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ABSTRACTIntroductionAntipsychotic (AP) medications are extensively utilized for diverse psychiatric and non-psychiatric conditions, but they are associated with significant adverse effects in older adults. This expert opinion review provides an updated profile of adverse effects associated with AP medications in older adults.Areas coveredThis review specifically examines real-world evidence for adverse events associated with AP use, including all-cause mortality, falls and fractures, diabetes, cardiovascular and cerebrovascular events, acute kidney injury, venous thromboembolism/pulmonary embolism, extrapyramidal symptoms, and infections based on real-world evidence.Expert opinionThis comprehensive safety review of AP revealed multiple adverse events in older adults. All-cause mortality, more associated with typical APs than atypicals, underscores a dose-dependent risk, urging cautious prescribing practices and avoidance of typical APs. Falls/fractures associated with atypical APs highlight the importance of judicious dosing and -close monitoring, especially after initiation. Cardiovascular risks, particularly stroke, with AP use emphasize the need for vigilant monitoring. Extrapyramidal symptoms, more linked to typical APs, also pose a significant risk in older adults. Pneumonia and pulmonary embolism/venous thromboembolism demand cautious consideration of APs, prompting the need for additional real-world studies to inform clinical practice. Conflicting evidence on diabetes and acute kidney injury necessitates ongoing studies and further research in older adults.

AbstractSharing data across hospitals for disease modeling is challenging due to concerns over patient privacy and the lack of an efficient privacy-preserving data mining framework. Contextual embedding models, which encode medical events into vector representations while preserving the contextual dependencies between events, have shown promise in privacy-preserving data mining without requiring original data disclosure. However, the medical event representations learned from multiple data sources lie in different embedding spaces and cannot be directly integrated. Existing embedding harmonization algorithms require a list of common medical events between different data sources and use them as corresponding pairs for transformation, known as the supervised harmonization method. However, common medical events can be difficult to collect in clinical practice. To promote data mining across hospitals, we developed a novel unsupervised embedding harmonization system that introduces an unsupervised harmonization algorithm to align contextual embeddings without the need for corresponding pairs. The proposed framework also considered different contextual embedding techniques, including Word2Vec and Med2Vec, to explore the robustness of the proposed unsupervised harmonization algorithm. The proposed framework was evaluated using medical events extracted from the Medical Information Mart for Intensive Care III database. By integrating the embeddings from multiple sources, the proposed framework can achieve better disease prediction accuracy and medical event clustering compared to models built on a single data source. The proposed unsupervised harmonization method, which achieves similar performance to the supervised harmonization model under different contextual embedding techniques, holds great promise for predictive modeling and event clustering in healthcare.

•Approximately one in four multiple sclerosis (MS) patients initiated high-efficacy disease-modifying agents (heDMAs).•Both demographic and clinical factors influenced the selection of heDMA for MS.•Study findings have important implications for understanding the differential factors for selecting and personalizing DMA treatment.

Millions of U.S. people have been heavily affected by opioids. In March 2023, the Food and Drug Administration approved naloxone as an over-the-counter medication. This has allowed more access to patients at high risk of opioid overdose. However, the patient’s willingness to pay for naloxone at the pharmacy counter has not been assessed.

Background: Overactive bladder (OAB) is a prevalent condition commonly treated with anticholinergic medications. The extent to which anticholinergic burden is associated with costs and healthcare resource use (HCRU) in the long-stay nursing home (LSNH) setting is currently unknown. Objectives: This research evaluated the impact of anticholinergic burden on HCRU and related costs among LSNH residents with OAB. Methods: This was a cohort study based on 2013–2015 Minimum Data Set-linked Medicare claims data involving LSNH residents aged ≥ 65 years with OAB and having Parts A, B and D coverage 6 months pre- and ≥ 12 months post-nursing home admission date (index date). Cumulative anticholinergic burden was determined using the Anticholinergic Cognitive Burden scale and defined daily dose. Direct medical costs related to HCRU were examined. HCRU included inpatient, outpatient, emergency room (ER), and physician office visits. Costs and HCRU associated with levels of anticholinergic burden were evaluated using generalized linear models. Results: A total of 123,308 LSNH residents with OAB were included in this study. Most residents (87.2%) had some level (12.8%, none; 18.0%, low; 41.9%, moderate; and 27.3%, high) of cumulative anticholinergic burden. Results indicate that all types of resource utilization were higher among those with any level of anticholinergic burden than those with no burden. The outpatient, ER, and physician costs tended to be higher with increasing anticholinergic burden. Conclusions: Costs and HCRU patterns reflected increasing trends with anticholinergic burden. Targeted efforts towards reducing anticholinergic burden among LSNH residents with OAB may result in decreases in costs and HCRU.

