Journal of Gerontological Nursing

Geropharmacology 

Patient and Provider Perspectives on Deprescribing Proton Pump Inhibitors

Chisom Ikeji, MD; Anne Williams, PharmD; George Hennawi, MD, CMD, FACP; Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP

Abstract

The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9–17.]

Abstract

The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9–17.]

Polypharmacy, defined as the use of five or more medicines daily, is prevalent among older adults within the United States. In the community, it is estimated that 30% of adults age ≥65 and 85% of nursing home patients are exposed to polypharmacy (Avraham & Biglow, 2018; Scott et al., 2015). Due to age-related pharmacokinetic and physiological changes, this places older adults at an increased risk for medication-related hospital admissions, increased likelihood of nursing home placement, impairment of mobility, and ultimately death (Hanlon et al., 1997). These driving factors make the initiative to reduce polypharmacy in older adults through deprescribing critical (Brandt, 2016).

Proton pump inhibitors (PPIs) are one of the most commonly prescribed potentially inappropriate medications among older adults. A study investigating polypharmacy in outpatient settings demonstrated that PPIs account for approximately one half of all potentially inappropriate medications prescribed to older adults (Ali, Roberts, & Tierney, 2009; Lee, Lo, Ubhi, & Milewski, 2017). Similarly, among hospitalized patients prescribed chronic PPI therapy, 49% to 65% have no indication for chronic use (Björnsson et al., 2006). Data from the National Nursing Home Survey found that an estimated 50% of nursing home residents receiving PPIs did not have evidence-based indications for use (Rane, Guha, Chatterjee, & Aparasu, 2017). These findings are particularly concerning for older adults given the risks associated with inappropriate PPI use. PPI therapy has been associated with increased risk for Clostridium difficile infections, community acquired pneumonia, acute interstitial nephritis, vitamin B12 deficiency, iron deficiency, and bone fractures (Corsonello et al., 2018; Gulmez et al., 2007; Xie et al., 2017). In addition, a recent study published by the U.S. Department of Veterans Affairs found a significant increase in all-cause mortality associated with PPI use (Xie et al., 2019). Due to the strong body of evidence demonstrating these risks, the 2019 American Geriatrics Society (AGS) Beers Criteria® strongly recommends limiting PPI use to <8 weeks for most older adults.

Deprescribing is an effective method to reduce inappropriate PPI therapy and improve patient safety. Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm or is no longer beneficial (Thompson & Farrell, 2013). Studies conducted within long-term care facilities, nursing homes, and outpatient settings have demonstrated that deprescribing can often be achieved without adverse events and may improve longevity (Iyer, Naganathan, McLachlan, & Le Couteur, 2008). Initiatives for PPI deprescribing have begun to grow worldwide. However, due to a variety of barriers within clinical practice, deprescribing does not always occur as frequently as it should. Several provider barriers to deprescribing have been identified, such as professional hindrances, lack of deprescribing guidelines, time limitations, patient complexity, and clinical uncertainty (Linsky, Meterko, Stolzmann, & Simon, 2017; Reeve, Wiese, Hendrix, Roberts, & Shakib, 2013).

The intent of the current study is to characterize PPI use among older adults and illustrate patient and provider barriers to deprescribing. Although previous studies have investigated patient and provider deprescribing awareness, these studies were not conducted in populations within the same health care system, limiting comparisons. By evaluating perspectives of providers and their health system's patients, the current study provides clearer insight into barriers limiting sustainable PPI deprescribing initiatives. Ultimately, this study will inform and enhance the implementation of PPI deprescribing protocols.

Method

The current study was an observational, single-center, retrospective chart review conducted at the Center for Successful Aging (CSA) at MedStar Good Samaritan Hospital in Baltimore, Maryland. The CSA is an outpatient geriatric clinic that provides person-centered, interprofessional care. Surveys were also completed by patients and providers. The study received Institutional Review Board approval.

