharmacodynamics elevate this risk as well. Physicians prescribing drugs for elderly patients need to know about the drugs' catabolic pathways, protein binding, and inductive and inhibitory effects on cytochrome P450 in order to avoid drug interactions and polypharmacy. CONCLUSION:Multiple aids and instruments are available to ensure practical and reasonable drug monitoring, so that the risks of drug interactions and undesired side effects can be detected early and avoided.
Clinical pharmacology of old age.
Koren Gideon,Nordon Galia,Radinsky Kira,Shalev Varda
Expert review of clinical pharmacology
: With the majority of elderly persons consuming multiple drugs, inappropriate drug use is a major issue in geriatric medicine. : We reviewed PubMed, Embase, and Cochrane from inception to 1 May 2019 for potentially inappropriate use of medications, polypharmacy, and age-dependent changes in pharmacokinetics and pharmacodynamics. We selected to highlight new aspects that have emerged in recent years: appropriate monitoring of drug adherence and the introduction of Big Data analysis in advancing geriatric pharmacology. : There are major gaps in the pharmacological treatment of the elderly. Most drugs were designed and tested in adults, with no pharmacokinetic and pharmacodynamic data on changes in old age. This void must be corrected through systematic and well-designed research programs. Potentially inappropriate use of medications (PIM) in the elderly is a serious issue in advanced age. Analysis of PIM shows relatively low predictive value in real life medicine. Most physicians continue to prescribe to the elderly medicines which should not be given at all, or not combined. Polypharmacy is a complex issue in old age, and in many cases treating physicians are not conducting critical assessment of the need for numerous medications.
Chronic Pain Management in the Elderly.
Schwan Josianna,Sclafani Joseph,Tawfik Vivianne L
Chronic pain is extremely prevalent in older adults and is associated with significant morbidity, including limited mobility, social isolation, and depressed mood. Pain is defined by a biopsychosocial model highlighting the importance of a multidisciplinary approach to treatment, including multimodal medications, selected interventions, physical therapy and rehabilitation, and psychological treatments. In this narrative review, the authors highlight the use of these approaches in older adults with specific attention paid to considerations unique to aging, including alterations in drug metabolism, avoidance of polypharmacy, and physiologic changes predisposing to painful conditions.
Polypharmacy in older adults: the role of the multidisciplinary team.
Baruth Joshua M,Gentry Melanie T,Rummans Teresa A,Miller Donna M,Burton M Caroline
Hospital practice (1995)
Patients over the age 65 are a quickly expanding segment of the US population and represent a large percentage of patients requiring inpatient care. Older adults are more likely to experience polypharmacy and adverse drug effects. This review explains the risks of polypharmacy and potentially inappropriate medications in the elderly. Specific classes of medications frequently used in older adults in acute care settings are examined, including anticholinergic, sedative hypnotics, and antipsychotic medications. We discuss strategies aimed at addressing polypharmacy in this population including a drug regimen review (which is distinct from medication reconciliation), screening tools, pharmacist-led interventions, and computer-based strategies in the context of current literature and research findings. We provide a summary of general guidelines that may be helpful for geriatricians and hospitalists in improving patient care and clinical outcomes.
Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation?
Baumgartner Andrew D,Clark Collin M,LaValley Susan A,Monte Scott V,Wahler Robert G,Singh Ranjit
Journal of clinical pharmacy and therapeutics
WHAT IS KNOWN AND OBJECTIVE:Use of potentially inappropriate medications (PIMs) remains common in older adults, despite the easy availability of screening tools such as the Beers and Screening Tool of Older Person's Prescriptions (STOPP) criteria. Multiple published studies have implemented these screening tools to encourage deprescribing of PIMs, with mixed results. Little is known about the reasons behind the success or failure of these interventions, or what could be done to improve their impact. Implementation science (IS) provides a set of theories, models and frameworks to address these questions. The goal of this study was to conduct a focused narrative review of the deprescribing literature through an IS lens-to determine the extent to which implementation factors were identified and the intermediate steps in the intervention were measured. A better understanding of the existing literature, including its gaps, may provide a roadmap for future research. METHODS:PubMed search from 2000-2019 using appropriate MeSH headings. INCLUSION CRITERIA:controlled trials or prospective cohort studies intended to reduce PIMs in the elderly that used hospitalizations and/or emergency department visits as outcome measures. Studies were reviewed to identify potential implementation factors (known as determinants), using the Consolidated Framework for Implementation Research (CFIR) as a guide. In addition, intermediate outcomes were extracted. RESULTS AND DISCUSSION:Of the 548 reviewed abstracts, 14 studies met the inclusion criteria and underwent detailed analysis. Of the 14 studies, 10 acknowledged potential implementation determinants that could be mapped onto CFIR. The most commonly identified determinant was the degree of pharmacist integration into the medical team (seven of 14 studies), which mapped onto the CFIR construct of 'networks and communication'. Several important CFIR constructs were absent in the reviewed literature. Intermediate measures were captured by 12 of the 14 reviewed papers, but the choice of measures was inconsistent across studies. WHAT IS NEW AND CONCLUSION:In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes. These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions due to negative results, when the correct interpretation might be that they failed in implementation. In other words, they were 'lost in translation'. Studies that rigorously examine and report on the implementation process are needed to tease apart this important distinction.
Pharmacological Interactions in the Elderly.