ABSTRACTIntroductionAnticholinergic medications are effective for a wide variety of indications, but are associated with significant central adverse effects, especially cognitive decline and dementia in older adults.Areas coveredWe conducted a review of relevant literature in the past decade to address anticholinergic scales and evidence of anticholinergic-related dementia/cognitive decline in older adults. We discussed various anticholinergic scales used to classify anticholinergic medications. The review focused on the evidence from previous reviews and individual studies evaluating the anticholinergic-related risk of developing cognitive decline/dementia. This review also discussed clinical and methodological issues of studies along with recommendations for practice and research.Expert opinionThe review demonstrates moderate to strong risk of dementia with anticholinergic use in multiple studies involving older adults, irrespective of the study design, analytical approach, anticholinergic exposure and outcome definition. This risk is particularly significant with the cumulative burden and high-level anticholinergics. There also exists a dose–response relationship between anticholinergic use and increased risk for dementia. Therefore, anticholinergic agents can be considered as a modifiable risk factor for dementia and cognitive decline in older adults. Based on the current evidence, regular assessment and optimization of anticholinergic burden prior to prescribing these medications can minimize anticholinergic-related morbidity in older adults.

•This study examined the risk of all-cause-mortality in patients with Parkinson's Disease (PD) using inappropriate antipsychotic.•Inappropriate atypical antipsychotic (AAP) use is associated with a higher risk of all-cause-mortality in older patients with PD which is mainly mediated by pneumonia.•Inappropriate AAP use should be avoided to improve quality of care in PD.

•The study found three adherence trajectories among multiple sclerosis (MS) initiating oral disease-modifying agents (DMAs).•The proportion of complete adherers varied across the oral DMAs.•The study found there was no difference in annualized relapse rates across the three DMAs,•Adherence trajectory grouped as rapid decliners had a higher rate of relapses than completely adherent patients.

A study of data from the Medical Expenditure Survey of 1996 reveals that 19% of community dwelling elderly patients take some form of prescribed psychotropic drug, with 9.1% taking some form of antidepressant drug. Demographic variables did not reveal any predisposing factors other than need and availability of prescription insurance. Women were more likely than men to take psychotropic medication.

Background: Psychotropic agents account for 23% to 51% of all inappropriate medications prescribed based on 1991 inappropriate medication criteria for nursing home residents. The criteria were revised to apply to all people older than 65 years. This study used the revised criteria in ambulatory settings to quantify potentially inappropriate prescription of psychotropic agents and identify associated characteristics. Methods: The 1996 public use data files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed for inappropriate prescription of psychotropic medications for the elderly in office-based settings and outpatient departments. Disease-independent and disease-dependent criteria were analyzed. Results: Elderly patients were prescribed a psychotropic agent in 8.7% of all visits, antidepressant and antianxiety agents being the most frequently prescribed medications. Commonly, elderly patients receiving psychotropic agents were female, white, aged between 65 and 74 years, and received health care in a metropolitan area. Potentially inappropriate psychotropic agents were prescribed in 27.2% of all visits involving a psychotropic agent for the elderly. Disease-independent criteria (eg, antidepressant agents and long-acting benzodiazepines) accounted for most of the potentially inappropriate prescriptions. Factors positively associated with potentially inappropriate prescriptions included older age, 'seen before' status, and antidepressant drug class, while enrollment in Medicaid, antipsychotic drug class, living in the Northeast region, and receiving health care in a metropolitan area were negatively associated. Conclusions: Potentially inappropriate prescription of psychotropic agents is very common for the elderly patient in the ambulatory setting. By focusing on the agents most frequently involved (eg, amitriptyline and long-acting benzodiazepines), provider characteristics (eg, location), and patient characteristics (eg, age), the greatest impact on potentially inappropriate prescribing can be achieved. Arch Intern Med. 2000;160:2825-2831

Patients with multiple sclerosis (MS) frequently switch their Disease-Modifying Agents (DMA) for effectiveness and safety concerns. This study aimed to develop and compare the random forest (RF) machine learning (ML) model with the logistic regression (LR) model for predicting DMA switching among MS patients.

