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Polypharmacy in the Geriatric Population

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Northeast Florida Medicine, Vol. 69, No. 3, September 2018

Polypharmacy; A Case-based Primer on the Practice in the Geriatric Population

Haya S. Kaseer, PharmD,2
Robert P. Shannon, MD, FAAHPM,3
Jessica A. Peterson, PharmD4
1Department of Pharmacy, School of Health Sciences, Mayo Clinic College of Medicine, Jacksonville, FL
2University of Florida, College of Pharmacy, Gainesville, FL
3Department of Family and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, FL
4Maine Medical Center, Portland, ME

Address Correspondence to:

Michael J. Schuh, PharmD, MBA, FAPhA
Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224
Phone: (904) 953-2673
Email: schuh.michael@mayo.edu

Date of Release: September 1, 2018
Date Credit Expires: September 1, 2020
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Polypharmacy; A Case-based Primer on the Practice in the Geriatric Population” authored by Michael J. Schuh, PharmD, MBA, FAPhA, Haya S. Kaseer, PharmD, Robert P. Shannon, MD, FAAHPM, and Jessica Peterson, PharmD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

Michael J. Schuh, PharmD, MBA, FAPhA, Clinical Pharmacist, Assistant Professor of Family and Palliative Medicine, Assistant Professor of Pharmacy, School of Health Sciences, College of Medicine, Mayo Clinic, Haya S. Kaseer, PharmD, Mayo Clinic, Robert P. Shannon, MD, FAAHPM, Assistant Professor of Family and Palliative Medicine, Jessica Peterson, PharmD, Clinical Pharmacist, Maine Medical Center.

Needs Assessment:

Polypharmacy is an ever-increasing cause for concern in an inherently vulnerable population. Geriatric patients are axiomatically more vulnerable due to multimorbidity, waning cognitive capacity and social isolation whose situation is compounded by the natural aging process. In a world of increasing depersonalization, increasing technology, and waning social and family support, polypharmacy is a threat that is identifiable, soluble, and potentially correctible by early identification and appropriate pharmacy-lead team-based primary care models of care. This care-based updated will assist the healthcare team to achieve that goal.

Objectives:

1. Identify patients at high risk for complications associated with polypharmacy.
2. Be able to create a plan of care to mitigate the risk of drug-drug interactions on behalf of the patient.
3. Be able to evaluate and counsel the patient who needs additional comprehensive medication management pharmacy consultation.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact the DCMS at 904-355-6561 or dcms@dcmsonline.org. 

Faculty Disclosure:

Michael J. Schuh, PharmD, MBA, FAPhA, Haya S. Kaseer, PharmD, Robert P. Shannon, MD, FAAHPM, and Jessica Peterson, PharmD report no significant relations to disclose, financial or otherwise, with an commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

Polypharmacy in the geriatric population is challenging for all caretakers involved. Those patients often have a variety of comorbid medical conditions requiring numerous medications. On occasion, these medications are no longer consistent with the treatment goals and can cause serious side effects. Geriatric patients may benefit from the expertise of pharmacists who are well-trained in pharmacology, pharmacokinetics and pharmacodynamics working in collaboration with primary physicians in both the inpatient and outpatient setting. The authors present a case-based primer on the principles of polypharmacy in the geriatric population. .

Polypharmacy is simply defined as “the administration of multiple medications concomitantly or the administration of excessive medications.”1 Approximately 61 percent of individuals older than 65 take at least one prescription medication, and most are taking an average of three, exclusive of over-the-counter (OTC) medications or supplements.2

Another recent analysis found the prevalence of polypharmacy in the United States (defined as ≥8 medications) was 15.7 percent; females had a higher rate of polypharmacy than males. Polypharmacy is most dominant in the southern region of the United States. Between 1988 and 2010, multiple medication use increased dramatically. The median number of prescription medications used in adults aged ≥ 65 has doubled, and the proportion of adults taking five medications or more has tripled from 12.8 percent to 39.0 percent.3,4

Clinical practice guidelines often recommend several medications to treat chronic disease. Consequently, an elderly patient with at least two medical conditions, such as hypertension and diabetes, will often be on more than five medications.5

Polypharmacy in the elderly is associated with increased healthcare expenses and emergency room visits.6 Geriatric patients are at increased risk for adverse drug events due to drug interactions, altered drug metabolism, or absorption from declining organ function. Medications also contribute to increased fall risk in geriatric patients. It is estimated that 1 in 3 older adults fall annually, associated with increased emergent care visits, increased cost, and death. Reducing polypharmacy can reduce the number of falls and subsequent debility.7