Chart Review

Patients were included if they were age ≥65 with an active PPI order and receiving primary care at the CSA between January 2017 and December 2017. Data were collected using electronic health records (EHRs) and analyzed using Microsoft® Excel. Patients' EHRs were reviewed to identify PPI duration of use, indication for use, agent, frequency, and dose, as well as history of osteoporosis/osteopenia, C. difficile, and DEXA scan. Because each patient was only counted once, if a patient had multiple PPI prescriptions during the study period, only the prescription that the patient was on for the majority of the study period was included. On the other hand, the duration of PPI exposure included the period of time the patient was prescribed any PPI, regardless of dose or frequency. Inappropriate PPI therapy was determined using U.S. Food and Drug Administration and Centers for Medicare & Medicaid Services (2013) recommendations. Any dose, duration, or frequency outside of these recommendations was considered inappropriate.

Survey

Patient and provider perspectives were evaluated via a pre-validated questionnaire. Surveys were conducted between April 2018 and August 2018 for all groups. Patients age ≥65 who spoke English, were cognitively intact, and currently receiving PPI therapy presenting for an outpatient visit at the CSA were identified via EHR review and asked to complete a PPI survey. The patient survey was adapted from the previously validated questionnaire, Patients' Attitudes Towards Deprescribing Versions for Older Adults and Caregivers, which was revised from the Patients' Attitudes Towards Deprescribing questionnaire to better suit older adults and caregivers (Reeve, Low, Shakib, & Hilmer, 2016). The questionnaire was adapted to focus on PPI deprescribing specifically. Questions were worded based on the viewpoint of the older adult or caregiver using a 5-point Likert response scale (strongly agree, agree, no opinion, disagree, and strongly disagree). Barriers to deprescribing were assessed by asking questions to determine belief in appropriateness, concerns about stopping, involvement in medication management, and global understanding of medication. A paper version of the patient survey was completed in the office then entered electronically using SurveyMonkey®. Patient answers were anonymous, and surveys did not collect demographic characteristics. The survey comprised 14 questions in the English language, requiring 10 to 15 minutes to complete.

Providers, physicians, physician assistants, nurse practitioners, and pharmacists practicing ambulatory medicine in geriatrics, internal medicine, and family medicine at MedStar Good Samaritan Hospital in Baltimore, Maryland, were e-mailed a link to the survey questionnaire. All responses were anonymous and electronically submitted via SurveyMonkey. Participation in the survey was voluntary and agreement to answer the questions was taken as consent to participate. The provider survey was developed and modified from published studies evaluating practitioner deprescribing perspectives, which included the previously validated Beliefs About Medicines Questionnaire (Reeve et al., 2016; Reeve et al., 2013). The survey was developed to assess providers' general attitudes regarding patient PPI use, deprescribing practices, comfort level of deprescribing, understanding of PPI indications, and perceived barriers to deprescribing. Providers were asked to indicate their overall comfort level with discontinuation or reducing dose of PPIs on a scale of 0 to 10, ranging from not comfortable to very comfortable. Providers were also asked to identify all factors that make it difficult to deprescribe from a provided list, which included an “other” category, which allowed free-text responses. The survey comprised 10 questions in the English language and took approximately 5 minutes to complete.

Results

Retrospective Chart Review

A total of 107 patients met inclusion criteria for this study. Sixty percent were female (n = 69) and breakdown of ages was: 65 to 69, 14% (n = 15); 70 to 79, 35% (n = 37); 80 to 89, 36% (n = 39); and 90 to 99, 15% (n = 16). The most prevalent PPIs prescribed were omeprazole (42%, n = 45) and pantoprazole (36%, n = 39), followed by esomeprazole (14%, n = 15) and lansoprazole (8%, n = 8). Among all PPI users, 74% (n = 79) had documented indications of gastroesophageal reflux disease (GERD) or heartburn (Table 1). A significant number of patients received PPI therapy for ≥5 years (39%, n = 42), but the majority of patients received PPI therapy for >1 year (84%, n = 90) (Figure 1). Only 12% (n = 13) of patients had indications for long-term use, which were bleeding gastric ulcer (8%, n = 9), Barrett's esophagitis (2%, n = 2), and severe esophagitis (2%, n = 2). Of note, 32% (n = 34) of patients had a history of osteopenia or osteoporosis documented in the chart. In addition, 6% (n = 6) of patients had a medical history positive for C. difficile infections.

