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Added other contextual uses of deprescribing and when it should be considered for patients
Added information on barriers to deprescribing as faced by physicians and patients.
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Several tools exist to help physicians decide when to deprescribe and what medications can be added to a [[Pharmaceutical drug|pharmaceutical]] regimen. The [[Beers Criteria]] and the STOPP/START criteria help identify medications that have the highest risk of [[Adverse drug reaction|adverse drug events]] (ADE) and [[Drug interaction|drug-drug interactions]]. The [[MATCH-D|Medication appropriateness tool for comorbid health conditions during dementia]] (MATCH-D) is the only tool available specifically for people with dementia, and also cautions against polypharmacy and complex medication regimens.<ref>{{Cite web | url=http://www.match-d.com.au |title = MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia}}</ref><ref>{{cite journal | vauthors = Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C | title = Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel | journal = Internal Medicine Journal | volume = 46 | issue = 10 | pages = 1189–1197 | date = October 2016 | pmid = 27527376 | pmc = 5129475 | doi = 10.1111/imj.13215 }}</ref>
Several tools exist to help physicians decide when to deprescribe and what medications can be added to a [[Pharmaceutical drug|pharmaceutical]] regimen. The [[Beers Criteria]] and the STOPP/START criteria help identify medications that have the highest risk of [[Adverse drug reaction|adverse drug events]] (ADE) and [[Drug interaction|drug-drug interactions]]. The [[MATCH-D|Medication appropriateness tool for comorbid health conditions during dementia]] (MATCH-D) is the only tool available specifically for people with dementia, and also cautions against polypharmacy and complex medication regimens.<ref>{{Cite web | url=http://www.match-d.com.au |title = MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia}}</ref><ref>{{cite journal | vauthors = Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C | title = Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel | journal = Internal Medicine Journal | volume = 46 | issue = 10 | pages = 1189–1197 | date = October 2016 | pmid = 27527376 | pmc = 5129475 | doi = 10.1111/imj.13215 }}</ref>

Barriers faced by both physicians and patients have made it challenging to apply deprescribing strategies in practice.<ref name=":0">{{Cite journal|last=Reeve|first=Emily|last2=Thompson|first2=Wade|last3=Farrell|first3=Barbara|date=2017-03|title=Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action|url=https://www.ncbi.nlm.nih.gov/pubmed/28063660|journal=European Journal of Internal Medicine|volume=38|pages=3–11|doi=10.1016/j.ejim.2016.12.021|issn=1879-0828|pmid=28063660}}</ref> For physicians, these include fear of consequences of deprescribing, the prescriber's own confidence in their skills and knowledge to deprescribe, the feasibility of deprescribing, and the complexity of having multiple providers.<ref name=":0" /><ref>{{Cite journal|last=Anderson|first=Kristen|last2=Stowasser|first2=Danielle|last3=Freeman|first3=Christopher|last4=Scott|first4=Ian|date=2014-12-08|title=Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis|url=https://www.ncbi.nlm.nih.gov/pubmed/25488097|journal=BMJ open|volume=4|issue=12|pages=e006544|doi=10.1136/bmjopen-2014-006544|issn=2044-6055|pmc=4265124|pmid=25488097}}</ref> For patients, attitudes or beliefs about the medications, fears and uncertainties surrounding deprescribing, and influence of physicians, family, and the media are also reported barriers to deprescribing.<ref name=":0" />


A team approach is a relatively new method gaining popularity due to its effectiveness in managing patient care and obtaining the best outcomes. A team can include a primary provider, pharmacist, nurse, counselor, physical therapist, chaplain and others involved in patient care. Combining the ideas and points of view of the different providers allows a more [[Holistic health|holistic]] approach to the health of a patient. In 2013, the United States legislature mandated that every [[Medicare Part D|Medicare D]] patient receive an annual Medication Therapy Management (MTM) review by a team of healthcare professionals.<ref>{{cite journal | vauthors = Maher RL, Hanlon J, Hajjar ER | title = Clinical consequences of polypharmacy in elderly | journal = Expert Opinion on Drug Safety | volume = 13 | issue = 1 | pages = 57–65 | date = January 2014 | pmid = 24073682 | pmc = 3864987 | doi = 10.1517/14740338.2013.827660 }}</ref>
A team approach is a relatively new method gaining popularity due to its effectiveness in managing patient care and obtaining the best outcomes. A team can include a primary provider, pharmacist, nurse, counselor, physical therapist, chaplain and others involved in patient care. Combining the ideas and points of view of the different providers allows a more [[Holistic health|holistic]] approach to the health of a patient. In 2013, the United States legislature mandated that every [[Medicare Part D|Medicare D]] patient receive an annual Medication Therapy Management (MTM) review by a team of healthcare professionals.<ref>{{cite journal | vauthors = Maher RL, Hanlon J, Hajjar ER | title = Clinical consequences of polypharmacy in elderly | journal = Expert Opinion on Drug Safety | volume = 13 | issue = 1 | pages = 57–65 | date = January 2014 | pmid = 24073682 | pmc = 3864987 | doi = 10.1517/14740338.2013.827660 }}</ref>

