Association between potentially inappropriate medications prescription and health-related quality of life among US older adults.

BACKGROUND: Potentially inappropriate medications (PIMs) are associated with worse health outcomes among older adults. Our objective was to examine the association between PIM prescription and health-related quality of life (HRQoL) among older adults in the United States using nationally representative data. METHODS: This was a retrospective study utilizing 2011-2015 Medical Expenditure Panel Survey (MEPS) data. Community dwelling US adults aged 65 years or older were included. A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to define exposure to PIMs during the study period. The Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) were used to measure HRQoL. Survey-weighted linear regression models were constructed to investigate the association between PIM exposure and participants' PCS and MCS scores. Analyses were stratified across three age cohorts (65-74, 75-85, and ≥85 years). RESULTS: Unadjusted analysis showed poorer scores in the PIM exposed group for both PCS and MCS (all p < 0.001). PIM exposure was associated with poorer PCS scores across all age groups with those aged 65-74 years (adjusted regression coefficient = -1.60 [95% CI = -2.27, -0.93; p < 0.001]), those 75-84 years (adjusted regression coefficient: -1.49 [95% CI = -2.45, -0.53; p = 0.003]), and those 85 years and older (adjusted regression coefficient = -1.65 [95% CI = -3.03, -0.27; p = 0.02]). PIM exposure was also associated with poorer MCS scores in participants aged 65-74 years (adjusted regression coefficient = -0.69 [95% CI = -1.16, -0.22; p = 0.004]) and 85 years and older (adjusted regression coefficient = -2.01 [95% CI = -3.25, -0.78; p = 0.002]). CONCLUSIONS: Our results suggest that patients' exposure to PIMs is associated with poorer HRQoL. Further work is needed to assess whether interventions to deprescribe PIMs may help to improve patients' HRQoL.

Medication Use Among Patients Reporting Xerostomia of an Academic Dental Clinic.

Background: Global prevalence of xerostomia has been reported at 22% (range 0.01%-45%), negatively impacting oral health, nutrition intake, and quality of life. The causal relationship between xerostomia and medications remains uncertain but greater understanding could guide interventions. Objective: To describe the demographic characteristics and medication regimens in patients with xerostomia of an academic dental clinic. Method: This is a retrospective academic dental clinic record review from July 1, 2018 to October 27, 2020. Patient records were obtained from the University at Buffalo, School of Dental Medicine. Xerostomia status was determined via query of electronic health records and validated by manual review. Pharmacologic class and xerostomic potential of medications were identified by the Veterans Affairs Drug Classification System and drug compendia, respectively. Predictors of medication use were assessed using a multiple logistic regression model. Results: Of 37 403 examined records, 366 (0.98%) were identified as xerostomic. After excluding confounding factors (Sjogren's and radiation), 275 of 317 patients received at least one xerostomic medication, majority were female (240, 66%) versus male (126, 34%). Mean ± (SD) age was 64.9 ± 15.11 years. A total of 208 (57%) patients were aged ≥65. The median number of total and xerostomic medications were 8 (interquartile range [IQR], 4-12) and 4 (IQR, 2-7), respectively. The 3 most prevalent xerostomic pharmacologic classes were antidepressants (131, 35%), gastric medications (101, 28%), and vitamin D (87, 24%). Conclusion: Despite observed prevalence of xerostomia lower than global prevalence, xerostomic medication burden for patients experiencing xerostomia was high. Pharmacist-led interprofessional collaborations should be investigated to reduce xerostomic burden.

Targeted Medication Review of Falls-Risk Medications in Older Patients: A Community Pharmacy-Based Approach.