Total Daily Dose and Indication of Proton Pump Inhibitors

Table 1:

Total Daily Dose and Indication of Proton Pump Inhibitors

Duration of proton pump inhibitor treatment.

Figure 1.

Duration of proton pump inhibitor treatment.

Patient Survey Results

A total of 19 patients completed the survey. Patients reported using omeprazole most frequently (47%, n = 9), followed by pantoprazole (37%, n = 7), and lastly esomeprazole (16%, n = 3). Seventy-nine percent (n = 15) of patients had been on the medication for longer than 12 months. A majority (89%, n = 17) of patients stated that they were taking PPIs for heartburn or GERD. Of those surveyed, 89% (n = 17) of participants agreed or strongly agreed to have a good understanding of why they were prescribed their PPI.

Appropriateness Factor. Fifty-eight percent (n = 11) of patients agreed or strongly agreed that they would be willing to discontinue their PPI to see how they felt without it. In contrast, 42% (n = 8) of patients disagreed or strongly disagreed. When asked if they would like their physician to reduce the dose of the PPI, 47% (n = 9) of patients agreed or strongly agreed, 32% (n = 6) disagreed or strongly disagreed, and 21%, (n = 4) had no opinion. In response to the question, “I think my PPI may not be working,” 63% (n = 12) disagreed or strongly disagreed, whereas 32% (n = 6) agreed or strongly agreed. No patients reported that they think the drug may be causing side effects (Table 2).

Patient Survey Results (N = 19)Patient Survey Results (N = 19)

Table 2:

Patient Survey Results (N = 19)

Concerns About Stopping Factor. Forty-seven percent (n = 9) of patients indicated that they would be reluctant to stop their PPI, whereas 42% (n = 8) disagreed or strongly disagreed. In response to the question, “I get stressed when changes are made to my PPI,” 58% (n = 11) of patients strongly disagreed or disagreed, 37% (n = 7) had no opinion, and 5% (n = 1) agreed with this statement. Sixty-eight percent (n = 13) of patients responded disagree or strongly disagree to the question, “If my doctor recommended stopping PPI, I would feel that he/she was giving up on me.” Approximately one third (n = 6) of patients had a bad experience when stopping the medication (Table 2).

Involvement Factor and Global Question. Of patients surveyed, 89% (n = 17) agreed or strongly agreed to being involved in making decisions about their PPI with their physician. The majority 84% (n = 16) agreed or strongly agreed to discontinuing the medication if their physician said it was possible (Table 2).

Provider Survey Results

A total of 74 providers completed the online questionnaire. Survey questions were grouped into two categories to assess the beliefs and perceptions regarding PPI deprescribing and provider identified barriers to deprescribing (Table 3).

Provider Beliefs and Perceptions (N = 74)

Table 3:

Provider Beliefs and Perceptions (N = 74)

Beliefs and Perceptions. With respect to discontinuation of PPIs, providers generally were comfortable with the process: 69% of providers rated themselves >7 on the comfort scale of discontinuing PPIs and 69% rated themselves >7 with dose or frequency de-escalation of PPIs. In both questions, no providers rated themselves as “I am not comfortable.” Approximately 90% of providers believed that PPIs are overprescribed and 84% have attempted to deprescribe PPIs. With respect to outcomes, 36% were successful and 11% were able to reduce the dose or frequency, whereas 27% switched to a H2 receptor antagonist or antacid. Some of the additional comments noted that they were unable to successfully change the dose or discontinue PPI medication due to “I didn't follow up with the patient,” and “rebound symptoms experienced by patients.”

Approximately three fourths of providers answered neutral, disagree, or strongly disagree when asked if they believe that patients can adequately follow directions for deprescribing. In addition, 74% answered sometimes to the question, “How often do you find it difficult to determine whether a PPI should be prescribed and appropriate timing of deprescribing?”