Revision as of 19:07, 25 November 2019

Polypharmacy involves the concurrent consumption of numerous different drugs

Polypharmacy is the concurrent use of multiple medications by a patient.[1][2][3][4] Polypharmacy is most common in the elderly, affecting about 40% of older adults living in their own homes.[5] About 21% of adults with intellectual disability are also exposed to polypharmacy.[6] Polypharmacy is not necessarily ill-advised, but in many instances can lead to negative outcomes or poor treatment effectiveness, often being more harmful than helpful or presenting too much risk for too little benefit. Therefore, health professionals consider it a situation that requires monitoring and review to validate whether all of the medications are still necessary. Concerns about polypharmacy include increased adverse drug reactions, drug interactions, prescribing cascade, and higher costs.[7] Polypharmacy is often associated with a decreased quality of life, including decreased mobility and cognition.[2]

The definition of polypharmacy is still debated. Definitions have ranged from two medications at a time to 18, or to more medications than clinically necessary. Five or more concurrent regular medications appears to be the most common definition. Despite the uncertainty around a definition, experts generally agree on the magnitude, potential for harm and potential for reduction in medication regimens for older people.[8]

Whether or not the advantages of polypharmacy (over monotherapy) outweigh the disadvantages or risks depends upon the particular combination and diagnosis involved in any given case.[9] The use of multiple drugs, even in fairly straightforward illnesses, is not an indicator of poor treatment and is not necessarily overmedication. A perfectly legitimate treatment regimen could include, for example, the following: a statin, an ACE inhibitor, a beta-blocker, aspirin, paracetamol and an antidepressant in the first year after a myocardial infarction.[10] Moreover, it is well accepted in pharmacology that it is impossible to accurately predict the side effects or clinical effects of a combination of drugs without studying that particular combination of drugs in test subjects. Knowledge of the pharmacologic profiles of the individual drugs in question does not assure accurate prediction of the side effects of combinations of those drugs; and effects also vary among individuals because of genome-specific pharmacokinetics. Therefore, deciding whether and how to reduce a list of medications (deprescribe) is often not simple and requires the experience and judgment of a practicing physician. However, such thoughtful and wise review is an ideal that too often does not happen, owing to problems such as poorly handled care transitions (poor continuity of care, usually because of siloed information), overworked physicians, and interventionism.

Polypharmacy continues to grow in importance because of aging populations. Many countries are experiencing a fast growth of the older population, 65 years and older.[11][12] [13] This growth is a result of the baby-boomer generation getting older and an increased life expectancy as a result of ongoing improvement in health care services worldwide.[14][15]

Medical uses

Considerations often associated with thoughtful, therapeutic polypharmacy include:

  1. Drugs given for a single somatic locale act on biochemical mechanisms present throughout the body such that their nonlinear interactions can produce an (unknown except empirically) global physiological state of health;[16]
  2. The more independent variables, "handles", to manipulate, the greater the likelihood of finding and stabilizing a small available parametric space of healthy function while minimizing unwanted effects.[17]

Often certain medications can interact with others in a positive way specifically intended when prescribed together, to achieve a greater effect than any of the single agents alone. This is particularly prominent in the field of anesthesia and pain management – where atypical agents such as antiepileptics, antidepressants, muscle relaxants, NMDA antagonists, and other medications are combined with more typical analgesics such as opioids, prostaglandin inhibitors, NSAIDS and others. This practice of pain management drug synergy is known as an analgesia sparing effect.

As another example, in anesthesia (particularly IV anesthesia and general anesthesia) multiple agents are almost always required – including hypnotics or analgesic inducing/maintenance agents such as midazolam or propofol, usually an opioid analgesic such as morphine or fentanyl, a paralytic such as vecuronium, and in inhaled general anesthesia generally a halogenated ether anesthetic such as sevoflurane or desflurane.