Advances in Disease-Modifying Antirheumatic Drugs (DMARDs) have expanded the treatment landscape for Rheumatoid Arthritis (RA). Guidelines recommend adding either conventional synthetic (cs), biologic (b), or targeted synthetic (ts) DMARDs to methotrexate (MTX) for managing RA. Limited evidence exists regarding the factors that contribute to adding a DMARD agent to the MTX regimen. This study examined the factors associated with adding the first DMARD in RA patients initiating MTX.

Machine learning algorithms are being increasingly used for predicting hospital readmissions. This meta-analysis evaluated the performance of logistic regression (LR) and machine learning (ML) models for the prediction of 30-day hospital readmission among patients in the US.

Background:Parkinson’s disease (PD) is a debilitating neurological disorder that has a significant impact on activities of daily living (ADL). Limited data exists regarding the functional status of nursing home residents with PD. Objective:The study examined the nature, extent, and predictors of limitation of ADL in patients with PD residing in nursing homes. Methods:This study used cross-sectional design involving data from the National Nursing Home Survey (NNHS). The dependent variable was the total number of ADL for which the patient needed assistance. Assistance for ADL comprised of five items of transferring, dressing, eating, toileting and bathing. Multivariable linear regression was used to examine the individual, biological and environmental factors associated with assistance needed for ADL. Results:The nationally representative study sample was of 98,093 nursing home residents with PD for an overall prevalence of 6.57%. The mean age of the study sample was 81.03±0.34 years. Mood symptoms (45%), behavioral symptoms (24%)and dementia (8%) were common among PD patients. Assistance needed for each ADL ranged from 68.24% for eating to 99.25% for bathing. Older age, being married, living in metropolitan statistical area (MSA), living in other place prior to admission, and presence of mood symptoms were positively related to assistance for ADL. Presence of behavioral symptoms and use of levodopa combination therapy were negatively related to assistance for ADL. Conclusions:Majority of the nursing home residents with PD had disability in all the five items of ADL. Various individual, environmental and biological factors were associated with ADL in nursing home residents with PD.

Aim:To evaluate comparative safety of paroxetine and other selective serotonin reuptake inhibitors (SSRIs) for the risk of hip fractures. Patients & methods:A propensity score-matched retrospective cohort study was conducted using 2007–2010 Minimum Data Set linked Medicare data. Robust Cox proportional hazards model was used to evaluate the risk of hip fractures in depressed elderly nursing home residents. Results:Cox analysis did not find any significant difference in the risk of hip fractures for the paroxetine users (hazard ratio: 1.09; 95 CI: 0.91–1.32) when compared with other SSRIs. Results from the sensitivity analysis supported the main findings. Conclusion:There was no differential risk of hip fractures between paroxetine and other SSRIs. Future studies are needed to evaluate other anticholinergic effects of paroxetine.

To examine the risk of dementia with anticholinergic use among elderly nursing home residents with depression.

Background:Past literature suggests that the use of second-generation antidepressants improves cognition in depressed elderly patients. Objective:This study assessed the comparative cognitive profile of commonly used second-generation antidepressant classes in elderly residents with depression. Methods:A multiple propensity score adjusted retrospective cohort study was conducted using 2007-2010 Medicare Part D claims and Minimum Data Set (MDS). Elderly nursing home residents (65 years or older) with depression using a new prescription of selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tetracyclics constituted the study cohort. The outcome of interest was cognition, measured using the MDS Cognition Scale. Cognition was measured at each quarterly assessment after antidepressant initiation for a maximum of 1 year. The propensity score–adjusted repeated-measures mixed model was used to evaluate the comparative profile of SSRIs, SNRIs, and tetracyclics with respect to cognition. Results:The study cohort comprised 1518 elderly nursing home residents. Of these, 1081 received SSRIs (71.21%), 320 received tetracyclics (21.08%), and 117 received SNRIs (7.71%). The propensity score–adjusted repeated-measures mixed model did not show any statistically significant difference in cognition with the use of SSRIs (β = −0.14; 95% CI = −0.53, 0.25) or tetracyclics (β = −0.36; 95% CI = −0.80, 0.08) when compared with SNRIs, after controlling for other factors. Conclusions:The cognitive effect of SSRIs, SNRIs, and tetracyclics was similar in elderly nursing home residents with depression. Further studies are needed to evaluate the long-term cognitive effects of second-generation antidepressants in this vulnerable population.

