Geriatric Syndromes

GERIATRIC

SYNDROMES

FARHAD ZARGARI, MD, PHD

GERIATRIC SYNDROMES

GERIATRIC SYNDROMES

1-Disability

2-Dementia and Delirium

3-Falls

4-Poly-pharmacy

5-Pressure Ulcers

6-Urinary Incontinence

DISABILITY

1-LONGER LIVES AND DISABILITY

Are we living healthier as well as longer lives, or are our

additional years spent in poor health? There is

considerable debate about this question among

researchers, and the answers have broad implications for

the growing number of older people around the world.

One way to examine the question is to look at changes

in rates of disability, one measure of health and function.


Disability is part of the human condition. Almost everyone

will be temporarily or permanently impaired at some

point in life, and those who survive to old age will

experience increasing difficulties in functioning.


Disability is the umbrella term for impairments, activity

limitations and participation restrictions, referring to the

negative aspects of the interaction between an

individual (with a health condition) and that individual’s

contextual factors (environmental and personal factors).


Disability is “an evolving concept”, also “disability results

from the interaction between persons with impairments

and attitudinal and environmental barriers that hinder

their full and effective participation in society on an

equal basis with others”. Defining disability as an

interaction means that “disability” is not an attribute of

the person.


Responses to disability have changed since the 1970s,

prompted largely by the self-organization of people with

disabilities, and by the growing tendency to see disability

as a human rights issue. Historically, people with

disabilities have largely been provided for through

solutions that segregate them, such as residential

institutions and special schools. Policy has now shifted

towards community and educational inclusion, and

medically- focused solutions have given way to more

interactive approaches recognizing that people are

disabled by environmental factors as well as by their

bodies.


Disability encompasses the child born with a congenital

condition such as cerebral palsy or the young soldier

who loses his leg to a land-mine, or the middle-aged

woman with severe arthritis, or the older person with

dementia, among many others.

DISABILITY AND HUMAN RIGHTS

Disability is a human rights issue because:

People with disabilities experience inequalities – for example,

when they are denied equal access to health care,

employment, education, or political participation because of

their disability.

People with disabilities are subject to violations of dignity – for

example, when they are subjected to violence, abuse,

prejudice, or disrespect because of their disability.

Some people with disability are denied autonomy – for

example, when they are subjected to involuntary sterilization,

or when they are confined in institutions against their will, or

when they are regarded as legally incompetent because of

their disability.

DISABILITY AND DEVELOPMENT

Disability is a development issue, because of its

bidirectional link to poverty: disability may increase the

risk of poverty, and poverty may increase the risk of

disability. A growing body of empirical evidence from

across the world indicates that people with disabilities

and their families are more likely to experience

economic and social disadvantage than those without

disability.


Some researchers think there will be a decrease in the

prevalence of disability as life expectancy increases,

termed a “compression of morbidity.” Others see an

“expansion of morbidity”—an increase in the prevalence

of disability as life expectancy increases. Yet others

argue that, as advances in medicine slow the

progression from chronic disease to disability, severe

disability will lessen, but milder chronic diseases will

increase.


In the United States, between 1982 and 2001 severe

disability fell about 25 percent among those aged 65 or

older even as life expectancy increased. This very

positive trend suggests that we can affect not only how

long we live, but also how well we can function with

advancing age. Unfortunately, this trend may not

continue in part because of rising obesity among those

now entering older ages.


The analysis of the Global Burden of Disease estimates

that 15.3% of the world population (some 978 million

people of the estimated 6.4 billion in 2004 had

“moderate or severe disability”, while 2.9% or about 185

million experienced “severe disability”. Among those

aged 0–14 years, the figures were 5.1% and 0.7%, or 93

million and 13 million children, respectively. Among those

15 years and older, the figures were 19.4% and 3.8%, or

892 million and 175 million, respectively.


Based on 2010 population estimates – 6.9 billion with 5.04

billion 15 years and over and 1.86 billion under 15 years –

and 2004 disability prevalence estimates (World Health

Survey and Global Burden of Disease) there were around

785 (15.6%) to 975 (19.4%) million persons 15 years and

older living with disability. Of these, around 110 (2.2%) to

190 (3.8%) million experienced significant difficulties in

functioning. Including children, over a billion people (or

about 15% of the world’s population) were estimated to

be living with disability.