Błeszyńska Emilia,Wierucki Łukasz,Zdrojewski Tomasz,Renke Marcin
Medicina (Kaunas, Lithuania)
Pharmacological therapy in the elderly is particularly complicated and challenging. Due to coexistence of three main predisposing factors (advanced age, multiple morbidity and polypharmacotherapy), this group of patients is prone to occurrence of drug interactions and adverse effects of incorrect drug combinations. Since many years patient safety during the treatment process has been one of key elements for proper functioning of healthcare systems around the world, thus different preventive measures have been undertaken in order to counteract factors adversely affecting the therapeutic effect. One of the avoidable medical errors is pharmacological interactions. According to estimates, one in six elderly patients may be at risk of a significant drug interaction. Hence the knowledge about mechanisms and causes of drug interactions in the elderly, as well as consequences of their occurrence are crucial for planning the process of pharmacotherapy. For the purpose of pharmacovigilance, a review of available methods and tools gives an insight into possible ways of preventing drug interactions. Additionally, recognizing the actual scale of this phenomenon in geriatric population around the world emphasizes the importance of a joint effort among medical community to improve quality of pharmacotherapy.
Medication-related hospital admissions and readmissions in older patients: an overview of literature.
Linkens A E M J H,Milosevic V,van der Kuy P H M,Damen-Hendriks V H,Mestres Gonzalvo C,Hurkens K P G M
International journal of clinical pharmacy
Background The number of medication related hospital admissions and readmissions are increasing over the years due to the ageing population. Medication related hospital admissions and readmissions lead to decreased quality of life and high healthcare costs. Aim of the review To assess what is currently known about medication related hospital admissions, medication related hospital readmissions, their risk factors, and possible interventions which reduce medication related hospital readmissions. Method We searched PubMed for articles about the topic medication related hospital admissions and readmissions. Overall 54 studies were selected for the overview of literature. Results Between the different selected studies there was much heterogeneity in definitions for medication related admission and readmissions, in study population and the way studies were performed. Multiple risk factors are found in the studies for example: polypharmacy, comorbidities, therapy non adherence, cognitive impairment, depending living situation, high risk medications and higher age. Different interventions are studied to reduce the number of medication related readmission, some of these interventions may reduce the readmissions like the participation of a pharmacist, education programmes and transition-of-care interventions and the use of digital assistance in the form of Clinical Decision Support Systems. However the methods and the results of these interventions show heterogeneity in the different researches. Conclusion There is much heterogeneity in incidence and definitions for both medication related hospital admissions and readmissions. Some risk factors are known for medication related admissions and readmissions such as polypharmacy, older age and additional diseases. Known interventions that could possibly lead to a decrease in medication related hospital readmissions are spare being the involvement of a pharmacist, education programs and transition-care interventions the most mentioned ones although controversial results have been reported. More research is needed to gather more information on this topic.
Antiepileptic drug therapy in the elderly: a clinical pharmacological review.
Kaur Upinder,Chauhan Indal,Gambhir Indrajeet Singh,Chakrabarti Sankha Shubhra
Acta neurologica Belgica
Seizure disorder is the third most common neurological disorder in the elderly after stroke and dementia. With the increasing geriatric population, the situation of clinicians seeing more and more elderly epilepsy patients is very likely. Not only is the diagnosis of epilepsy tedious in the elderly, its management raises many challenging issues for the treating physicians. Altered physiology, age-related decline in organ function, and plasma protein binding and altered pharmacodynamics make the elderly patients with seizure disorder a difficult group to treat. This is further complicated by the presence of comorbidities and polypharmacy which increase the chances of drug interactions. The adverse effects that might be tolerated well in younger populations may be disastrous for the aged. Although the newer antiepileptic drugs are found to have a favorable safety profile, there is relative scarcity of randomized-controlled trials involving older and newer antiepileptics in the geriatric population. This review tries to compile the available literature on management of epilepsy in the elderly population including evidence of safety and efficacy of newer and older antiepileptics with special reference to the 'geriatric giants'. It also deals with the interactions between antiepileptic medications and other commonly prescribed drugs in the elderly such as anti-hypertensives and antiischemic agents. The recommended guidelines of various international bodies are also analyzed from the perspective of elderly with seizure disorder.
[Principles of pharmacotherapy in the elderly].
Telekes András,Deme Dániel
The proportion of elderly patients is getting increased in the developed countries as a consequence of which pharmacotherapy takes a more and more important place in the healthcare system. Important biological alterations are characteristic for the elderly subjects, which have effect on the pharmacokinetics and pharmacodynamics of the pharmaceuticals. Gradually decreased kidney function may demand the modification of the administration of the pharmaceuticals. Certain pharmaceuticals and drug-interactions are potentially dangerous for this population. Therefore several factors have to be taken into account in conjunction with the therapy of elderly patients including co-morbidities, cognitive function and the social state. At the same time, the risk-benefit ratio of the pharmaceuticals is the worst among elderly patients with pharmaceutical therapy including polypragmasy. Thus, it is inevitable for the development of geriatric pharmacotherapy that the physiologic alteration of elderly has to be taken into account not only in the daily practice but also during the development and formulation of a pharmaceutical. The present paper gives an overview of the most important factors influencing the pharmacotherapy of the elderly. Orv Hetil. 2019; 160(23): 896-907.
Pharmacodynamics in the elderly.
Best practice & research. Clinical anaesthesiology
An overview is given of the influence of age on the pharmacodynamics of drugs used during general and locoregional anaesthesia. For some groups of agents a distinct separation into age-related changes in the pharmacokinetics and pharmacodynamics is possible, whereas for others the literature indicates only that responses in the elderly are enhanced. I start with an overview of the influence of age on cardiovascular and neuroendocrine function and include a short account of the state-of-the-art in pharmacodynamic modelling. The physiological changes that occur with age are associated with an increased sensitivity to the effects of anaesthetic agents. For most intravenous hypnotic agents, and inhalational anaesthetic agents, the increased sensitivity with age is, at least in part, explained by altered pharmacodynamics. For opioids and local anaesthetics applied for blockade of the central nervous system, the pharmacodynamic involvement is not always clear. For neuromuscular blocking agents, pharmacodynamic involvement appears to be nearly absent in the reduced dose requirements seen with age--so that the latter appear to be caused by altered pharmacokinetics. Future studies, using pharmacokinetic-pharmacodynamic (PK-PD) mixed-effects modelling, should further explore this area to obtain clinically applicable data for improving our insight into the delivery of anaesthetics to the elderly and improving the quality of anaesthesia in this fast-growing population.