Contraindications

The use of polypharmacy is correlated to the use of potentially inappropriate medications. Potentially inappropriate medications are generally taken to mean those that have been agreed upon by expert consensus, such as by the Beers Criteria. These medications are generally inappropriate for older adults because the risks outweigh the benefits. Examples of these include urinary anticholinergics, which can prevent up to one episode of incontinence every 48 hours on average. However, they can also cause constipation, dry eyes, dry mouth, impaired cognition, and increase the risk of falls.

Polypharmacy is associated with an increased risk of falls in the elderly. Certain medications are well known to be associated with the risk of falls, including cardiovascular and psychoactive medications. The use of four or more of these medicines is known to be associated with a significantly higher, cumulative risk of falls. Although often not practical to achieve, withdrawing all medicines associated with falls risk can halve an individual's risk of future falls.

Every medication has potential adverse side-effects. With every drug added, there is an additive risk of side-effects. Also, many medications have potential interactions with other substances. 15% of older adults are potentially at risk for a major drug-drug interaction.[18] When a new drug is prescribed, the risk of interactions increases exponentially. Doctors and pharmacists aim to avoid prescribing medications that interact; often, adjustments in the dose of medications need to be made to avoid interactions, such as with warfarin, as it may lose its effect.

Special populations

Patients at greatest risk for negative polypharmacy consequences include the elderly, psychiatric patients, patients taking five or more drugs concurrently, those with multiple physicians and pharmacies, recently hospitalized patients, individuals with concurrent comorbidities,[19] low educational level,[20] and those with impaired vision or dexterity.

It is not uncommon for those dependent or addicted to substances to enter or remain in a state of polypharmacy misuse. Note, however, that the term polypharmacy and its variants generally refer to legal drug use as-prescribed, even when used in a negative or critical context.

Measures can be taken to limit polypharmacy to its truly legitimate and appropriate needs. This is an emerging area of research, frequently called deprescribing.[21] This reduction in medications has been shown to reduce the number of medications and is safe as it does not significantly alter health outcomes.[22][unreliable medical source?] Clinical pharmacists can perform drug therapy reviews and teach physicians and their patients about drug safety and polypharmacy, as well as collaborating with physicians and patients to correct polypharmacy problems. Similar programs are likely to reduce the potentially deleterious consequences of polypharmacy. Such programs hinge upon patients and doctors informing pharmacists of other medications being prescribed, as well as herbal, over-the-counter substances and supplements that occasionally interfere with prescription-only medication.

Pill burden

Pill burden is the number of pills (tablets or capsules, the most common dosage forms) that a patient takes on a regular basis, along with all associated efforts that increase with that number - like storing, organizing, consuming, and understanding the various medications in one's regimen. The use of individual medications is growing faster than pill burden.[23]

High pill burden decreases compliance with drug therapy, resulting from the need to take a large quantity of pills or other forms of medication on a regular basis. It also increases the possibility of adverse medication reactions (side effects) and drug-drug interactions. High pill burden has also been associated with an increased risk of hospitalization, medication errors, and increased costs for both the pharmaceuticals themselves and for the treatment of adverse events. Finally, pill burden is a source of dissatisfaction for many patients.

High pill burden was once commonly associated with antiretroviral drug regimens to control HIV, but now is more often seen in other patient populations. For instance, adults with multiple common chronic conditions such as diabetes, hypertension, lymphedema, hypercholesterolemia, osteoporosis, constipation, inflammatory bowel disease, and clinical depression can often be prescribed more than a dozen different medications daily.[24] The adverse reactions of these combinations of drugs are not reliably predictable. Obesity is implicated in many of the aforementioned conditions, and it is not uncommon for a clinically obese patient to receive pharmacologic treatment for all of these. Because chronic conditions tend to accumulate in the elderly, pill burden is a particular issue in geriatrics.