Fig. 2.1. Global disability prevalence estimates from

different sources:

This figure compares the

population-weighted average

prevalence of disability for

high-income, middle- income,

and low-income countries

from multiple sources. The solid

grey bars show the average

prevalence based on

available data, the range lines

indicate the 10th and 90th

percentiles for available

country prevalence within

each income group. The data

used for this figure are not age

standardized and cannot be

directly compared with Table

2.1 and Table 2.3. WHS = World

Health Survey; GBD = the

Global Burden of Disease, 2004


Age-specific disability prevalence, derived from multi-

domain functioning levels in 59 countries, by country

income level and sex:


Age-specific disability prevalence, derived from multi-

domain functioning levels in 59 countries, by country

income level and sex:



American adults reported worse health than did

European adults as indicated by the presence of chronic

diseases and by measures of disability. At all levels of

wealth, Americans were less healthy than their European

counterparts. Analyses of the same data sources also

showed that cognitive functioning declined further

between ages 55 and 65 in countries where workers left

the labor force at early ages, suggesting that

engagement in work might help preserve cognitive

functioning.


Prevalence of

Chronic Disease and

Disability among Men

and Women Aged

50-74 Years in the

United States,

England, and Europe:

2004

Source: Adapted from Avendano

M, Glymour MM, Banks J,

Mackenbach JP. Health

disadvantage in US adults aged 50

to 74 years

REHABILITATION

Rehabilitation as “a set of measures that assist individuals

who experience, or are likely to experience, disability to

achieve and maintain optimal functioning in interaction

with their environments”. A distinction is sometimes made

between habilitation, which aims to help those who

acquire disabilities con- genitally or early in life to

develop maximal functioning; and rehabilitation, where

those who have experienced a loss in function are

assisted to regain maximal functioning.

DEMENTIA

2-THE BURDEN OF DEMENTIA

Physicians often define dementia based on the criteria

given in the Diagnostic and Statistical Manual of Mental

Disorders (DSM). In 2013 the American Psychiatric

Association released the fifth edition of the DSM (DSM-5),

which incorporates dementia into the diagnostic

categories of major and mild neurocognitive disorders.


To meet DSM-5 criteria for major neurocognitive disorder,

an individual must have evidence of significant cognitive

decline (for example, decline in memory, language or

learning), and the cognitive decline must interfere with

independence in everyday activities (for example,

assistance may be needed with complex activities such

as paying bills or managing medications). To meet DSM-5

criteria for mild neurocognitive disorder, an individual

must have evidence of modest cognitive decline, but

the decline does not interfere with everyday activities

(individuals can still perform complex activities such as

paying bills or managing medications, but the activities

require greater effort).


Dementia is a syndrome due to disease of the brain –

usually of a chronic or progressive nature – in which there

is disturbance of multiple higher cortical functions,

including memory, thinking, orientation, comprehension,

calculation, learning capacity, language, and

judgment. Consciousness is not clouded. The

impairments of cognitive function are commonly

accompanied, and occasionally preceded, by

deterioration in emotional control, social behavior, or

motivation. This syndrome occurs in a large number of

conditions primarily or secondarily affecting the brain.


The cause of most dementia is unknown, but the final

stages of this disease usually means a loss of memory,

reasoning, speech, and other cognitive functions. The risk

of dementia increases sharply with age and, unless new

strategies for prevention and management are

developed, this syndrome is expected to place growing

demands on health and long term care providers as

population ages.


The disease is not easy to diagnose, especially in its early

stages. The memory problems, misunderstandings, and

behavior common in the early and intermediate stages

are often attributed to normal effects of aging,

accepted as personality traits, or simply ignored.


Many cases remain undiagnosed even in the

intermediate, more serious stages. A cross-national

assessment conducted by the Organization for

Economic Cooperation and Development (OECD)

estimated that dementia affected about 10 million

people in OECD member countries around 2000, just

under 7 percent of people aged 65 or older.







Types of Dementia

Alzheimer’s disease

Vascular dementia=Post-stroke dementia

Dementia with Lewy bodies (DLB)

Frontotemporal lobar degeneration (FTLD)

Mixed dementia

Parkinson’s disease (PD) dementia

CreutzfeldtJakob disease

Normal pressure hydrocephalus


The total number of people with dementia worldwide in

2010 is estimated at 35.6 million and is projected to

nearly double every 20 years, to 65.7 million in 2030 and

115.4 million in 2050. The total number of new cases of

dementia each year worldwide is nearly 7.7 million,

implying one new case every four seconds.