Many elderly patients take medications without a clear indication. Often, drugs are not routinely assessed for continued need. Examples include long term use of proton pump inhibitors for a history of acid reflux, xanthine oxidase inhibitors for a distant episode of gout, and hormone replacement therapy in patients long past menopause. Studies of community-based older patients have documented an average of one unnecessary drug per patient, including drugs with no identifiable current indication or those that provide marginal benefit for the disease indication.8

Additionally, the elderly often self-medicate, sometimes preferring supplements for health and medical conditions.9 A recent study showed analgesics, vitamins and dietary supplements are commonly self-administered by older adults. Dietary supplements may be viewed as benign by patients and providers, but can have major interactions with prescription medications. This view is problematic in the setting of polypharmacy and decreased organ function, and increases the risk for drug interactions and adverse effects.10   

 

Patient Centered Medical Home/Beers Criteria

The Patient Centered Medical Home (PCMH) is a healthcare delivery model recognized to improve the quality and efficiency of care while responding to each patient’s unique needs. This model focuses on a team approach, incorporating physicians, nurses, social workers, and pharmacists. The PCMH provides comprehensive, patient-centered care, including acute care, chronic condition management, and preventative services to patients from childhood to end of life.11,12 

The Beers Criteria is an evidence-based list of medications from The American Geriatric Society which helps identify the risk level of certain medications that can cause harm to elderly patients. The list includes common drug-drug interactions associated with harmful outcomes, and identifies drugs to avoid in patients with kidney impairment. A clinician can use this list to monitor medication use and recommend discontinuation, dose adjustments, and/or increased monitoring.13 

 

Pharmacy Medication Management: The Evolving Role of Pharmacist

Numerous studies demonstrate the benefits of clinical pharmacist interventions in the setting of polypharmacy.7, 14,15,16, 17 Medication therapy management (MTM) clinically integrates pharmacists in the PCMH in a variety of practice models. Physicians may be time-limited during office visits and unable to address polypharmacy or conduct comprehensive medication reviews. MTM is a comprehensive, patient-centered service that can enhance therapeutic outcomes while ensuring individualized care. MTM provides face to face patient education to review medication use, simplify medication regimens, and improve adherence.  

MTM focuses on improving the quality of care in elderly patients, utilizing clinical guidelines and patient goals. The pharmacist reviews the patient’s medications, counsels the patient on proper administration and management of side effects, and educates the patient on non-pharmacological interventions. The pharmacist identifies potential concerns, and reviews the medical and relevant drug history to suggest a plan that meets the patient’s goals. After composing the recommendations, the pharmacist discusses modifications with the physician to improve quality of life and prevent potential complications.

The role of the pharmacist is especially significant in chronic disease management. The pharmacist ensures that the patient understands short-term and long-term treatment goals, therapeutic monitoring, and possible adverse effects, and can alleviate patient knowledge gaps in understanding when complex treatments have been initiated by multiple physicians.18 

 

Medication Reconciliation

Medication errors frequently occur during transitions of care. Errors result when patients can’t recall home medications, and when records are unavailable. 

Medication reconciliation is a required process of creating a medication list for a patient during transitions of care. Medication reconciliation reduces the incidence and severity of medication errors during both prescribing and dispensing. Maintaining an up-to-date list and accounting for medication changes at every appointment helps to reduce inadvertent medication errors, and harm to the patient.19,20 

Screening tools are helpful in preventing medication errors in the elderly. The screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria recognize the dual nature of inappropriate prescribing by including a list of potentially inappropriate medications (STOPP criteria) and potential prescribing omissions (START criteria).21 Potentially inappropriate medications identified by STOPP criteria include digoxin, beta blocker with history of COPD, TCA with dementia, long-acting benzodiazepines, and prolonged use of first generation antihistamines.22 Potential prescribing omissions, defined as treatments indicated but not prescribed, by START criteria include ACE inhibitor following acute myocardial infarction, ACE inhibitor in chronic heart failure with no existing contraindications, statin therapy in patients with documented history of cardiovascular events, and ACE inhibitor or Angiotensin Receptor Blocker in diabetes with nephropathy.23 There is no evidence that using the START/STOPP criteria reduces morbidity, mortality, or cost in the geriatric population. However, these criteria may identify opportunities for better patient prescribing practices.24

  

Comprehensive Geriatric Assessment

The geriatric assessment is a multidimensional tool intended to gather information on the medical, psychological, social, and functional abilities and restrictions of the elderly population. Areas to assess include current symptoms and their functional influence, current medications along with indications and effects, past allergies and medical conditions, recent life changes, current caregiver network, measure of cognitive function, nutritional status, and services required. It is important to inquire about demographics, patient’s chief complaint and present illness, past medical history, social history, daily nutritional health, physical activity, sleep hygiene, and recreational activities. It is useful to perform regular physical examinations and laboratory tests, and a thorough review of systems for every elderly patient.25

