title: A Delphi process to address medication appropriateness for older persons with multiple chronic conditions.
abstract: BACKGROUND
  Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.
  
  
  METHODS
  Modified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.
  
  
  RESULTS
  The panel reached consensus on a set of markers to identify problems with medication regimens, including patient/caregiver report of non-adherence, medication complexity, cognitive impairment, medications identified by expert opinion as inappropriate for older persons, excessively tight blood sugar and blood pressure control among persons with diabetes mellitus, patient/caregiver report of adverse medication effects or medications not achieving desired outcomes, and total number of medications. The panel also reached consensus on approaches to address these problems, including endorsement of strategies to discontinue medications with known benefit if necessary because of problems with feasibility or lack of alignment with patient goals.
  
  
  CONCLUSIONS
  The results of the Delphi process provide the basis for an algorithm to improve medication regimens among older persons with MCCs. The algorithm will require assessment not only of medications and diagnoses but also cognition and social support, and it will support discontinuation of medications both when risks outweigh benefits and when regimens are not feasible or do not align with goals.
authors.affiliation: Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. terri.fried@yale.edu.|Department of Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA. terri.fried@yale.edu.
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
authors.affiliation: Clinical Epidemiology Research Center, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.
authors.forename: Kristina
authors.initials: K
authors.lastname: Niehoff
authors.affiliation: Department of Quantitative Health Sciences, UMass Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Tjia
authors.affiliation: Yale School of Nursing, Yale University West Campus, P.O. Box 27399, West Haven, CT, 06516, USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Redeker
authors.affiliation: Palo Alto Geriatrics Research Education and Clinical Center (GRECC), Veterans Affairs Palo Alto Health Care System, GRECC 182-B, 3801 Miranda Avenue, Palo Alto, CA, 94304, USA.|Center for Primary Care and Outcomes Research (PCOR), Stanford University, 117 Encina Commons, Stanford, CA, 94305, USA.
authors.forename: Mary K
authors.initials: MK
authors.lastname: Goldstein
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000453:epidemiology*; D032921:Consensus; D003697:Delphi Technique; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology*; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D011795:Surveys and Questionnaires
keywords: Chronic conditions; Medications; Polypharmacy