Objective To assess a community pharmacist-provided targeted medication review (TMR) intervention to reduce the number of falls risk-increasing drugs (FRIDs) prescribed to older patients in a community pharmacy setting. Design A single-site, prospective, interventional pilot study with a historical control group. Setting A single independent community pharmacy in rural Western New York. Participants A convenience sample of subjects was recruited for the intervention group based on the following inclusion criteria: 65 years of age or older, at least one prescription filled at the pharmacy within the past 90 days from date of enrollment in study, enrolled in a local Medicare plan, and prescription for at least one prespecified FRID filled at the pharmacy within 90 days before date of enrollment in study. A control group was collected that had different Medicare Part D plans than the intervention group but otherwise met inclusion criteria and ensured that between all of the control-group patients we included at least one patient prescribed each of the FRID classes that were found in the intervention group. Thirty-six subjects completed the study intervention, and 63 controls were collected. This offset in numbers between groups resulted from intervention subjects taking multiple FRIDs and the control needing to take the same class of FRID, thus one intervention subject may have required multiple control subjects to parallel each FRID class. Intervention The intervention involved the community pharmacist assessing the patient's fall risk, then educating the patient on the risks of the FRID he or she was prescribed, and recommending to either replace or discontinue the FRID. The outcomes assessment occurred three months later, with the pharmacist repeating the falls-risk assessment and following up regarding the patient's agreed-upon action plan. Results The intervention group had 52 FRIDs identified while the control group had 89. The discontinuation rate of FRIDs at three months was significantly higher in the intervention group (7.7% versus 0%; P = 0.0172). Conclusion This study demonstrated that a community pharmacist TMR intervention can reduce the use of FRIDs.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study.

OBJECTIVE: Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community. METHODS: Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development. RESULTS: Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital." CONCLUSION: The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves. PRACTICE IMPLICATIONS: Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

Trends in fall-related mortality and fall risk increasing drugs among older individuals in the United States,1999-2017.

BACKGROUND: Previous studies have demonstrated increasing mortality due to falls among older adults. The objective of this study was to determine whether there was an increase in fall risk increasing drug prescribing and if this is concurrent with an increase in fall-related mortality in persons 65 years and older in the United States. METHODS: The study is a serial cross-sectional analysis utilizing data from both the National Vital Statistics System (NVSS) and the medical expenditure panel survey (MEPS) for years 1999-2017. Adults aged 65 years and older were evaluated for death due to falls from the NVSS and for prescription fills of fall risk increasing drugs per the Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) fall checklist from the MEPS. RESULTS: The analysis included 374 972 fall-related mortalities and 7 858 177 122 fills of fall risk increasing drugs. 563 037 964 persons age 65 and older received at least one fall risk increasing drug. Age-adjusted mortality due to falls increased from 29.40 per 100 000 in 1999 to 63.27 per 100 000 in 2017. The percent of persons who received at least one prescription for a fall risk increasing drug increased from 57% in 1999 to 94% in 2017 (p for trend <.0001). CONCLUSIONS AND RELEVANCE: Both use of fall risk increasing drugs and mortality due to falls are on the rise. Fall risk increasing drugs may partially explain the increase in mortality due to falls; this cannot be firmly concluded from the current study. Future research examining the potential relationship between fall risk increasing drugs and fall-related mortality utilizing nationally representative person-level data are needed.

Knowledge and Attitudes of Student Pharmacists Regarding Polypharmacy and Deprescribing: A Cross-Sectional Study.

Pharmacists play a key role in deprescribing medications. Incorporation of this concept into pharmacy school curricula is important in ensuring that graduates can address the complex needs of an aging population. The aims of this study were to assess if and how student pharmacists were exposed to deprescribing within their curriculum, to assess students' perceptions regarding their attitudes, ability and confidence in deprescribing, and to assess if reported curricular exposure to this topic resulted in improved perceptions or objective knowledge assessment scores. An electronic survey was distributed to third- and fourth-year pharmacy students at 132 schools of pharmacy. The survey included three sections including: (i) demographics and questions on their exposure to deprescribing and other experiences within their curriculum; (ii) questions regarding their attitudes, ability, and confidence regarding deprescribing on a 5-point Likert-scale; (iii) a knowledge assessment on polypharmacy and deprescribing in the form of 12 multiple-choice questions. Likert-scale questions were analyzed as scales utilizing the mean score for items measuring student perceptions regarding deprescribing attitudes, ability, and confidence. Comparisons were made on each variable between students with and without curricular exposure to deprescribing using t-tests. Ninety-one responses were included in the analysis. Only 59.3% of respondents reported exposure to deprescribing in their didactic coursework. The mean scores on the polypharmacy and deprescribing knowledge assessments were 61.0% and 64.5%, respectively. Those with exposure to deprescribing concepts within their curriculum were more likely to agree that their school's curriculum prepared them to deprescribe in clinical practice (t(89) = -2.26, p = 0.03). Pharmacy schools should evaluate their curricula and consider the addition of specific deprescribing objectives and outcome measures for didactic and experiential training.