 

Opioids and Controlled Substance Treatment Plans

Opioids are listed on the Beers Criteria due to increased risk for falls, fractures, and potential interaction with other psychotropic medications. Despite this recommendation, elderly patients are frequently prescribed chronic opioids for nonmalignant pain. The use of prescription opioids has increased in older adults in the United States.26, 27, 28

The elderly are at risk for adverse drug events due to opioid use, and they are not immune to opioid misuse and overdose. Compassionate care requires a delicate balance of undertreating pain and inappropriate prescribing. If opioids are deemed appropriate for long term use, providers must discuss benefits and risks, including side effects and potential for dependence or addiction. 

Controlled Substance Treatment Plans should be formulated between the patient and physician, including goals of treatment, with a schedule for periodic evaluations. Non-pharmacologic treatments should be considered as alternatives or in conjunction with medications. Treatment plans should outline appropriate medication use and define medication misuse. Providers should address other medications that can interact with opioids and efforts should be made to minimize other central nervous system (CNS) modulating medications.28

 

Palliative Care

Polypharmacy is common in patients at end of life. There is little guidance on appropriate discontinuation of medications in the setting of palliative care. The pharmacist and members of the palliative care interdisciplinary team should focus the conversation on the wishes of the patient and family, and create a plan of care consistent with the notion of “assess, anticipate and alleviate suffering.” All modalities aimed at comfort, including those on the Beers Criteria should be considered and offered; all other treatments should become elective or discontinued.29 Continuing unnecessary medications can increase harm to patients and add to the burden of polypharmacy, and providers should highlight the disadvantages of continuing medications.30 Medications such as aspirin or statins are particularly important in palliative care discussions.

 

Specialty-based

Geriatrics: Geriatric patients are often cared for by multiple specialists. When care is not coordinated between each provider, patients are at risk for polypharmacy, duplications in therapy, drug interactions and increased side effects.31 

Oncology: Cancer progression and treatment affect the overall quality of life, functioning, and life expectancy of older adults. Polypharmacy is a serious concern in cancer patients.32 Chemotherapy agents are associated with several adverse effects, including gastrointestinal abnormalities, peripheral neuropathy, hand and foot syndrome, and hypersensitivity reactions. In the setting of polypharmacy, toxicity and adverse effects may increase due to drug-drug interactions or metabolism-induced complications. This can lead to lack of adherence, treatment failure and suffering. A patient’s medications should be evaluated thoroughly to avoid therapeutic barriers and adverse consequences. 

Neurology & Psychiatry: With each amendment of the Beers Criteria, there is a greater focus on antipsychotics, benzodiazepines, tricyclic antidepressants, opioids, and other CNS-impacting agents. Polypharmacy with multiple of these medications is risky and dangerous.28 When managing mental health and controlling pain in the elderly, it is imperative to evaluate each patient’s medications and ensure the use of CNS-impacting agents is limited to what is truly needed. Subjective assessment of a patient’s mental and pain status is essential to manage these medications, including listening to caregivers in patients with cognitive impairment.

Cardiology: Hypertension, atrial fibrillation, and heart failure are some chronic disease states commonly seen in the geriatric population necessitating the use of anti-hypertensives, nitrates, antiplatelets drugs, and anticoagulants. Cardiac medications have risks of bleeding, orthostatic hypotension, bradycardia, and falls that are often seen in the geriatric population. Therefore, polypharmacy requires special attention to ensure appropriate medications are prescribed, and adverse effects are managed. Patient education and monitoring are crucial to achieving treatment goals.

Case #1

  • Demonstrates the diversity of symptoms resulting from polypharmacy.
  • Illustrates how fragmented care contributes to polypharmacy.
  • Shows the “multiplier effect” of iatrogenic symptoms.

A 64-year-old female presented to her pulmonologist for evaluation of dyspnea. Her medications included diclofenac, cyclobenzaprine, and hydrocodone/acetaminophen from her chronic pain physician, clonazepam, nortriptyline, and duloxetine from her psychiatrist, and topiramate, gabapentin, and cetirizine from her primary care physician. The patient also had chronic renal disease, cognitive impairment, six falls over several months, anxiety, mydriasis, episodes of sweating, nausea, and occasional myoclonic jerks and tremor. She was unmotivated to exercise or socially engage, was anemic, and gained 20 pounds over the last year.