Barriers to Deprescribing. Of the 74 respondents, the top barrier to deprescribing was a reluctance to change a medication prescribed by a different prescriber (49%, n = 36) (Table 4). The second most common choice was “fear of potential negative outcomes from deprescribing” (43%, n = 32) followed by “time constraints during appointment” (39%, n = 29), “uncertainty about evidence-based guidelines regarding PPI deprescribing” (36%, n = 27), “access to clinical notes” (32%, n = 24), and “attention and effort needed to deprescribe” (22%, n = 16). There were 11 free-text responses in the “other” section. The most common free-text response was centered on patient unwillingness or reluctance, followed by lack of understanding of the indication for the medication. One comment was in regard to pharmacy automated requests for refills persisting despite PPI discontinuation.

Provider Barriers to Deprescribing Proton Pump Inhibitors (PPI) (N = 74)

Table 4:

Provider Barriers to Deprescribing Proton Pump Inhibitors (PPI) (N = 74)

Discussion

The current study illustrated that although 98% of older adults received chronic PPI therapy, only 12% had indications for long-term use. Considering this finding, 86% of geriatric patients in this study received potentially inappropriate PPI therapy. This finding aligns with provider surveys, where 89% of providers believed PPIs were overprescribed but few reported that they often knew the duration (14%) or the indication (20%) of their patients' PPI therapy. The prevalence of potentially inappropriate PPI use among older adults in the current study was higher than national and international data, where inappropriate PPI therapy ranged from 20% to 40% (Chia & Bek, 2018; Nauton, Peterson, Deeks, Young, & Kosari, 2018; Thompson & Farrell 2013). Chronic PPI use has been shown to increase the risk for fracture, a particular concern among older adults where hip and vertebral fractures are a significant cause for morbidity and mortality (Brauer, 2009; Liu et al., 2019). The current study highlights the concern for fractures as approximately one-third of patients had a documented history of osteopenia or osteoporosis. Of note, this is likely an underestimation of the prevalence of bone disorders in geriatric patients receiving PPI therapy, as 56% of patients in the current study had not received DEXA screening per U.S. Preventive Services Task Force (2018) recommendations.

Understanding patient beliefs and attitudes regarding PPI deprescribing is critical to institute sustainable changes and overcome identified patient concerns. Nurses, especially those in home care, play a crucial role in medication management in older adults. Nurses can also gain an understanding about the individual patient's understanding of his/her therapy by asking specific questions outlined in the survey. For this reason, nurses should understand the importance of PPI deprescribing and be provided with educational programs on the processes of deprescribing.

Although most patients surveyed indicated they would try stopping their PPI to see how they felt without it, a significant proportion (42%) were reluctant to stop their PPI or reduce the dose (32%), even though 33% believed their PPI may not be working. Similar to other studies, patients reported that they would reduce or discontinue their PPI if encouraged by their physician (Turner & Tannenbaum, 2017). This finding suggests that patients may be more likely to reduce PPI use if providers initiate deprescribing conversations.

Similar to patients, providers experience their own barriers to PPI deprescribing. It is equally crucial to consider these barriers when instituting sustainable deprescribing protocols. Four of the five greatest barriers identified by surveyed providers included reluctance to change medications they did not initiate, fear of negative outcomes, time constraints, and uncertainty regarding evidence-based guidelines. Several of these themes are consistent with previous works where providers expressed fear of deprescribing another provider's medication, concern for negative outcomes, and uncertainty of evidence-based guidelines (Ailabouni, Nishtala, Mangin, & Tordoff, 2016; Djatche et al., 2018). To address these barriers, the majority of surveyed providers indicated they would be more comfortable deprescribing (59%) or de-escalating (55%) PPI therapy after additional training. The fourth largest barrier identified by providers (78%) was that patients would not be able to follow deprescribing directions, a barrier pharmacists are adept at managing. Pharmacists can reduce provider barriers to deprescribing by navigating guidelines and coordinating care with prescribing providers. In addition, nurses are often the first health care provider patients encounter and can take the necessary time to initiate deprescribing discussions. The critical information nurses gather can be communicated to members of a multidisciplinary team, including physicians and pharmacists, streamlining the deprescribing process.