Antidepressant use in the elderly: the role of pharmacodynamics and pharmacokinetics in drug safety.
Sultana Janet,Spina Edoardo,Trifirò Gianluca
Expert opinion on drug metabolism & toxicology
INTRODUCTION:Antidepressants (ADs) are widely used among elderly persons, making AD-related safety an important issue. AREAS COVERED:This review highlights safety considerations related to AD use including risks associated with inappropriate and off-label use. The age-related pharmacokinetic and pharmacodynamic changes underlying safety concerns connected to ADs are outlined. Drug-drug interactions as a cause of AD-related adverse drug reactions (ADRs) are also discussed. We reviewed scientific evidence concerning three important safety outcomes related to ADs in elderly persons: cardiac arrhythmias, hyponatraemia and falls/fractures. EXPERT OPINION:Several AD-related ADRs in elderly people are likely to be preventable. Current evidence suggests that selective serotonin re-uptake inhibitors (SSRIs) are best avoided particularly in persons with kidney disease due to the risk of hyponatraemia. The use of tricyclic antidepressants (TCAs) should be limited in the elderly due to anticholinergic adverse effects. TCAs should also be avoided in elderly persons at high risk of cardiovascular events due to a risk of cardiac arrhythmia. Emerging evidence suggests that SSRIs also have arrhythmogenic potential. Both TCAs and SSRIs should be used cautiously in elderly persons at risk of falls. Future research in this area should aim to investigate the lowest effective dose of AD possible, the relationship between AD dose and adverse effects, and which elderly subgroups are most prone to develop severe ADRs.
Mapping of drug-related problems among older adults conciliating medical and pharmaceutical approaches.
Laroche Marie-Laure,Van Ngo Thi Hong,Sirois Caroline,Daveluy Amélie,Guillaumin Michel,Valnet-Rabier Marie-Blanche,Grau Muriel,Roux Barbara,Merle Louis
European geriatric medicine
PURPOSE:To lay the fundamentals of drug-related problems (DRPs) in older adults, and to organize them according to a logical process conciliating medical and pharmaceutical approaches, to better identify the causes and consequences of DRPs. MATERIALS AND METHODS:A narrative overview. RESULTS:The causes of DRPs may be intentional or unintentional. They lie in poor prescription, poor adherence, medication errors (MEs) and substance use disorders (SUD). Poor prescription encompasses sub-optimal or off-label drug choice; this choice is either intentional or unintentional, often within a polypharmacy context and not taking sufficiently into account the patient's clinical condition. Poor adherence is often the consequence of a complicated administration schedule. This review shows that MEs are not the most frequent causes of DRPs. SUD are little studied in older adults and needs to be more investigated because the use of psychoactive substances among older people is frequent. Prescribers, pharmacists, nurses, patients, and caregivers all play a role in different causes of DRPs. The potential deleterious outcomes of DRPs result from adverse drug reactions and therapeutic failures. These can lead to a negative benefit-risk ratio for a given treatment regimen. DISCUSSION/CONCLUSION:Interdisciplinary pharmacotherapy programs show significant clinical impacts in preventing or resolving adverse drug events and, suboptimal responses. New technologies also seem to be interesting solutions to prevent MEs. Better communication between healthcare professionals, patients and their caregivers would ensure greater safety and effectiveness of treatments.
Antirheumatic drugs in older adults and polypharmacy issues.
Coskun Benlidayi Ilke,Gokce Kutsal Yesim
Zeitschrift fur Gerontologie und Geriatrie
Older individuals experience various noninflammatory and autoimmune inflammatory rheumatic diseases. Given the increased incidence of rheumatic conditions in older adults, it is of great importance for healthcare providers to be aware of the potential benefits and risks of antirheumatic drugs. The present article aims to provide a comprehensive review regarding antirheumatic drug use in older patients, particularly by focusing on safety issues and polypharmacy. Antirheumatic medications include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and disease-modifying antirheumatic drugs (DMARDs), which comprise conventional synthetic DMARDs, targeted synthetic DMARDs and biological DMARDs. Due to the alteration in drug pharmacokinetics and pharmacodynamics in old people, antirheumatic drug efficiency and safety may be different than in the younger population. Polypharmacy and multimorbidity are other potential challenges to be faced during the treatment of older patients with rheumatic diseases. The current review also discusses the strategies to minimize adverse reactions due to antirheumatic drugs.
Medication review and reconciliation in older adults.
Beuscart Jean-Baptiste,Pelayo Sylvia,Robert Laurine,Thevelin Stefanie,Marien Sophie,Dalleur Olivia
European geriatric medicine
Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.
Pharmacology, polypharmacy and the older adult: a review.
British journal of community nursing
District nurses routinely visit and care for older patients who are prescribed multiple medicines. Older people living with multiple comorbidities and polypharmacy are commonly encountered in community nursing. It is important for nurses to recognise that regular medicines use and age-related physiological changes in older people place them at greater risk of medication-related harm. In order to understand this, an underpinning knowledge of the pharmacological principles relating to older people is required. This review will consider the effects of age-related changes and the impact of ageing on pharmacokinetics and pharmacodynamics. The relationship between polypharmacy and identifying high-risk drugs and adverse drug events will be explored. Medicines use in older adults with multimorbidity including frailty will be discussed. The role of district nurses in supporting older people with medicines optimisation will be considered, with a focus on how the community nurse can contribute to reducing avoidable harm for patients.
Overuse of antidepressants in older outpatients with Alzheimer's disease and associated disorders: an observational study.