 

Case #2

  • Illustrates the importance of screening for potential medication-medication and medication-nutrition interactions.
  • Demonstrates the importance of respecting a patient’s autonomy and goals of care.
  • Identifies necessary dose modifications in the setting of impaired renal function.

A 71-year-old female was referred for a comprehensive medication review with a pharmacist by her family physician. Her chief concerns included feeling fatigued and depressed. She reported dizziness, nausea, acid reflux, and “wanted to stay in bed all day.” Her blood pressure was significantly elevated with systolic readings in the 170-180’s. 

Her past medical history was significant for undifferentiated connective tissue disease, uncontrolled hypertension, renal dysfunction, and hypothyroidism. Current medications include apixaban, atorvastatin, calcium carbonate, carvedilol, chlorthalidone, hydralazine, hydroxychloroquine, levothyroxine, nitrofurantoin, prednisone, spironolactone, tramadol, ferrous sulfate, and vitamin B complex.

Thyroid-stimulating hormone and calcium levels were elevated. Patient reported taking her levothyroxine one hour apart from her ferrous sulfate. She wished to stop as many medications as possible and was not agreeable to starting additional medications for hypertension.

 

Case #3

  • Illustrates the positive impact of de-prescribing.
  • Demonstrates role of judicious and appropriate use of comfort medications even if on the Beers Criteria list.
  • Shows the need for earlier palliative care interventions.

A 76-year-old female who was in transit from Virginia to St. Augustine, Florida was seen in the palliative medicine clinic following an overnight observation in the emergency department for acute altered mental status superimposed on advanced dementia, renal impairment, hypertension, hyperlipidemia, osteoarthritis, sarcopenia, anemia, weight loss, acute urinary retention, and constipation. She was on several medications including a diuretic, a statin, and donepezil. The patient was hallucinating intermittently, frequently agitated, and seemed to be in pain. Beyond “sundowning,” she had sleep-wake cycle disruption. The physical exam showed advanced dementia with poor functional capacity: she was wheelchair bound and incontinent of urine and feces with very little verbal capacity.

Case #1

The clinical pharmacist MTM suggestions:

  • Taper to stop the scheduled clonazepam and use lorazepam only for acute anxiety attacks. Clonazepam has an extended half-life in the elderly and through accumulation is additive with other CNS depressants, contributing to fall risk, depression, respiratory depression and dyspnea.
  • Taper down gabapentin and topiramate doses since glomerular filtration rate (GFR) is 50 mL/min, to prevent reduced cognition and additive CNS/respiratory depression.
  • Minimize all serotonergic medications if possible, (duloxetine, cyclobenzaprine, nortriptyline) as patient exhibited possible signs of serotonin toxicity.
  • Consider recommended sleep hygiene protocol or alternative agents for depression/sleep; current therapy may be ineffective.
  • Dyspnea may be multifactorial. Deconditioning, added weight, and respiratory depression from multiple medications are likely contributory factors.
  • Refer patient to the pain rehabilitation clinic (PRC) for overall taper of pain and CNS depressive medications to lowest possible dose or discontinuation.

The pulmonologist suggested that the patient and her primary physicians follow the pharmacist recommendations. After enrollment into a PRC, the above recommendations were followed, and following the 21-day program, the total prescription and over-the counter medication count was reduced from 19 to 7.

 

Case #2

The clinical pharmacist MTM suggestions:

  •  Maximize doses of current antihypertensives instead of adding additional agents.  Recommended home blood pressure monitoring, lifestyle modifications, and appointment with registered dietician.
  •  Separate levothyroxine and ferrous sulfate administration by at least four hours. Recheck Thyroid-Stimulating Hormone (TSH) in six weeks.
  •  Take tramadol only as needed. Tramadol requires dosing adjustments in patients with impaired renal function. The active metabolite of tramadol is excreted in the kidney and the half-life may be prolonged in patients with renal dysfunction, leading to increased CNS depression, somnolence and fatigue. Augment analgesia with acetaminophen if needed.
  •  Elevated calcium may contribute to nausea. Stop calcium carbonate use for reflux symptoms. Utilize non-pharmacologic methods or ranitidine. Check parathyroid hormone. Consider withdrawal of chlorthalidone if serum calcium is still elevated.
  •  Nitrofurantoin is not recommended with patient’s current renal function impairment; however, she was convinced this medication prevented UTIs which reoccurred whenever she discontinued use in the past. Therefore, in this case it was continued.
  •  Consider wean off prednisone which can contribute to CNS symptoms and increase blood pressure. Patient was unsure of clinical indication or efficacy.