•This study found that patients with Multiple Sclerosis (MS) have lower physical and mental Health-Related Quality of Life (HRQoL) than their non-MS counterparts.•MS patients were more likely to seek help for help for Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) than non-MS adults.

To examine the prevalence and predictors of potentially inappropriate anticholinergic medication use in older adults with dementia.

Antipsychotic use is associated with serious adverse events in the elderly, and consequently can lead to further healthcare utilization such as nursing home admission. To evaluate the risk of nursing home admission associated with typical versus atypical antipsychotic use among the US community-dwelling elderly population. A retrospective cohort design was conducted using Medicare and Medicaid Analytical eXtract (MAX) data from four US states. The cohort included all dual-eligible beneficiaries (aged ≥65 years) who initiated antipsychotic treatment during July 2001–December 2003. The risk of nursing home admission during the 6-month follow-up period was evaluated using Cox proportional hazards regression model and extended Cox model stratified on matched pairs based on propensity score, using atypical agents as the reference category. The average risk of nursing home admission was similar among atypical antipsychotic users compared to typical users (hazard ratio [HR] 0.91; 95 % confidence interval [CI] 0.81–1.01]) However, the results of extended Cox regression revealed that the effect varied with time; typical users had a moderately lower risk of nursing home admission within the initial 90 days of therapy [HR 0.87; 95 % CI 0.77–0.97] but substantial risk was observed for 90–180 days of typical antipsychotic exposure [HR 1.58; 95 % CI 1.08–2.12]. The study found that, among elderly beneficiaries, typical antipsychotic use was associated with a time-dependent increase in risk of nursing home admission. Given the safety concerns with atypical antipsychotics and their extensive use in the elderly, there is a need to be cautious while prescribing antipsychotics in the vulnerable elderly population.

Pain is a significant problem in patients with breast cancer. Limited data exist regarding the nature and extent of pain management in women with breast cancer visiting outpatient settings. This study examined the pain management practices and the factors associated with prescribing pain medications among breast cancer patients.

BACKGROUND Antipsychotic medications are extensively used in nursing homes for management of behavioral and psychiatric disorders in the elderly. Prior research suggests that pneumonia is one of the common causes of anti psychotic-related mortality in this population. None of the studies compared typical and atypical antipsychotics with respect to pneumonia.OBJECTIVE To examine the risk of pneumonia with use of typical versus atypical antipsychotics in dual eligible elderly nursing home residents.METHODS The study involved a retrospective cohort design matched on propensity score using Medicare and Medicaid Analytical eXtract data from 4 US states. The study population included all elderly dual eligible (Medicaid and Medicare) nursing home residents (aged ≥65 years) who initiated antipsychotics any time between July 1, 2001, and December 31, 2003. The risk of pneumonia during the 6-month follow-up period was modeled using a Cox proportional model and extended Cox hazard model stratified on matched pairs based on propensity score, using atypical agents as the reference category.RESULTS Analysis of Medicaid-Medicare data revealed that there were 49,904 new antipsychotic (46,293 atypical and 3611 typical) users in the unmatched cohort and 7218 (3609 atypical and 3609 typical) users in the matched cohort. The unadjusted rate of pneumonia was 8.17% (4.61 events per person year) for atypical users and 5.21% (5.21 events per person year) for typical users. The results of Cox regression (average hazard ratio [HR] 1.24; 95% CI 0.94–1.64) and extended regression (<50 days: HR 1.17, 95% CI 0.83–1.66; and 50–180 days: HR 1.36, 95% CI 0.87–2.14) suggest that there was no significant difference in the risk of pneumonia among typical and atypical users.CONCLUSIONS The study found no differential risk of pneumonia between typical versus atypical antipsychotic use in dual eligible nursing home residents. Given the differential risk of mortality with typical and atypical antipsychotic use in nursing homes, more research is needed to evaluate other contributory factors of mortality with respect to these 2 antipsychotic classes.

Antipsychotic use among dual-eligible nursing home residents is a concern for cost and safety considerations.