Reducing pill burden is recognized as a way to improve medication compliance. This is done through "deprescribing", where the risks and benefits are weighed when considering whether to continue a medication.[25] This includes drugs such as bisphosphonates (for osteoporosis) where it is often used indefinitely although there is only evidence to use it for five to ten years.[25] The use of memory tricks has also been seen to improve adherence and reduce pill burden in several countries.[26] These include associating medications with mealtimes, recording the dosage on the box, storing the medication in a special place, leaving it in plain sight in the living room, or putting the prescription sheet on the refrigerator.[26] The development of applications has also shown some benefit in this regard.[26]

The selection of long-acting active ingredients over short-acting ones may also reduce pill burden. For instance, ACE inhibitors are used in the management of hypertension. Both captopril and lisinopril are examples of ACE inhibitors. However, lisinopril is dosed once a day, whereas captopril may be dosed 2-3 times a day. Assuming that there are no contraindications or potential for drug interactions, using lisinopril instead of captopril may be an appropriate way to limit pill burden.

Interventions

The most common intervention in polypharmacy patients is deprescribing, which includes the identification and discontinuance of medications when the benefit no longer outweighs the harm. In elderly patients, this can commonly be done as a patient becomes more frail and treatment focus needs to shift from preventative to palliative.[27] Deprescribing was also deemed feasible and effective in other settings such as residential care, communities and hospitals.[28] This preventative measure should be considered for anyone who exhibits one of the following: (1) a new symptom or adverse event arises, (2) when the person develops an end-stage disease, (3) if the combination of drugs is risky, or (4) if stopping the drug does not alter the disease trajectory.[29]

Several tools exist to help physicians decide when to deprescribe and what medications can be added to a pharmaceutical regimen. The Beers Criteria and the STOPP/START criteria help identify medications that have the highest risk of adverse drug events (ADE) and drug-drug interactions. The Medication appropriateness tool for comorbid health conditions during dementia (MATCH-D) is the only tool available specifically for people with dementia, and also cautions against polypharmacy and complex medication regimens.[30][31]

Barriers faced by both physicians and patients have made it challenging to apply deprescribing strategies in practice.[26] For physicians, these include fear of consequences of deprescribing, the prescriber's own confidence in their skills and knowledge to deprescribe, the feasibility of deprescribing, and the complexity of having multiple providers.[26][32] For patients, attitudes or beliefs about the medications, fears and uncertainties surrounding deprescribing, and influence of physicians, family, and the media are also reported barriers to deprescribing.[26]

A team approach is a relatively new method gaining popularity due to its effectiveness in managing patient care and obtaining the best outcomes. A team can include a primary provider, pharmacist, nurse, counselor, physical therapist, chaplain and others involved in patient care. Combining the ideas and points of view of the different providers allows a more holistic approach to the health of a patient. In 2013, the United States legislature mandated that every Medicare D patient receive an annual Medication Therapy Management (MTM) review by a team of healthcare professionals.[33]

It is unclear if specific interventions to improve adequate polypharmacy in older adults have significant clinical results, but they seem to reduce inappropriate prescribing and medication-related problems.[34][needs update] High quality evidence is needed to make any conclusions about the effects of such interventions in care homes.[35] Deprescribing rounds has been proposed as a potentially successful methodology in reducing polypharmacy. [36]