The total estimated worldwide costs of dementia were

US$ 604 billion in 2010. In high-income countries, informal

care (45%) and formal social care (40%) account for the

majority of costs, while the proportionate contribution of

direct medical costs (15%) is much lower. In low-income

and lower-middle-income countries direct social care

costs are small, and informal care costs (i.e. unpaid care

provided by the family) predominate.


Alzheimer’s disease(AD) is the most common form of

dementia and accounted for between two-fifth and four

fifth of all dementia cases cited in the OECD report. More

recent analyses have estimated the worldwide number

of people living with AD/dementia at between 27 million

and 36 million. The prevalence of AD and other

dementias is very low at younger ages, then nearly

doubles with every five years of age after age 65.


In the OECD review, for example, dementia affected

fewer than 3 percent of those aged 65 to 69, but almost

30 percent of those aged 85 to 89. More than one-half of

women aged 90 or older had dementia in France and

Germany, as did about 40 percent in the United States,

and just under 30 percent in Spain.


The projected costs of caring for the growing numbers of

people with dementia are daunting. The 2010 World

Alzheimer Disease Report estimates that the total

worldwide cost of dementia exceeded US$600 billion in

2010, including informal care provided by family and

others, social care provided by community care

professionals, and direct costs of medical care. Family

members often play a key caregiving role, especially in

the initial stages of what is typically a slow decline. Ten

years ago, U.S. researchers estimated that the annual

cost of informal caregiving for dementia in the United

States was US$18 billion.


The complexity of the disease and the wide variety of

living arrangements can be difficult for people and

families dealing with dementia, and countries must cope

with the mounting financial and social impact. The

challenge is even greater in the less developed world,

where an estimated two-thirds or more of dementia

sufferers live but where few coping resources are

available.


Projections by World Alzheimer Disease Report suggest

that 115 million people worldwide will be living with

AD/dementia in 2050, with a markedly increasing

proportion of this total in less developed countries.


The Growth of

Numbers of People

with Dementia in High-

income Countries and

Low- and Middle-

income Countries:

2010-2050

Source: Alzheimer’s Disease International,

World Alzheimer Report, 2010.

GERIATRIC FALLS

HELP! I’VE FALLEN AND I CAN’T GET UP!

3-GERIATRIC FALLS

Falls are the leading cause of external injuries.

Most common in children less than 5 years old and adults 65

and older.

Trauma is the 5th cause of death in those >65 years

Falls are responsible for 70% of accidental deaths in

people over 75 years old.

1/4 of the elderly people who fracture their hips die

within 6 months of the injury.

35%-40% of people 65+ fall each year. Those who

fall are 2-3 times more likely to fall again.

10%-20% of falls cause serious injuries.

3-GERIATRIC FALLS

Falls are the leading cause of external injuries.

Most common in children less than 5 years old and adults 65

and older.

Trauma is the 5th cause of death in those >65 years.

Falls are responsible for 70% of accidental deaths in

people over 75 years old.

1/4 of the elderly people who fracture their hips die

within 6 months of the injury.

3-GERIATRIC FALLS

Up to 20-30% of falls in older adults result in an injury

requiring medical care

Most fractures in Medicare population are due to falls

Falls in older adults are the leading cause of traumatic

brain injury

Men have a higher rate of fatal falls (due to TBI)

Women are more likely to have non-fatal falls

3-GERIATRIC FALLS

Age GroupFirst Leading

of Trauma Death

Second Leading

Cause of

Death

35 – 64Motor Vehicle

36.8%

Falls

29.6%

65+Falls

43.3%

Motor Vehicle

10.2%

3-GERIATRIC FALLS

Consequences of Geriatric Falls

Death

Injury

Fractures 10-15%

Hip 1-2%

Long Lie

Fear of Falling

Reduced Activity/Independence (25%)

3-GERIATRIC FALLS-HIP FRACTURE

In 1996 more than 250,000 older Americans had fractured hips.

90% are associated with falls

Excess of $10 billion

Leading fall-related injury that results in hospitalization –which are often prolonged and costly.

