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      Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium

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          Abstract

          The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20–30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20–30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy.

          Journal of Comorbidity 2011;1:28–44

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          Most cited references132

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          Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

          Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.
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            Polypharmacy in elderly patients.

            Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.
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              Appropriate prescribing in elderly people: how well can it be measured and optimised?

              Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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                Author and article information

                Journal
                J Comorb
                J Comorb
                joc
                Journal of Comorbidity
                Swiss Medical Press GmbH (Hochwald, Switzerland )
                2235-042X
                27 December 2011
                2011
                : 1
                : 28-44
                Affiliations
                [1] 1Istituto di Ricerche Farmacologiche ‘Mario Negri’, Milan, Italy
                [2] 2Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
                Author notes
                Correspondence: Alessandro Nobili, Laboratory for Quality Assessment of Geriatric Therapies and Services, Istituto di Ricerche Farmacologiche ‘Mario Negri’, via Giuseppe La Masa, 19, 20156 Milan, Italy. Tel.: +39 02 39014512; fax: +39 02 39001916; E-mail: alessandro.nobili@ 123456marionegri.it
                Article
                2011006
                10.15256/joc.2011.1.4
                5556419
                29090134
                fbbd57fa-26d9-405c-944d-37289cae22f6
                Copyright: © 2011 The Authors

                This is an open-access article distributed under the Creative Commons Attribution-NonCommercial License, which permits all noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 20 October 2011
                : 16 November 2011
                Categories
                Review

                adverse drug events,aging,geriatrics,internal medicine,multimorbidity,polypharmacy

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