Gourdon Mathilde,Petit Laurence,Delpierre Sandrine,Sebbagh-Eczet Mélanie,Estrada Janina,Marquis Caroline,Raynaud-Simon Agathe,Bonnet-Zamponi Dominique
Geriatrie et psychologie neuropsychiatrie du vieillissement
Forty per cent of French subjects over 65 years old with Alzheimer's disease and related disorders (ADRD) are chronically exposed to antidepressants, suggesting an overuse of these drugs. The main objective of our study was to estimate the prevalence of the overuse of antidepressants in this population and the factors associated with this. METHODOLOGY:a single-centre, prospective, cross-sectional study carried out at the Bretonneau outpatient department between 1 December 2014 and 31 May 2015. All patients aged 70 and above, suffering from ADRD (according to DSM IV criteria) and currently being prescribed an antidepressant were eligible. "Overuse" was defined as off-label prescriptions or prescriptions that went beyond the recommended duration of treatment. This was assessed by the geriatrician in charge and validated by an expert committee, who were blind to the geriatrician's assessment. RESULTS:Fifty-four patients were included in the study (mean age: 82.9 years (± 5.4); 70.4% women; 60% with mild to moderate dementia). The main indication of antidepressant treatment was a major depressive episode (59.3%). The geriatrician could not reach a conclusion on overuse in 10 cases (18.5%). Inter-rater agreement between geriatricians and the expert committee was good (kappa coefficient: 0.73 [0.5-0.95]). Finally, 33 (61%) of these patients were overusing antidepressants: a third had an off-label prescription and two thirds had exceeded the recommended treatment duration. The only factor associated with this overuse was co-prescription of psychotropic drugs (p = 0.009). CONCLUSIONS:the overuse of antidepressants is common in older patients with dementia, particularly overuse due to exceeding the treatment duration. This is significantly associated with co-prescription with another psychotropic drug, suggesting that this represents a more global problem of the overuse of psychotropic drugs.
REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors (REMEDI[e]S): French implicit and explicit criteria.
Roux Barbara,Berthou-Contreras Julie,Beuscart Jean-Baptiste,Charenton-Blavignac Marion,Doucet Jean,Fournier Jean-Pascal,de la Gastine Blandine,Gautier Sophie,Gonthier Régis,Gras Valérie,Grau Muriel,Noize Pernelle,Polard Elisabeth,Rudelle Karen,Valnet-Rabier Marie-Blanche,Tannou Thomas,Laroche Marie-Laure
European journal of clinical pharmacology
PURPOSE:To establish a consensus on both explicit and implicit criteria in order to identify potentially inappropriate prescribing (PIP) in French older people aged 75 years and over or 65 years and over with multimorbidity. METHODS:Fifteen experts in geriatrics, general practice, pharmacy, and clinical pharmacology were involved in a two-round Delphi survey to assess preliminary explicit and implicit criteria based on an extensive literature review and up-to-date evidence data. Experts were asked to rate their level of agreement using a 5-level Likert scale for inclusion of criteria and also for rationale and therapeutic alternatives. A consensus was considered as reached if at least 75% of the experts rated criteria as "strongly agreed" or "agreed." RESULTS:The new tool included a seven-step algorithm (implicit criteria) encompassing the three main domains that define PIP (i.e. overprescribing, underprescribing, and misprescribing) and 104 explicit criteria. Explicit criteria were divided into 6 tables related to inappropriate drug duplications (n = 7 criteria), omissions of medications and/or medication associations (n = 16), medications with an unfavourable benefit/risk ratio and/or a questionable efficacy (n = 39), medications with an unsuitable dose (n = 4) or duration (n = 6), drug-disease (n = 13), and drug-drug interactions (n = 19). CONCLUSION:The REMEDI[e]S tool (REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors) is an original mixed tool, adapted to French medical practices, aimed at preventing PIP both at the individual level in clinical practice and the population level in large-scale studies. Therefore, its use could contribute to an improvement in healthcare professionals' prescribing practices and safer care in older adults.
Medicines Related Problems (MRPs) Originating in Primary Care Settings in Older Adults - A Systematic Review.
Ude-Okeleke Rosetta Chinyere,Aslanpour Zoe,Dhillon Soraya,Umaru Nkiruka
Journal of pharmacy practice
BACKGROUND:As people age, they become increasingly vulnerable to the untoward effects of medicines due to changes in body systems. These may result in medicines related problems (MRPs) and consequent decline or deterioration in health. AIM:To identify MRPs, indicators of deterioration associated with these MRPs, and preventative interventions from the literature. DESIGN AND SETTING:Systematic review of primary studies on MRPs originating in Primary Care in older people. METHODS:Relevant studies published between 2001 and April 2018 were obtained from Medline (via PubMed), CINAHL, Embase, Psych Info, PASCAL, Scopus, Cochrane Library, Science Direct, and Zetoc. Falls, delirium, pressure ulcer, hospitalization, use of health services and death were agreed indicators of deterioration. The methodological quality of included studies was assessed using the Down and Black tool. RESULTS:There were 1858 articles retrieved from the data bases. Out of these, 21 full text articles met inclusion criteria for the review. MRPs identified were medication error, potentially inappropriate medicines, adverse drug reaction and non-adherence. These were associated with indicators of deterioration. Interventions that involved doctors, pharmacists and patients in planning and implementation yielded benefits in halting MRPs. CONCLUSION:This Systematic review summarizes MRPs and associated indicators of deterioration. Appropriate interventions appeared to be effective against certain MRPs and their consequences. Further studies to explore deterioration presented in this systematic review is imperative.
A proactive remote pharmaceutical care for rural elderly population: The Houston-Apollo polypharmacy project.