What Happens After the Hip Fracture?

One in four people that have a hip fracture that lived independently before the fracture had to live in a nursing home for a year afterward, according to the CDC.

Some never recover their balance and strength.

This can lead to depression and dementia and a downhill spiral.

Unfortunately 1/4 of the elderly people who fracture their hips die within 6 months of the injury.

3-GERIATRIC FALLS-BRAIN INJURY

Also a common injury following a fall

Many elderly on “blood thinners”

Symptoms may be subtle and not apparent at the time

of injury.

RISK FACTORS FOR FALLS

Increased age

Living alone

Previous falls

Use of a cane or walker

Acute illness

Reduced vision

Glare intolerance

Altered depth perception

Decreased night vision

Decline in peripheral vision


CVA that results in hemiparesis, sensory and/or

motor function deficits.

Decreased range of motion and flexibility in lower

legs and spine.

Weakness

Decreased step length (short shuffling steps)

Alzheimer’s or dementia

Arthritis

Parkinson’s disease

Foot problems

Toenail length, callouses, bunions, deformities


Difficulty rising from a chair

Neurologic changes

Slowed reaction times

Diminished sensory awareness for light touch, vibration,

and temperature

Decline in proprioception

Decreased hearing

Impaired speech discrimination

Excessive cerumen accumulation

Loss of high frequency tones

Risky behaviors


Medications

Some antidepressants

Sedatives

Some antihypertensive and cardiac medications

Hypoglycemic drugs

Alcohol

3-GERIATRIC FALLS

American Geriatrics Society: Most Common Intrinsic Fall

Risk Factors

Muscle weakness: 4.4

History of falls: 3.0

Gait or balance deficit: 2.9

Use of assistive device: 2.6

Visual deficit: 2.5

Arthritis: 2.4

Depression: 2.2

Cognitive impairment: 1.8

Age over 80 years: 1.7

Data from AGS Panel on Falls Prevention. Guideline for the prevention of falls in older

persons. J Am Geriatr Soc 2001;49(5):664–72.

4-POLY-PHARMACY

POLYPHARMACY-DEFINITION

Polypharmacy means “many drugs.”

In practice, polypharmacy refers to the use of more

medication than is clinically indicated or warranted.

Polypharmacy can result in a gradual accumulation of

side effects and/or adverse drug reactions, which

negatively effects elders’ health and well-being.


Polypharmacy is the use of four or more medications by

a patient, generally adults aged over 65 years.

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, affecting about 40% of

older adults living in their own homes.


Although polypharmacy can be appropriate, it is more

often inappropriate. Concerns about polypharmacy

include increased adverse drug reactions, drug

interactions, prescribing cascade, and higher costs.

Polypharmacy is often associated with a decreased

quality of life, decreased mobility and cognition.


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, low educational level, and those with

impaired vision or dexterity.


The literature review found that polypharmacy continues

to increase and is a known risk factor for important

morbidity and mortality.


Older adults comprise 12% of the U.S. population, but use

35% of the prescription medications and 50 percent of

the over-the-counter medications.

The average medication usage for persons over 65 is:

2 to 6 prescription drugs, plus …

1 to 3.4 over-the-counter medicines.

In 2011, 58 percent of adults 65 years or older reported

taking 5 or more medications and 18% reported taking

10 or more (Slone Epidemiology Center).

The average American senior spends $870 annually for

pharmaceuticals.

POLYPHARMACY-CAUSES

1-Age:

Community elders- 90% > 1med; 40% > 5meds; 12% > 10meds.

Highest number of drugs per person in greater than 80 year

olds

POLYPHARMACY-CAUSES

2-Chronic Diseases:

Increased prevalence of somatic complaints and chronic

disease

POLYPHARMACY-CAUSES

3-Drug Regimen Changes:

New meds, different doses…

Changes from generic to brand- nomenclature, color and/or

shape

POLYPHARMACY-CAUSES

4-Providers – Patients Relationship:

The more the providers and physician visits, the more the

number of medications patients take.

2/3 of all physician visits end with a prescription.

Expectations to receive medication is growing from the patient

side.

Shortage in communicating with PCP about medications

changes.

Self-treatment

POLYPHARMACY-COMPLICATIONS

Polypharmacy leads to:

More adverse drug reactions.