See also

References

  1. ^ Munger MA (November 2010). "Polypharmacy and combination therapy in the management of hypertension in elderly patients with co-morbid diabetes mellitus". Drugs & Aging. 27 (11): 871–83. doi:10.2165/11538650-000000000-00000. PMID 20964461.
  2. ^ a b "Polypharmacy in Elderly Patients" (PDF). Vumc.nl. Retrieved 16 January 2015.
  3. ^ "polypharmacy". TheFreeDictionary.com. Retrieved 16 January 2015.
  4. ^ Stawicki SP, Gerlach AT (2009). "Polypharmacy and medication errors: Stop, listen, look, and analyze..." OPUS 12 Scientist. 3 (1): 6–10.
  5. ^ Haider SI, Johnell K, Thorslund M, Fastbom J (December 2007). "Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992 - 2002". International Journal of Clinical Pharmacology and Therapeutics. 45 (12): 643–53. doi:10.5414/cpp45643. PMID 18184532.
  6. ^ Haider SI, Ansari Z, Vaughan L, Matters H, Emerson E (November 2014). "Prevalence and factors associated with polypharmacy in Victorian adults with intellectual disability". Research in Developmental Disabilities. 35 (11): 3071–80. doi:10.1016/j.ridd.2014.07.060. PMID 25129201.
  7. ^ Haider SI, Johnell K, Weitoft GR, Thorslund M, Fastbom J (January 2009). "The influence of educational level on polypharmacy and inappropriate drug use: a register-based study of more than 600,000 older people". Journal of the American Geriatrics Society. 57 (1): 62–9. doi:10.1111/j.1532-5415.2008.02040.x. PMID 19054196.
  8. ^ Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S (June 2017). "Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy". Pharmacology Research & Perspectives. 5 (3): e00321. doi:10.1002/prp2.321. PMC 5464348. PMID 28603638.
  9. ^ Tamminga CA (July 2011). "When is polypharmacy an advantage?". The American Journal of Psychiatry. 168 (7): 663. doi:10.1176/appi.ajp.2011.11050695. PMID 21724668.
  10. ^ Sergi G, De Rui M, Sarti S, Manzato E (July 2011). "Polypharmacy in the elderly: can comprehensive geriatric assessment reduce inappropriate medication use?". Drugs & Aging. 28 (7): 509–18. doi:10.2165/11592010-000000000-00000. PMID 21721596.
  11. ^ Cruz LP, Miranda PM, Vedana KG, Miasso AI (2011). "Medication therapy: adherence, knowledge and difficulties of elderly people from bipolar disorder" (PDF). Revista Latino-Americana de Enfermagem. 19 (4): 944–52. doi:10.1590/S0104-11692011000400013. PMID 21876947.
  12. ^ Gellad WF, Grenard JL, Marcum ZA (February 2011). "A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity". The American Journal of Geriatric Pharmacotherapy. 9 (1): 11–23. doi:10.1016/j.amjopharm.2011.02.004. PMC 3084587. PMID 21459305.
  13. ^ Page AT, Falster MO, Litchfield M, Pearson SA, Etherton-Beer C (July 2019). "Polypharmacy among older Australians, 2006-2017: a population-based study". The Medical Journal of Australia. 211 (2): 71–75. doi:10.5694/mja2.50244. PMID 31219179.
  14. ^ Cline CM, Björck-Linné AK, Israelsson BY, Willenheimer RB, Erhardt LR (June 1999). "Non-compliance and knowledge of prescribed medication in elderly patients with heart failure". European Journal of Heart Failure. 1 (2): 145–9. doi:10.1016/S1388-9842(99)00014-8. PMID 10937924.
  15. ^ Yasein NA, Barghouti FF, Irshaid YM, Suleiman AA (March 2013). "Discrepancies between elderly patient's self-reported and prescribed medications: a social investigation". Scandinavian Journal of Caring Sciences. 27 (1): 131–8. doi:10.1111/j.1471-6712.2012.01012.x. PMID 22616831.
  16. ^ Mandell AJ, Selz KA (August 1992). "Dynamical systems in psychiatry: now what?". Biological Psychiatry. 32 (4): 299–301. doi:10.1016/0006-3223(92)90034-w. PMID 1358230.
  17. ^ Callahan J, Sashin JI (1987). "Models of affect-response and anorexia nervosa". Annals of the New York Academy of Sciences. 504 (1): 241–59. Bibcode:1987NYASA.504..241C. doi:10.1111/j.1749-6632.1987.tb48736.x. PMID 3477119.
  18. ^ Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC (April 2016). "Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011". JAMA Internal Medicine. 176 (4): 473–82. doi:10.1001/jamainternmed.2015.8581. PMC 5024734. PMID 26998708.
  19. ^ Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW (August 2005). "Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance". JAMA. 294 (6): 716–24. doi:10.1001/jama.294.6.716. PMID 16091574.
  20. ^ Haider SI, Johnell K, Thorslund M, Fastbom J (February 2008). "Analysis of the association between polypharmacy and socioeconomic position among elderly aged > or =77 years in Sweden". Clinical Therapeutics. 30 (2): 419–27. doi:10.1016/j.clinthera.2008.02.010. PMID 18343279.