Limitations

Several limitations of the current study include the low population size from a single center, which may limit the generalizability of perspectives discussed above. In addition, data regarding demographic information or the specific role of the prescriber were not collected on the surveys; therefore, age, sex, and individual prescriber trends cannot be discussed. The authors also acknowledge the potential for responder bias and recall bias in the patient surveys. Another limitation is that most providers did not have a direct relationship with the patients. However, all respondents care for patients within the same health care system, which comprises a similar patient population. The chart review had several limitations of its own. Using only EHR records, it can be difficult to ascertain past attempts to deprescribe as well as a complete list of medical conditions to identify appropriate indications for use.

Conclusion

These findings illustrate a health systems approach to better understanding opportunities and barriers to deprescribing that can be addressed. Elucidating the perspectives of patients and providers strengthens the success of implementing sustainable programs. Despite numerous perceived barriers, successful PPI deprescribing requires providers to have open conversations with their patients. Furthermore, the process of deprescribing needs an interprofessional team approach coupled with resources to support its ongoing success.

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Total Daily Dose and Indication of Proton Pump Inhibitors

Medication/Total Daily Dose (mg)Indicationn (%)
Omeprazole (n = 45)
  10GERD3 (7)
  20GERD23 (51)
Barrett's esophagitis1 (2)
Severe esophagitis1 (2)
Bleeding gastric ulcer2 (4)
No indication2 (4)
  40GERD6 (13)
Bleeding gastric ulcer2 (4)
No indication3 (7)
  80GERD2 (4)
Pantoprazole (n = 39)
  20GERD5 (13)
Bleeding gastric ulcer1 (3)
No indication1 (3)
  40GERD22 (56)
Severe esophagitis1 (3)
Bleeding gastric ulcer2 (5)
History of peptic ulcer disease1 (3)
No indication1 (3)
  80GERD3 (8)
Bleeding gastric ulcer1 (3)
NSAID prophylaxis1 (3)
Esomeprazole (n = 15)
  20GERD1 (7)
Barrett's esophagitis1 (7)
History of peptic ulcer disease1 (7)
No indication2 (13)
  40GERD7 (47)
No indication2 (13)
History of peptic ulcer disease1 (7)
Lansoprazole (n = 8)
  15GERD1 (13)
  30GERD5 (63)
Bleeding gastric ulcer1 (13)
  60GERD1 (13)

Patient Survey Results (N = 19)

Factor Evaluatedn (%)
Appropriateness
  I would like to try stopping my proton pump inhibitor (PPI) to see how I feel without it
    Agree/strongly agree11 (58)
    No opinion0 (0)
    Disagree/strongly disagree8 (42)
  I would like my doctor to reduce the dose of my PPI
    Agree/strongly agree9 (47)
    No opinion4 (21)
    Disagree/strongly disagree6 (32)
  I think my PPI may not be working
    Agree/strongly agree6 (32)
    No opinion1 (5)
    Disagree/strongly disagree12 (63)
  I believe my PPI may be giving side effects
    Agree/strongly agree0 (0)
    No opinion5 (26)
    Disagree/strongly disagree14 (74)
Concerns About Stopping
  I would be reluctant to stop my PPI
    Agree/strongly agree9 (47)
    No opinion2 (11)
    Disagree/strongly disagree8 (42)
  I get stressed whenever changes are made to my PPI
    Agree/strongly agree1 (5)
    No opinion7 (37)
    Disagree/strongly disagree11 (58)
  If my doctor recommended stopping my PPI I would feel that they were giving up on me
    Agree/strongly agree6 (33)
    No opinion0 (0)
    Disagree/strongly disagree13 (68)
  I have had a bad experience when stopping my PPI
    Agree/strongly agree6 (32)
    No opinion6 (32)
    Disagree/strongly disagree7 (37)
Involvement
  I have a good understanding of the reason I was prescribed PPI
    Agree/strongly agree17 (89)
    No opinion1 (5)
    Disagree/strongly disagree1 (5)
  I'd like to be involved in making decisions about my PPI with my doctor
    Agree/strongly agree17 (89)
    No opinion1 (5)
    Disagree/strongly disagree1 (5)
Global Question
  If my doctor said it was possible, I would be willing to stop my PPI
    Agree/strongly agree16 (84)
    No opinion0 (0)
    Disagree/strongly disagree3 (16)