Aims:Existing randomized controlled trials do not address the comparative effectiveness of different angiotensin-converting enzyme inhibitors (ACEIs) on hospitalization due to heart failure (HF)-hospitalization in patients with HF. We sought to examine the effect of four ACEIs on HF-hospitalization in a large real-world HF population. Methods:The study was a retrospective analysis of a national cohort of patients with HF identified from the Department of Veterans Affairs (TX, USA). A multiple propensity score analysis was used to balance 47 baseline patient characteristics between the different ACEIs. The effect of different ACEIs on time to HF-hospitalization was assessed using the multiple propensity score-weighted multivariable Cox proportional hazard model. Results:The study included 139,994 patients with 69.50% (97,293) on lisinopril, 21.79% (30,503) on fosinopril, 8.41% (11,775) on captopril and 0.30% (423) on enalapril. Propensity scores balanced nearly all differences between different ACEIs groups. Enalapril (hazard ratio [HR]: 0.800; 95% CI: 0.492–1.297), fosinopril (HR: 0.971; 95% CI: 0.877–1.074), and lisinopril (HR: 1.005; 95% CI: 0.918–1.101) when compared with captopril were found to have similar effectiveness in reducing HF-hospitalizations. Conclusion:In patients with HF, we found that the four ACEIs are equally effective in reducing HF-hospitalization in day-to-day practice.

To examine the nature and extent of unmet prescription medication need (UPMN) in children and its predictors using the 2003 National Survey of Children’s Health (NSCH).

•Only one in five older adults with multiple sclerosis (MS) were prescribed disease modifying agents (DMAs).•Injectable DMAs are widely used among older adults, followed by orals and then infusions.•Various demographic and clinical factors were associated with the selection of DMAs.

:Since the introduction of oral disease-modifying agents (DMA) in 2010, the treatment options for multiple sclerosis (MS) have changed significantly. There is limited information regarding the factors associated with switching to oral DMA among prevalent injectable DMA users.

Objective: To examine healthcare outcomes associated with Beers' criteria of inappropriate medication use based on a literature review.Data Sources: A search of MEDLINE, International Pharmaceutical Abstracts, and Cumulative Index to Nursing and Allied Health Literature was conducted to identify articles published from October 1991 to October 2006. The following key words were used: Beers, inappropriate, medication, drug, use, prescribing, and elderly. A manual search was also conducted using the references listed in the articles identified through the database search.Study Selection And Data Extraction: Studies that examined the impact or outcomes of Beers' criteria of inappropriate medication use (1991, 1997, and 2003 critera) were selected. Each article was examined for study setting, data source, study sample, study design, criteria, analysis and covariates, type of healthcare outcome, and study findings. Of 235 articles retrieved, 18 presented studies that examined healthcare outcomes associated with inappropriate medication use based on Beers' criteria. Specifically, setting-specific evidence as well as overall evidence was examined from the selected studies. The review considered evidence of association if more than 50% of the findings were statistically significant.Data Synthesis: Most of the 18 studies evaluated were retrospective cohort studies involving patients 65 years of age or older from diverse healthcare settings. In community settings, there was no evidence of association with respect to mortality and other healthcare use, and evidence regarding quality of life and costs was inconclusive. However, inappropriate medication use was associated with hospitalization measures in community elderly. In nursing homes, there was no evidence of association with mortality and the association with hospitalization measures was inconclusive. In hospitals, there was inconclusive evidence to make any generalizations. Across healthcare settings, inappropriate medication use was associated with adverse drug reactions and costs but not with other outcome measures.Conclusions: There is evidence that Beers' criteria of inappropriate medication use is associated with adverse healthcare impact in the community-dwelling elderly. With increasing use of Beers' criteria as quality-of-care measures, there is a need to strengthen the predictive validity of these criteria in all healthcare settings.

Using 1995–1996 National Hospital Ambulatory Medical Care Surveys, this study examined the prevalence, nature, and demographics of visits to hospital outpatient departments (OPDs) for adverse effects of medications, and the resource utilization associated with these visits. Weighted analyses of visits resulting in principal diagnoses of adverse effects of medications revealed that 0.19% of OPD visits were due to such incidents. These estimates projected annually represent 125,508 visits or 4.77 visits per 10,000 persons. The highest visit rates were seen in females, patients over 74 years old, and patients living in the Midwest. The agents most often responsible for these visits were hormones, antibiotics, and analgesics. The most frequently cited reasons for the visits were adverse effects of medications and skin rashes. Many medication-related OPD visits require diagnostic services and pharmacotherapy, thus a reduction in these problems would decrease the burden on health care systems.