  21. ^ Page AT, Clifford RM, Potter K, Schwartz D, Etherton-Beer CD (September 2016). "The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis". British Journal of Clinical Pharmacology. 82 (3): 583–623. doi:10.1111/bcp.12975. PMC 5338123. PMID 27077231.
  22. ^ Potter K, Flicker L, Page A, Etherton-Beer C (4 March 2016). "Deprescribing in Frail Older People: A Randomised Controlled Trial". PLOS ONE. 11 (3): e0149984. Bibcode:2016PLoSO..1149984P. doi:10.1371/journal.pone.0149984. PMC 4778763. PMID 26942907.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  23. ^ Page AT, Falster MO, Litchfield M, Pearson SA, Etherton-Beer C (July 2019). "Polypharmacy among older Australians, 2006-2017: a population-based study". The Medical Journal of Australia. 211 (2): 71–75. doi:10.5694/mja2.50244. PMID 31219179.
  24. ^ Ha, Christina Y. (2014-02-01). "Medical Management of Inflammatory Bowel Disease in the Elderly: Balancing Safety and Efficacy". Clinics in Geriatric Medicine. 30 (1): 67–78. doi:10.1016/j.cger.2013.10.007. ISSN 0749-0690. PMID 24267603.
  25. ^ a b Hilmer SN, Gnjidic D, Le Couteur DG (December 2012). "Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients". Australian Family Physician. 41 (12): 924–8. PMID 23210113.
  26. ^ a b c d e f Pérez-Jover, Virtudes; Mira, José J.; Carratala-Munuera, Concepción; Gil-Guillen, Vicente F.; Basora, Josep; López-Pineda, Adriana; Orozco-Beltrán, Domingo (2018-02-10). "Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases". International Journal of Environmental Research and Public Health. 15 (2). doi:10.3390/ijerph15020310. ISSN 1660-4601. PMC 5858379. PMID 29439425.{{cite journal}}: CS1 maint: unflagged free DOI (link) Cite error: The named reference ":0" was defined multiple times with different content (see the help page).
  27. ^ Cadogan CA, Ryan C, Hughes CM (February 2016). "Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many". Drug Safety. 39 (2): 109–16. doi:10.1007/s40264-015-0378-5. PMC 4735229. PMID 26692396.
  28. ^ Page, Amy T.; Clifford, Rhonda M.; Potter, Kathleen; Schwartz, Darren; Etherton‐Beer, Christopher D. (2016-09). "The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta‐analysis". British Journal of Clinical Pharmacology. 82 (3): 583–623. doi:10.1111/bcp.12975. ISSN 0306-5251. PMC 5338123. PMID 27077231. {{cite journal}}: Check date values in: |date= (help)CS1 maint: PMC format (link)
  29. ^ Rankin, Audrey; Cadogan, Cathal A; Patterson, Susan M; Kerse, Ngaire; Cardwell, Chris R; Bradley, Marie C; Ryan, Cristin; Hughes, Carmel (2018-09-03). Cochrane Effective Practice and Organisation of Care Group (ed.). "Interventions to improve the appropriate use of polypharmacy for older people". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008165.pub4. PMC 6513645. PMID 30175841.{{cite journal}}: CS1 maint: PMC format (link)
  30. ^ "MATCH-D Medication Appropriateness Tool for Comorbid Health conditions during Dementia".
  31. ^ Page AT, Potter K, Clifford R, McLachlan AJ, Etherton-Beer C (October 2016). "Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel". Internal Medicine Journal. 46 (10): 1189–1197. doi:10.1111/imj.13215. PMC 5129475. PMID 27527376.
  32. ^ Anderson, Kristen; Stowasser, Danielle; Freeman, Christopher; Scott, Ian (2014-12-08). "Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis". BMJ open. 4 (12): e006544. doi:10.1136/bmjopen-2014-006544. ISSN 2044-6055. PMC 4265124. PMID 25488097.
  33. ^ Maher RL, Hanlon J, Hajjar ER (January 2014). "Clinical consequences of polypharmacy in elderly". Expert Opinion on Drug Safety. 13 (1): 57–65. doi:10.1517/14740338.2013.827660. PMC 3864987. PMID 24073682.
  34. ^ Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C (October 2014). "Interventions to improve the appropriate use of polypharmacy for older people". The Cochrane Database of Systematic Reviews. 10 (10): CD008165. doi:10.1002/14651858.CD008165.pub3. PMID 25288041.
  35. ^ Alldred DP, Kennedy MC, Hughes C, Chen TF, Miller P (February 2016). "Interventions to optimise prescribing for older people in care homes". The Cochrane Database of Systematic Reviews. 2: CD009095. arXiv:1510.02343. doi:10.1002/14651858.CD009095.pub3. PMID 26866421.
  36. ^ Edey R, Edwards N, Von Sychowski J, Bains A, Spence J, Martinusen D (February 2019). "Impact of deprescribing rounds on discharge prescriptions: an interventional trial". International Journal of Clinical Pharmacy. 41 (1): 159–166. doi:10.1007/s11096-018-0753-2. PMID 30478496.

Further reading

External links

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