Decreased adherence to drug regimens.

Higher rates of disease symptomatology.

(Unnecessary) drug expenses.

All of the above contribute to client distress and poorer

quality of life, which are of great concerns.

POLYPHARMACY-COMPLICATIONS

Polypharmacy leads to:

More adverse drug reactions (ADR).

Decreased adherence to drug regimens.

Higher rates of disease symptomatology.

(Unnecessary) drug expenses.

All of the above contribute to client distress and poorer

quality of life, which are of great concerns.

ADVERSE DRUG REACTIONS

Side effects: considered minor enough to allow

continuation of therapy.

Adverse Drug Reactions (ADRs): May necessitate

discontinuation of drug and require treatment of adverse

event.


An adverse drug reaction (ADR) is defined as the unwanted, negative consequences associated with the use of a medications or medications.

Over 100,000 deaths a year are attributed to adverse drug reactions, making ADRs the fourth leading cause of death in the U.S. (Lazarou, Pomeranz, & Corey, 2009).

Other examples of ADRs include:

Peptic ulcers

Anemia

Deceased white blood cell production (which increases infection risk)

Liver damage

Kidney damage

Confusion/drowsiness (which can lead to falls and subsequent injuries)


About 3 to 7% of all hospital admissions in the United

States are for treatment of adverse drug reactions.

Elderly 7 times more likely to have unwanted side effect

and 2-3 times more likely to have ADRs

Adverse drug reactions occur during 10 to 20% of

hospital admissions, and about 10 to 20% of these

reactions are severe.

The most consistent risk factor for an adverse drug

reactions is:

The number of drugs being taken.

Multiple medications is the factor most strongly

correlated with increased risk of ADRs. Exponential

increase in ADRs with addition of more drugs to a

regimen (2 drugs-15%, 5 drugs-50-60% ).


1

10

100

0 2 4 6 8 10 12 14 16 18 20

number of drugs taken

per

cen

t of

pat

ien

ts w

ith

AD

R


Other risk factors for ADRs include:

Having six or more chronic diseases.

Taking twelve or more doses of medication (of any type) per

day.

Taking nine or more medications total.

Having had a prior adverse drug reaction.

Being older than 85 years (this is important because persons 85

and older are the fastest growing segment of the population).

Having decreased kidney function.


Drugs most frequently associated with adverse reactions

in the elderly:

Psychotropic drugs, especially benzodiazepines (valium,

ativan)

Anti-hypertensive agents (blood pressure medications)

Diuretics

Digoxin (a heart medication)

NSAIDS (Non-steroidal anti-inflammatory drugs, i.e. aspirin,

Aleve, celebrex)

Corticosteroids (i.e. prednisone - often used to treat arthritis)

Warfarin (coumadin - a blood thinner for treating blood clots)

Theophylline (theo-dur - for treating COPD, asthma)

PHARMACOKINETICS AND AGING

Pharmacokinetics means “What the body does to the

drug.”

It refers to the following functions by which the body

processes medications:

Absorption

Distribution

Metabolism

Excretion

Normal changes in these processes that occur with

aging increase the risk of adverse medication reactions

among older adults.


Absorption

Age-related changes in the gastrointestinal tract and skin seem

to have little impact on medication usage.

So fortunately, there is not much to worry about here, however,

this is not the case for other components of medication

metabolism…


Distribution

Important age-related changes:

Decrease in lean body mass and total body water.

Increased percentage body fat.

Increase in volume of distribution for fat-dissolving drugs, such

as sedatives (I.e. valium, dalmane, librium) that penetrate the

central nervous system.

This means older adults need most lower dosages of such

medications to achieve a therapeutic effect; they are at risk

for toxicity at doses considered normal for younger persons.

Protein-binding changes with aging are of modest significance

for most drugs, especially at steady-state (when the amount of

drug going in is the same as the amount of drug going out).


Metabolism

Many medications are processed by the liver.

Although liver function is relatively unchanged with age, there

is some overall decline in metabolic capacity.

Plus, many of the chronic conditions common among older

adults do negatively impact liver function.

Decreased liver mass and hepatic blood flow lead to:

High variability with no good estimation algorithms for doctors

to determine appropriate medication dosages for older adults.