After discussion with the primary provider, the patient’s hydralazine dose was increased. Patient reduced tramadol use and added acetaminophen. She had a consultation with a registered dietician and blood pressure normalized. Repeat TSH was within normal limits. 

 

Case #3

Fortunately, despite the advanced dementia, the patient had valid documentation of advance care planning including designation of healthcare surrogate and a living will declaring her wish to “allow a natural death” while focusing on comfort care. 

Deprescibing is a thoughtful process of discontinuing medications especially pertinent in the case when the patient’s survival time wanes.33 After discussion with the family on the risk/benefit ratio, potential for drug-induced harm, and ways to stay consistent with her primary goal of comfort, the family concurred that she no longer needed the diuretic, statin or donepezil; hence, all were discontinued.

To attend to the patient’s agitation and sleep/wake cycle disruption, a very low dose of quetiapine was combined with low dose mirtazapine at bedtime. Oxycodone for arthritic pain was offered simultaneously with constipation mitigation strategies, and a referral for hospice was accomplished. She perked up cognitively for a few days and then died with her family at her side. While the patient’s wishes were articulated on paper, she was not afforded timely counsel to focus earlier on comfort goals, exposing her to potential missed opportunities of life, pain, and existential suffering.

  • Evaluate and treat the problems that the patient declares important.
  •  Review completely the medication list for safety and efficacy.
  •  Create plan of care consistent with patient/surrogate goals.
  •  Assess benefits versus burdens, alternatives and probabilities of reaching individual goals.
  •  Recommend for or against implementation, continuation or discontinuation.
  •  Reassess periodically for achievement of goals.
  •  Ask for help at every step in the process as needed.

Polypharmacy in geriatric patients is a common issue leading to poorer health outcomes, increased costs and decreased quality of life. Primary care providers need to be aware of the unique characteristics of the geriatric population, including altered organ function, impaired drug clearance, and cognitive impairment. Providers should also attempt to advocate and coordinate the multiple recommendations from specialist providers in the geriatric population. A multidisciplinary approach, utilizing all the specialized skill sets of various healthcare providers, including pharmacists and palliative care physicians, can be helpful in identifying medication related issues, managing polypharmacy, and streamlining regimens for patients’ preference and treatment goals. Ultimately, the patient’s treatment goals should be respected while maintaining the safest and most efficacious care possible.

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23. Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment) ― an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007 Nov;36(6):632-8.

24. Therapeutic Research Center. PL detail-document #270906, STARTing and STOPPing medications in the elderly. Pharmacist’s letter/prescriber’s letter. [Internet]. 2011 Sep. Available from: https://www.ngna.org/_resources/documentation/chapter/carolina_mountain/STARTandSTOPP.pdf.

25. Comprehensive Geriatric Assessment [Internet]. Boston (MA): Tufts University; 2017 [cited 2017 May 9]. 25 p. Available from: http://ocw.tufts.edu/data/42/499797.pdf.

26. Olfson M, Wang S, Crystal S, et al. National trends in the office-based prescription of schedule II opioids. J Clin Psychiatry. 2013 Sep;74(9):932-9.

27. Gerlach LB, Olfson M, Kales HC, et al. Opioids and other central nervous system–active polypharmacy in older adults in the United States. J Am Geriatr Soc. 2017 Sep;65(9):2052-56

28. Maust DT, Gerlach LB, Gibson A, et al. Trends in central nervous system–active polypharmacy among older adults seen in outpatient care in the United States. JAMA Intern Med. 2017 Apr 1;177(4):583-5.

29. Geijteman ECT, Dees MK, Tempelman MMA, et al. Understanding the continuation of potentially inappropriate medications at the end of life: perspectives from individuals and their relatives and physicians. J Am Geriatr Soc. 2016 Dec;64(12):2602–4.

30. McNeil MJ, Kamal AH, Kutner JS, et al. The burden of polypharmacy in patients near the end of life. J Pain Symptom Manage. 2016 Feb;51(2):178–183.e2.

31. Rambhade S, Chakarborty A, Shrivastava A, et al. A Survey on Polypharmacy and Use of Inappropriate Medications. Toxicol Int. 2012 Jan-Apr;19(1):68-73.

32. Lichtman S, Hurria A, Jacobsen P. Geriatric oncology: an overview. J Clin Oncol. 2014 Aug 20;32(24):2521-2. 33. Pruskowski J. Fast Facts and concepts # 321 [Internet]. 2016 Sep [cited 2017 Jul 10]. Available from: https://www.mypcnow.org/copy-of-fast-fact-320. accessed July 10, 2017.