Wang Chen-Yu,Chang Kai-Chieh,Chuang Chin-Ju,Chen Yi-Pin,Hsieh Cheng-Ying,Huang Yung-Cheng,Chen Li-Yu,Yang Yi-Hsuan,Jeng Yachung,Chen Hsiu-Hsi,Liao Ling-Chiao,Liou Horng-Huei
International journal of clinical practice
AIMS:To evaluate polypharmacy-related problems in the elderly people who live in rural through a proactive pharmaceutical care project under a novel remote medical service infrastructure (the Houston-Apollo polypharmacy project). METHODS:It is a prospectively cross-sectional study. The elderly aged 65 years old lived in communities executed the congregate meal service and joined the Houston-Apollo project were included. During March and July on 2020, the pharmaceutical care team of Houston-Apollo polypharmacy project interviewed old people and collected their medications by remote video. Polypharmacy situation and drug-related problems, including potentially inappropriate medications (PIMs), anticholinergic burden (ACB) and risk of sarcopaenia, were evaluated by clinical pharmacists. In addition, we analysed the categories of the prescription types between polypharmacy and non-polypharmacy users, polypharmacy users with and without PIMs or ACB. A patient-specific integrated pharmacist's note for medication education and a dear doctor letter (as needed) were generated and delivered within 2-weeks postinterviewed. Age- and sex-adjusted logistic regression model was used to evaluate the association between polypharmacy and these potential medication problems. RESULTS:There were 87 older people (mean age = 75.9) and 536 long-term medications were collected. Among them, 52% were defined as polypharmacy users. Polypharmacy was significantly associated with higher risk of PIMs and ACB. The adjusted odd ratio was 5.31 (95% CI: 2.02-13.9) and 10.1 (95% CI: 3.4-29.7), respectively. Among polypharmacy users, there were nearly double the prescriptions for the nervous system and musculoskeletal system among patients with PIMs compared with those without PIMs. Besides, polypharmacy users with ACB showed higher rate of prescriptions for the nervous system and the alimentary tract and metabolism system compared with those without ACB. CONCLUSION:Polypharmacy was significantly associated with negative impact of medication safety among the elderly people in rural area. A persistent remote pharmaceutical care intervention was crucial for improving this problem.
Prevalence of chronic diseases in older Palestinian adults and common pharmacological interventions: a cross-sectional study.
Najjar Anas,Warasna Beesan,Kitaneh Islam,Abu-Sharar Salam,Sawalha Maryam,Jamous Abrar,Qiq Muhannad,Amro Wafa,Makharzeh Enas,Amro Yazan,Subb Laban Bayan,Amro Ahmad
Lancet (London, England)
BACKGROUND:Older people (aged 60 years and older) are more susceptible than younger people to multiple medical disorders and are therefore more frequently exposed to polypharmacy. We investigated prevalence of chronic diseases and medical conditions, medications used, and associated sociodemographic factors among older adults of the Palestinian population. METHODS:A cross-sectional study was done between June, 2013, and January, 2014. The study population was Palestinians aged 60 years and older living in the West Bank and East Jerusalem. Study participants were selected in a stratified random manner. The sample was selected from all governorates (strata) according to the size of the population of each governate on the basis of census data from the Palestinian Central Bureau of Statistics. The research team visited and interviewed older residents in their houses. Questionnaire items were explained in informal language to participants by the interviewer, to ensure complete understanding, and answers were recorded by the interviewer. Informed written consent was obtained from each participant. The study design and protocols were revised and approved by the Research Ethics Committee at Al-Quds University. FINDINGS:1574 older Palestinian adults were invited to participate, of whom 1192 (76%) enlisted. The mean age was 70·3 years (SD 8·58, range 60-110 years). 55% (659 of 1192) were female and 45% (533) were male. The majority (84%; 996) were non-workers or retired; monthly income for 78% of participants (930) was less than 2500 NIS, which falls in the low-income group. More participants (78%; 934) had governmental health insurance than had private insurance (8%; 89) or no insurance (14%; 169). 40 chronic diseases and conditions were reported. The mean number of diseases reported per participant was 2·33 (SD 1·68, range 0-11). Cardiovascular, endocrine, and musculoskeletal conditions were the most frequently reported. 66% of participants (787 of 1192) reported at least one cardiovascular condition, 40% (480) at least one endocrine condition, and 32% (385) at least one musculoskeletal condition. The most prevalent cardiovascular condition was hypertension, which affected 54% of participants (647); the most prevalent endocrine condition was diabetes (38·2%, 455); and the most prevalent musculoskeletal condition was arthritis (13·7%, 163). The total number of different types of medication (both prescribed and over-the-counter drugs) was 175. The mean number of medications per participant was 4·54 (SD 2·83), and the highest number of different medications being taken by one participant was 17. Commonly prescribed therapeutic agents were aspirin (prescribed to 48% of participants, 575 of 1192), angiotensin-converting-enzyme inhibitors (34%, 403), diuretics (34%, 409), metformin (27%, 323), paracetamol (23%, 270), and protein pump inhibitors (23%, 275). INTERPRETATION:The findings provide insights into the most prevalent chronic diseases and conditions, as well as the most commonly used medications among older Palestinians. Cardiovascular, endocrine, and musculoskeletal conditions were the most prevalent diseases. Older Palestinians adults are subjected to polypharmacy, which should be assessed whenever they are evaluated for health problems, and drug interactions should be carefully checked. Physicians, pharmacists, health professionals, and health policymakers in Palestine should consider increasing citizens' health awareness and encourage healthy lifestyles to decrease the incidence of these diseases. In addition, intersectoral cooperation between the governmental and non-governmental organisations will be key in the fight against chronic diseases in older Palestinian adults. FUNDING:None.
Co-prescription trends in a large cohort of subjects predict substantial drug-drug interactions.