Student Pharmacist Perceptions of the Utility of a Medication Therapy Management-Based, Medication-Related, Falls Risk-Assessment Tool.

OBJECTIVE: To evaluate student pharmacists' perceptions of the Medication Fall Risk-Assessment Tool (MFRAT), a novel medication therapy management (MTM)-based clinical decision support tool.
DESIGN: A cross-sectional study
SETTING: One school of pharmacy
PARTICIPANTS: Participants were eligible if they had used the MFRAT as part of a wellness clinic or as part of required coursework prior to April 2016.
INTERVENTIONS: An online, author developed survey was distributed to assess previous MFRAT use, perceptions of the tool on a 5-point Likert-type scale, and qualitative feedback related in the areas of pharmacy workflow, clinical utility, and perceived patient acceptance.
MAIN OUTCOME MEASURE(S): Positive agreement to survey items served as the main outcome measure. A chi-square test was used to test for a difference in positive response between naive and experienced MFRAT users. Cronbach's alpha was calculated to assess internal consistency of items in each domain.
RESULTS: Of the 127 potential participants surveyed, 110 completed the survey for an overall response rate of 87%. Greater than 85% of participants found the MFRAT's report clinically useful. Eighty-seven percent of respondents agreed or strongly agreed that the information provided by the tool could easily be understood by patients. The most significant limitation to the use if the MFRAT in existing workflow was time required to enter a patient's medication profile.
CONCLUSION: The MFRAT was viewed positively in terms of clinical utility and perceived patient acceptance. Improvements will need to be made to make using the tool more time efficient in pharmacy MTM workflow.

Opportunities and Recommendations for Improving Medication Safety: Understanding the Medication Management System in Primary Care Through an Abstraction Hierarchy.

BACKGROUND: Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. OBJECTIVE: This paper aims to refine our understanding of the primary care office in relation to a patient's medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. METHODS: The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. RESULTS: This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. CONCLUSIONS: Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.

Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs.

BACKGROUND/OBJECTIVES: To examine the prevalence of potentially inappropriate medication (PIM) prescribing and its association with healthcare utilization and related expenditures utilizing nationally representative data from the United States. DESIGN: Retrospective cohort study. SETTING: The 2011-2015 Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: Community-dwelling sample of U.S. adults aged 65 and older during the first round of each MEPS cycle. MEASUREMENTS: A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to estimate the prevalence of PIM prescribing over the study period. Negative binomial models were assembled to examine associations between PIM exposure and healthcare utilization including hospitalizations, emergency department (ED) visits, and outpatient provider visits. Generalized linear models with the log link function and gamma distribution were used to analyze associations between PIM exposure and healthcare expenditures. Sensitivity analyses were conducted utilizing inverse probability treatment weighting using propensity scores for being prescribed a PIM. RESULTS: The period prevalence of PIM prescribing over the 5-year sample was 34.4%. PIM prescribing was positively associated with hospitalizations (adjusted incidence rate ratio [aIRR] = 1.17; 95 confidence interval [CI] = 1.08-1.26; P < .001), ED visits (aIRR = 1.26; 95% CI = 1.17-1.35; P < .001), and outpatient provider visits (aIRR = 1.18; 95% CI = 1.14-1.21; P < .001). PIM exposure was associated with higher marginal costs within outpatient visits ($116; 95% CI = $105-$243; P < .001), prescription medications ($128; 95% CI = $72-$199; P < .001), and total healthcare expenditures ($458; 95% CI = $295-$664; P < .001). Similar results were found in our propensity score analyses. CONCLUSION: PIMs continue to be prescribed at a high rate among older adults in the United States. Our results suggest that receipt of PIMs is associated with higher rates of healthcare utilization and increased costs across the healthcare continuum. Further work is needed to implement evidence-based deprescribing interventions that may in turn reduce unnecessary healthcare utilization.