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings.DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999.DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings.DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use.CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.

The use of consumers as a channel of marketing prescription drugs is now being more thoroughly explored by the pharmaceutical industry through direct-to-consumer advertising (DTCA). As medication distributor and counselor, the pharmacist is in a unique position to observe the effects of DTCA. The purpose of this study was to assess pharmacists’ attitudes toward DTCA. A survey mailed to a randomized statewide sample of pharmacists solicited their level of agreement to 24, Likert-type items pertaining to the possible effects of DTCA in addition to requesting relevant respondent demographic information. Results indicated that 59% of the pharmacists did not support DTCA. Chi-squared analysis indicated that support of DTCA was independent of respondent demographics. Factor analysis revealed four underlying dimensions (“action,” “disruption,” “knowledge,” and “market”) explaining 53.4% of the variance in attitudes. Discriminant analysis was used to correctly classify 76% of respondents as supporters and nonsupported of DTCA. The study concludes that pharmacists believe in the possibility of numerous entwined effects of DTCA, resulting in a complex composition of their attitudes.

To examine the prevalence, nature, demographics, and resource use associated with visits to office-based physicians in the United States during 1995 for medication-related morbidity.

OBJECTIVE: To estimate the prevalence of inappropriate medications prescribed by office-based physicians for patients 65 years or older.DESIGN: A nationwide cross-sectional survey of office visits by the elderly.SETTING: The National Ambulatory Medical Care Survey (NAMCS) 1992, a national probability sample survey of office visits by ambulatory patients within the continental US.SUBJECTS: A national probability sample of patients 65 years or older visiting office-based physicians. National estimates are based on the National Center for Health Statistics weighting procedure for the NAMCS sample.MAIN OUTCOME MEASURES: Prevalence of 20 inappropriate medications that should be entirely avoided in the elderly, using criteria developed by a panel of national experts in geriatric medicine and geriatric pharmacology.RESULTS: In the US during 1992, an estimated 8.47 million (95% CI 7.66 million to 9.28 million) office visits by the elderly indicated prescribing of at least 1 of the 20 inappropriate medications. Approximately 7.75 million (95% CI 6.98 million to 8.52 million) visits by the elderly involved 1 inappropriate medication and 0.72 million (95% CI 0.51 million to 0.93 million) visits included 2 inappropriate medications. According to the NAMCS, office-based physicians prescribed at least 1 inappropriate medication to 7.58% of the elderly who received prescriptions. The most frequently prescribed inappropriate medications were propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide. Elderly patients rarely received prescriptions from office-based physicians for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and carisoprodol. Furthermore, office-based physicians did not prescribe cyclandelate, pentobarbital, or phenylbutazone for the elderly.CONCLUSIONS: The prescribing of inappropriate medications by office-based physicians raises concerns regarding the quality of care for the elderly in ambulatory settings. The crux of improving patient care in ambulatory settings rests with collaborative efforts between physicians and pharmacists.

Fingolimod is the first approved oral disease-modifying agent (DMA) in 2010 to treat Multiple Sclerosis (MS). There is limited real-world evidence regarding the determinants associated with fingolimod use in the early years.

•Injectable DMAs are still widely used for MS even after the introduction of oral agents.•Only one in three newly diagnosed MS patients were prescribed oral DMAs.•Patient demographic and clinical factors were associated with selection of oral DMAs.

Members from Cohort 13 of the Academic Leadership Fellows Program (ALFP) 2016-2017 were challenged to present a debate on the topic: “In Turbulent Times, Pharmacy Education Leaders Must Take Aggressive Action to Prevent Further Declines in Enrollment” at the American Association of Colleges of Pharmacy INfluence 2017 meeting in Rio Grande, Puerto Rico. This paper is the result of thoughtful insights emerging from this debate. We present a discussion of the question of whether pharmacy education leaders must take aggressive action or strategic approaches to prevent further declines in enrollment. There are many thoughts regarding current declines in enrollment. Some educators contend that a more aggressive approach is needed while others argue that, while aggressive actions might lead to short-term gains, a more viable approach involves strategic actions targeting the underlying causes for decreasing enrollment. This paper explores themes of enrollment challenges, current and future workforce needs, and financial issues for both pharmacy programs and students. In summation, both aggressive actions and a strategic, sustainable approach are urgently needed to address declining enrollment.