Provider Beliefs and Perceptions (N = 74)

Factorn (%)
Self-rated (1 to 10) comfort with proton pump inhibitor (PP I) discontinuation
  I am not comfortable deprescribing PPIs (1 to 2)0 (0)
  I would need more information or training before feeling comfortable (3 to 4)5 (7)
  I am somewhat comfortable (5 to 6)18 (24)
  I would feel more comfortable while deprescribing if I had more training (7 to 8)21 (28)
  I am very comfortable deprescribing (9 to 10)30 (41)
Self-rated (1 to 10) comfort with PPI dose or frequency de-escalation
  I am not comfortable deprescribing PPIs (1 to 2)0 (0)
  I would need more information or training before feeling comfortable (3 to 4)3 (4)
  I am somewhat comfortable (5 to 6)21 (28)
  I would feel more comfortable while deprescribing if I had more training (7 to 8)17 (23)
  I am very comfortable deprescribing (9 to 10)33 (45)
Believe that PPIs are overused
  Agree/strongly agree66 (89)
  Neutral/disagree/strongly disagree8 (11)
Believe patients are able to follow deprescribing directions
  Agree/strongly agree20 (27)
  Neutral/disagree/strongly disagree54 (73)
Have attempted to discontinue a PPI
  Yes62 (84)
  No12 (16)
Uncertain about indication for patient's PPI
  Never/rarely15 (20)
  Sometimes37 (50)
  Often/usually22 (30)
Uncertain about duration of PPI use
  Never/rarely10 (14)
  Sometimes29 (39)
  Often/usually35 (47)
Uncertain when to deprescribe and appropriate timing to deprescribe
  Never/rarely10 (14)
  Sometimes55 (74)
  Often/usually9 (12)

Provider Barriers to Deprescribing Proton Pump Inhibitors (PPI) (N = 74)

Barriern (%)
Reluctance to change a medication prescribed by a different prescriber36 (49)
Fear of potential negative outcomes from deprescribing32 (43)
Time constraints during appointments29 (39)
Uncertainty about evidence-based guidelines regarding PPI deprescribing27 (36)
Access to clinical notes24 (32)
Attention and effort needed to deprescribe22 (16)
Patient's ability to communicate20 (30)
Decreased motivation to deprescribe10 (13)
Lack of decision-support systems6 (8)
Lack of adequate reimbursement0 (0)
Other: Additional barriers identified by providers
  Patients' reluctance to discontinue7 (9)
  Lack of understanding for indication2 (3)
  Automated pharmacy refill requests1 (1)
Authors

Dr. Ikeji is Geriatrics Fellow, Yale New Haven Hospital, New Haven, Connecticut; Dr. Williams is PGY-2 Ambulatory Care Pharmacy Resident, Faculty Development Fellow, UPMC St. Margaret l Department of Medical Education, Pittsburgh, Pennsylvania; Dr. Hennawi is Director of Geriatrics, MedStar Good Samaritan Hospital, and Medical Director, Center for Successful Aging, and Dr. Brandt is Executive Director, The Peter Lamy Center on Drug Therapy and Aging, Professor, Pharmacy Practice and Science, University of Maryland School of Pharmacy, and Clinical and Research Pharmacist, Center for Successful Aging, MedStar Good Samaritan Hospital, Baltimore, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP, Executive Director, The Peter Lamy Center on Drug Therapy and Aging, Professor, Pharmacy Practice and Science, University of Maryland School of Pharmacy, Clinical and Research Pharmacist, Center for Successful Aging, MedStar Good Samaritan Hospital, 220 Arch Street/SGO 01-125, Baltimore, MD 21201; e-mail: nbrandt@rx.umaryland.edu.

10.3928/00989134-20190912-03

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