Sutherland Jeffrey J,Daly Thomas M,Liu Xiong,Goldstein Keith,Johnston Joseph A,Ryan Timothy P
Pharmaceutical prescribing and drug-drug interaction data underlie recommendations on drug combinations that should be avoided or closely monitored by prescribers. Because the number of patients taking multiple medications is increasing, a comprehensive view of prescribing patterns in patients is important to better assess real world pharmaceutical response and evaluate the potential for multi-drug interactions. We obtained self-reported prescription data from NHANES surveys between 1999 and 2010, and confirm the previously reported finding of increasing drug use in the elderly. We studied co-prescription drug trends by focusing on the 2009-2010 survey, which contains prescription data on 690 drugs used by 10,537 subjects. We found that medication profiles were unique for individuals aged 65 years or more, with ≥98 unique drug regimens encountered per 100 subjects taking 3 or more medications. When drugs were viewed by therapeutic class, it was found that the most commonly prescribed drugs were not the most commonly co-prescribed drugs for any of the 16 drug classes investigated. We cross-referenced these medication lists with drug interaction data from Drugs.com to evaluate the potential for drug interactions. The number of drug alerts rose proportionally with the number of co-prescribed medications, rising from 3.3 alerts for individuals prescribed 5 medications to 11.7 alerts for individuals prescribed 10 medications. We found 22% of elderly subjects taking both a substrate and inhibitor of a given cytochrome P450 enzyme, and 4% taking multiple inhibitors of the same enzyme simultaneously. By examining drug pairs prescribed in 0.1% of the population or more, we found low agreement between co-prescription rate and co-discussion in the literature. These data show that prescribing trends in treatment could drive a large extent of individual variability in drug response, and that current pairwise approaches to assessing drug-drug interactions may be inadequate for predicting real world outcomes.
Potential drug-drug interactions in Alzheimer patients with behavioral symptoms.
Pasqualetti Giuseppe,Tognini Sara,Calsolaro Valeria,Polini Antonio,Monzani Fabio
Clinical interventions in aging
The use of multi drug regimens among the elderly population has increased tremendously over the last decade although the benefits of medications are always accompanied by potential harm, even when prescribed at recommended doses. The elderly populations are particularly at an increased risk of adverse drug reactions considering comorbidity, poly-therapy, physiological changes affecting the pharmacokinetics and pharmacodynamics of many drugs and, in some cases, poor compliance due to cognitive impairment and/or depression. In this setting, drug-drug interaction may represent a serious and even life-threatening clinical condition. Moreover, the inability to distinguish drug-induced symptoms from a definitive medical diagnosis often results in addition of yet another drug to treat the symptoms, which in turn increases drug-drug interactions. Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, are the most widely prescribed agents for Alzheimer's disease (AD) patients. Behavioral and psychological symptoms of dementia, including psychotic symptoms and behavioral disorders, represent noncognitive disturbances frequently observed in AD patients. Antipsychotic drugs are at high risk of adverse events, even at modest doses, and may interfere with the progression of cognitive impairment and interact with several drugs including anti-arrhythmics and acetylcholinesterase inhibitors. Other medications often used in AD patients are represented by anxiolytic, like benzodiazepine, or antidepressant agents. These agents also might interfere with other concomitant drugs through both pharmacokinetic and pharmacodynamic mechanisms. In this review we focus on the most frequent drug-drug interactions, potentially harmful, in AD patients with behavioral symptoms considering both physiological and pathological changes in AD patients, and potential pharmacodynamic/pharmacokinetic drug interaction mechanisms.
Preventable ADRs leading to hospitalization - results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients.
Schmiedl S,Rottenkolber M,Szymanski J,Drewelow B,Siegmund W,Hippius M,Farker K,Guenther I R,Hasford J,Thuermann P A,
Expert opinion on drug safety
BACKGROUND:Studies evaluating the impact of age and potentially inappropriate medication (PIM) on avoidable adverse drug reactions (ADRs) are scarce. METHODS:In this prospective, multi-center, long-term (8.5 years) observational study, we analysed ADRs leading to hospitalization in departments of internal medicine. ADRs causality and preventability were assessed using standardised algorithms. PIM was defined based on the PRISCUS-list. Multivariate analyses and estimation of ADR incidence rates were conducted. RESULTS:Of all 6,427 ADR patients, a preventable ADR was present in 1,253 (19.5%) patients (elderly patients ≥70 years: 828). Risk factors for preventable ADRs in elderly patients were multimorbidity, two to four ADR-causative drugs, and intake of particular compounds (e.g. spironolactone) but not sex, PIM usage, or the total number of drugs. Regarding particular compounds associated with preventable ADRs, highest incidence rates for preventable ADRs were found for patients aged ≥70 years for spironolactone (3.3 per 1,000 exposed persons (95% CI: 1.4-6.6)) and intermediate-acting insulin (3.3 per 1,000 exposed persons (95% CI: 1.6-6.1)). CONCLUSION:Avoiding PIM usage seems to be of limited value in increasing safety in elderly patients whereas our results underline the importance of an individualized medication review of the most commonly implicated drugs in preventable ADRs (supported by BfArM FoNr: V-11337/68605/2008-2010).
Identifying treatment related problems and associated factors among hospitalized post-stroke patients through medication management review: A multi-center study.