Minimal clinical manifestations of actual underlying problems,

so it is difficult for doctors to determine when someone may be

having problems.


Renal Excretion

Medications are eliminated from the body via the kidneys and

urinary system.

Age-related decreases in renal blood flow and kidney function

(specifically, glomerular filtration rate) impact older adults’

ability to eliminate medications.

In addition, decreased lean body mass leads to decreased

creatinine production (a measure of kidney function, with high

levels being a cause for concern), thus, for older adults serum

creatinine may appear normal even when significant renal

impairment exists!

PHARMACODYNAMICS AND AGING

Pharmacodynamics is the opposite of pharmacokinetics;

it refers to “What the drug does to the body.”

Generally, lower drug doses are required to achieve the

same effect with advancing age.

This is because:

Receptor numbers, affinity, or post-receptor cellular effects

may change with age.

Changes in homeostatic mechanisms can increase or

decrease drug sensitivity.


Panels of experts in pharmacology and geriatrics have

compiled lists of medications to avoid prescribing for

patients 65 years of age or older.

The most commonly used list is the Beers criteria, which

include 48 "potentially inappropriate medications" (PIMs)

for which there are more effective or safer alternatives

for older patients (Fick, et al, 2003).


However in spite of the Beers criteria:

Numerous studies in the last 15 years have found that PIMs

continue to be used in 12% to 40% of older patients in

community and nursing home settings (Raebel, Charles,

Dugan, & et al, 2007).

Administrative data from nearly 400 hospitals across the United

States reveals that nearly half of all older patients hospitalized

for 7 common conditions were prescribed at least 1 PIM

(Rothberg et al, 2008).


Such irrational polypharmacy can arise from several

factors:

The prescriber hesitates to discontinue medications the patient

has been taking a long time.

The prescriber may add more drugs to the patient's regimen

without removing any.

The prescriber orders medication to alleviate adverse reactions

to other medications.

he patient may be influenced by anecdotal reports touting the

benefits of certain medications.

MEDICATION NON-ADHERENCE

Sometimes being on multiple medications contributes to

patients not taking those medications as the physician

intended.

Not taking medications as prescribed.

Correlates more strongly with number of meds, rather

than age.

It is important to recognize that medication non-

adherence is a two-way street!

Physician factors play a role.

Patient factors play a role.


Example contributing factors:

Patients

Underreporting symptoms

Use of multiple providers

Use of others’ medications

Physicians

Limited time for discussion, diagnostics

Limited knowledge of geriatric pharmacology

The power of inertia


Additional contributing factors:

Large number of medications

Cost and other social barriers

Complexity of medication regimen or frequently changing medication schedule

Adverse reactions (ADRs)

Confusion about brand name/trade name

Difficult-to-open containers

Rectal, vaginal, subcutaneous modes of administration

Lack of insight into illness

Limited patient understanding of medication’s purpose

Cognitive impairment/psych issues

Illiteracy, language/cultural issues

Misunderstanding verbal instructions

Lack of follow up


Like polypharmacy itself, the strongest predictor of

medication non-adherence is the number of

medications.

Non-adherence rates are estimated at 25-50 percent of

older adults.

Non-adherence is intentional about 75% of the time.

33-69% of drug-related admissions result from non-

adherence (for all patients)

Patients discharged with 4 or more meds- over 50% error

rate

Changes in medication regimen made by patients to:

Increase convenience

Reduce adverse effects

SOLUTIONS TO POLYPHARMACY

Review medication

Anticipate Adverse Drug Events ( ADEs)

Avoid errors- prescribe carefully

Give verbal and written instructions

Simplify

Understand obstacles (cost, memory loss…)

Enlist family/nursing/PCP

Make sure there is good follow up

ALWAYS REMEMBER

“Prescribing cascade”- a drug added to treat

(mistakenly) the ADR of another drug.

Clinical Pearl- “Any symptom in an elderly person should

be evaluated as a potential ADR until proven otherwise”.

Many geriatric syndromes can occur as a consequence

of medications: delirium, falls and fractures,

incontinence.

ALWAYS REMEMBER

Polypharmacy is a reality of prescribing when patients

have multiple comorbidities.

We must all anticipate and guard against the potential

complications of polypharmacy.

Optimal prescribing is key!

Date post:	15-Jul-2015
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Geriatric Syndromes

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