Basheti Iman A,Ayasrah Shahnaz Mohammed,Ahmad Muayyad
Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society
Background:Stroke is a major cause of disability and one of the leading causes of death among the elderly. Treatment related problems can lead to undesirable consequences. The Medication Management Review (MMR) service is aimed at identifying, resolving and preventing TRPs, subsiding the undesirable outcomes associated with TRPs. Objectives:To explore the types, frequencies and severity of TRPs amongst post-stroke patients recruited through hospitals via conducting the MMR service by clinical pharmacists in Jordan. Associations between patient factors and the identified TRPs were explored. Methods:This cross-sectional descriptive study was conducted over three months in 2017 in different geographical areas throughout Jordan. Randomly recruited patients were interviewed at the hospitals to collect their demographic data and clinical characteristics. Types/frequencies/severity of TRPs for each stroke patient were identified by a clinical pharmacist. Associations between the identified TRPs and patient's factors were explored through multiple regression analysis.Key findings:Out of 198 stroke patients (mean age: 56.6 ± 14.2) who completed the study, 110 (55.6%) were males. Many of the patients (82 (41.6%)) were smokers and 61 (69.2%) had hypertension and/or diabetes. The mean number of TRPs per patient was 2.5 ± 1.1. The most common TRP categories involved efficacy issues (198 (40.6%)), inappropriate drug adherence (136 (27.9%)) and inappropriate patient knowledge (114 (23.4%)). More than 70.0% (342/487) of the identified TRPs were of major severity. Higher number of TRPs was found to be associated with being a male, having a lower educational level, being a current smoker, having a higher number of drugs and a poorer quality of life. Conclusion:Lack of drug efficacy, inappropriate drug adherence and patient knowledge were the major TRPs identified via delivering the MMR service to post-stroke patients. The identified TRPs highlights the importance of the MMR service, and supports planning future strategies aimed at decreasing the incidence of strokes.
Potential and clinical relevant drug-drug interactions among elderly from nursing homes: a multicentre study in Murcia, Spain.
Iniesta-Navalón Carles,Gascón-Cánovas Juan Jose,Gama Zenewton André da Silva,Sánchez-Ruiz José Francisco,Gutiérrez-Estrada Erick Angelico,De-la-Cruz-Sánchez Ernesto,Harrington-Fernández Owen
Ciencia & saude coletiva
This study purposes to determine the prevalence of potential and clinical relevant Drug-Drug-Interactions (pDDIs) in institutionalized older adults and to identify the pertinent factors associated. We conduct an observational, multicenter and cross-sectional study during the last quarter of 2010. We selected a sample of 275 subjects (aged ≥ 65 years) from 10 nursing homes of Murcia (Spain) by a two-stage complex sampling. pDDIs were identified using the College of Pharmacists Database. We only considered pDDIs of clinical relevance, and thereafter the relevant factors were identified through uni-level and multi-level regression analyses. A total of 210 pDDIs were identified, 120 of which were considered clinically relevant (57.1%), affecting a total of 70 elderly (25.8%). Eight pharmacological groups made up 70.2% of the clinically relevant pDDIs. More clinically relevant DDIs were found in people suffering several pathologies (OR = 2.3; 95%CI = 1.4-4.5), and also in people who take ten or more drugs daily (OR = 9.6; 95%CI = 4.8-19.1), and people who take anti-inflammatory drugs (OR = 3.9; 95%CI = 1.4-10.4). This study reveals that clinically relevant pDDIs are very common in institutionalized elderly people, and that caregivers should aim at improving their practice in order to reduce the prevalence of this phenomenon.
Older adults using multi-dose dispensing exposed to risks of potentially inappropriate medications.
Bobrova Veera,Heinämäki Jyrki,Honkanen Outi,Desselle Shane,Airaksinen Marja,Volmer Daisy
Research in social & administrative pharmacy : RSAP
BACKGROUND:Multi-dose dispensing (MDD) of medications is a health technology designed to promote medication adherence and patient safety. MDD has been used as an alternative to ordinary prescription dispensing for patients, mostly elderly with high medication use. OBJECTIVE:To evaluate the initiation phase of the MDD service to older adults ≥65 years and assess wheter the medication use of the new MDD patients is appropriate in terms of drug related problems. METHODS:The European Union EU(7)-PIM list and the Inxbase databases were used for identifying potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs). The study sample consisted of a total of 208 patients aged 65-108 years who were involved in the MDD service (PharmaService Ltd.) in Finland in 2015-2016. Clinically significant differences of PIM and DDI occurrences were identified using a Pearson's chi-square test throughout the demographic groups under study. RESULTS:Results demonstrate that for 81% of the study participants, at least one medication from the EU (7)-PIM list was prescribed, and up to 64% of PIMs were clinically significant. According to the Inxbase database, five patients (2.4%) were prescribed category D clinically significant DDIs. Additionally, 61% of the patients saw an increase in the number of medications prescribed within six months after the initial MDD order. CONCLUSIONS:The results suggest that the MDD service should be accompanied by a regular medication review tailored to specific patient groups (i.e., older patients) to avoid potential DRPs.
Medication management in older adults and interprofessional education: A needs assessment.
Kostas Tia,Knoebel Randall,Levine Stacie
Gerontology & geriatrics education
Elderly, multi-morbid patients are at high risk for suffering adverse drug events. Safe medication management is a key process in preventing these adverse events, and requires interprofessional teamwork. We performed a needs assessment survey of graduating medical students and faculty to evaluate student training in medication management, in particular students' preparedness in the three minimum geriatrics competencies pertaining to medication management, interprofessional educational opportunities, and optimal learning methods. Response rates were 45/105 (43%) for students and 38/93 (41%) for faculty. The majority of students felt that they did not receive sufficient training in medication management in older adults. Faculty either agreed with students or were unsure whether students received sufficient training. Neither students nor faculty felt that students were extremely prepared to carry out the three minimum geriatrics competencies at the time of medical school graduation. Students and faculty identified direct patient care experiences as the optimal learning method, and inappropriate medications as the highest priority topic. Students and faculty felt that students do not receive sufficient interprofessional educational opportunities. The results of this study are currently being used to create customized interprofessional educational experiences for medical students related to medication management in older adults.
STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress.
Expert review of clinical pharmacology
: STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. This review examines the clinical trial evidence pertaining to STOPP/START criteria as an intervention.: The literature was searched for registered clinical trials that used STOPP/START criteria as an intervention. In single-center trials, applying STOPP/START criteria improved medication appropriateness, reduced polypharmacy, reduced adverse drug reactions (ADRs), led to fewer falls, and lower medication costs. Two large-scale multi-center trials (SENATOR and OPERAM) examined the impact of computer-generated STOPP/START criteria on incident ADRs (SENATOR) and drug-related hospitalizations (OPERAM) in multi-morbid older people. Results of these trials will be publicized in 2020.: Applying STOPP/START criteria improves clinical outcomes in multi-morbid older people. Electronic deployment of STOPP/START criteria is a substantial technical challenge; however, recent clinical trials of software prototypes demonstrate feasibility. Even with well-functioning software for the application of STOPP/START criteria, the need remains for face-to-face interaction between attending clinicians and appropriately trained personnel (likely pharmacists) to explain and qualify specific STOPP/START recommendations in individual multi-morbid older patients. Such interaction is essential for the implementation of relevant STOPP/START recommendations.
Medication Discrepancies in Discharge Summaries and Associated Risk Factors for Elderly Patients with Many Drugs.
Caleres Gabriella,Modig Sara,Midlöv Patrik,Chalmers John,Bondesson Åsa
Drugs - real world outcomes
BACKGROUND AND OBJECTIVE:Elderly patients are at high risk for medication errors in care transitions. The discharge summary aims to counteract drug-related problems due to insufficient information transfer in care transitions, hence the accuracy of its medication information is of utmost importance. The purpose of this study was to describe the medication discrepancy rate and associated risk factors in discharge summaries for elderly patients. METHODS:Pharmacists collected random samples of discharge summaries from ten hospitals in southern Sweden. Medication discrepancies, organisational, and patient- and care-specific factors were noted. Patients aged ≥ 75 years with five or more drugs were further included. Descriptive and logistic regression analyses were performed. RESULTS:Discharge summaries for a total of 933 patients were included. Average age was 83.1 years, and 515 patients (55%) were women. Medication discrepancies were noted for 353 patients (38%) (mean 0.87 discrepancies per discharged patient, 95% confidence interval 0.76-0.98). Unintentional addition of a drug was the most common discrepancy type. Central nervous system drugs/analgesics were most commonly affected. Major risk factors for the presence of discrepancies were multi-dose drug dispensing (adjusted odds ratio 3.42, 95% confidence interval 2.48-4.74), an increasing number of drugs in the discharge summary (adjusted odds ratio 1.09, 95% confidence interval 1.05-1.13) and discharge from departments of surgery (adjusted odds ratio 2.96, 95% confidence interval 1.55-5.66). By contrast, an increasing number of drug changes reduced the odds of a discrepancy (adjusted odds ratio 0.93, 95% confidence interval 0.88-0.99). CONCLUSIONS:Medication discrepancies were common. In addition, we identified certain circumstances in which greater vigilance may be of considerable value for increased medication safety for elderly patients in care transitions.
Exploring polypharmacy burden among elderly patients with chronic diseases in Chinese community: a cross-sectional study.
Wang Yongli,Li Xiaodan,Jia Dongmei,Lin Beilei,Fu Bo,Qi Bei,Zhang Zhenxiang
BACKGROUND:In the long-term use of multiple medications for elderly patients diagnosed with chronic diseases, medication problems are prominent, which seriously reduces their quality of life. The burden of medications of patients critically affects their medication beliefs, behaviors and disease outcomes. It may be a solution to stress the burden of medications of patients. Its medication issues develops a novel perspective. The present study aimed to exploit the Chinese version of Living with Medicines Questionnaire-3(C-LMQ-3) to quantify the medicines burden of elderly patients diagnosed with chronic diseases in China, and evaluate the relevant demographic characteristics of sub-populations with high medicines burden. METHODS:The survey was distributed to elderly patients aged ≥ 60 years with chronic disease by using ≥ 5 medicines, C-LMQ-3 scores and domain scores were compared by the characteristics of elderly patients by employing descriptive statistics and performing statistical tests. RESULTS:On the whole, 430 responses were analyzed, and the participants were aged between 60 and 91 years, with the average age of 73.57 years (SD: 7.87). Most of the responses were female (61.7 %) with middle school education (38.5 %). Moreover, 54.1 % of the participants lived with spouse only, 16.2 % had both spouse and children, and 10.0 % lived alone. As indicated from regression analysis, higher C-LMQ-3 scores were associated with those who were with low education level, 60-69 years-old, using ≥ 11 medicines, using medicines ≥ 3 times a day, income per month (RMB) ≤ 3000, and who having higher monthly self-paid medication (RMB) ≥ 300 (p < 0.01). Burden was mainly driven by cost-related burden, concerns about medicines, and the lack of autonomy over medicine regimens. CONCLUSIONS:This study presents the preliminary evidence to elderly patients diagnosed with chronic diseases in mainland China that pay attention to multiple medications burden may help reduce the Drug Related Problems, whereas some elderly patients have a higher burden of medication. Chinese health care providers are required to primarily evaluate and highlight such patients, and formulate relevant intervention strategies to ensure medication adherence and daily medication management of elderly patients with polypharmacy.
Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system.
Crowley Erin K,Sallevelt Bastiaan T G M,Huibers Corlina J A,Murphy Kevin D,Spruit Marco,Shen Zhengru,Boland Benoît,Spinewine Anne,Dalleur Olivia,Moutzouri Elisavet,Löwe Axel,Feller Martin,Schwab Nathalie,Adam Luise,Wilting Ingeborg,Knol Wilma,Rodondi Nicolas,Byrne Stephen,O'Mahony Denis
BMC health services research
BACKGROUND:Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm. METHOD:This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention. DISCUSSION:The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019. TRIAL REGISTRATION:Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).