Interventions to deprescribe potentially inappropriate medications in the elderly: Lost in translation?

WHAT IS KNOWN AND OBJECTIVE: Use of potentially inappropriate medications (PIMs) remains common in older adults, despite the easy availability of screening tools such as the Beers and Screening Tool of Older Person's Prescriptions (STOPP) criteria. Multiple published studies have implemented these screening tools to encourage deprescribing of PIMs, with mixed results. Little is known about the reasons behind the success or failure of these interventions, or what could be done to improve their impact. Implementation science (IS) provides a set of theories, models and frameworks to address these questions. The goal of this study was to conduct a focused narrative review of the deprescribing literature through an IS lens-to determine the extent to which implementation factors were identified and the intermediate steps in the intervention were measured. A better understanding of the existing literature, including its gaps, may provide a roadmap for future research. METHODS: PubMed search from 2000-2019 using appropriate MeSH headings. INCLUSION CRITERIA: controlled trials or prospective cohort studies intended to reduce PIMs in the elderly that used hospitalizations and/or emergency department visits as outcome measures. Studies were reviewed to identify potential implementation factors (known as determinants), using the Consolidated Framework for Implementation Research (CFIR) as a guide. In addition, intermediate outcomes were extracted. RESULTS AND DISCUSSION: Of the 548 reviewed abstracts, 14 studies met the inclusion criteria and underwent detailed analysis. Of the 14 studies, 10 acknowledged potential implementation determinants that could be mapped onto CFIR. The most commonly identified determinant was the degree of pharmacist integration into the medical team (seven of 14 studies), which mapped onto the CFIR construct of 'networks and communication'. Several important CFIR constructs were absent in the reviewed literature. Intermediate measures were captured by 12 of the 14 reviewed papers, but the choice of measures was inconsistent across studies. WHAT IS NEW AND CONCLUSION: In recent high-quality studies of deprescribing interventions, we found limited acknowledgement of factors known to be important to successful implementation and inconsistent reporting of intermediate outcomes. These findings indicate missed opportunities to understand the factors underlying study outcomes. As a result, we run the risk of rejecting worthwhile interventions due to negative results, when the correct interpretation might be that they failed in implementation. In other words, they were 'lost in translation'. Studies that rigorously examine and report on the implementation process are needed to tease apart this important distinction.

A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic.

OBJECTIVE: To develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit (AWV) to make deprescribing recommendations targeted at potentially inappropriate medications (PIMs) in seniors. SETTING: A family medicine patient-centered medical home (PCMH) clinic in Buffalo, NY. PRACTICE DESCRIPTION: Implementation and evaluation of a pilot program incorporating a pharmacist-provided medication review targeting PIMs in seniors as part of a Medicare AWV. PRACTICE INNOVATION: A community pharmacy-based clinical pharmacist provided face-to-face medication reviews for patients older than 65 years as part of their AWV with a focus on deprescribing PIMs. No clinical pharmacy service existed at the practice when this program was implemented. EVALUATION: Identified PIMs, pharmacist recommendations, recommendation acceptance rate, time spent on intervention, health care utilization at 6 months postvisit, and barriers to implementation. RESULTS: Of the 21 patients enrolled, 13 unique patients received a total of 20 deprescribing recommendations from the pharmacist. The overall acceptance rate for pharmacist recommendations was 20%. The pharmacist spent a mean (± SD) of 34 (± 6) minutes per patient encounter. One patient in the intervention group was hospitalized, and 1 was seen in the emergency department (ED) during the 6-month follow-up period compared with 1 patient in the control group who had an ED visit. We identified multiple logistical and organizational barriers to the implementation of the intervention. CONCLUSION: In this prospective pilot study, a workflow to include a pharmacist medication review to facilitate deprescribing in the primary care setting was tested. We encountered several barriers to integrating the pharmacist into the AWV workflow to deliver the intervention. Future pragmatic clinical trials are warranted to improve provider awareness and comfort with deprescribing PIMs in seniors.

Pharmacy Students' Ability to Identify Fall Risk-Increasing Drugs Using an Innovative Assessment Tool.

Objective. To evaluate change in the ability of third-year pharmacy students to identify drugs that increase fall risk after training in and experience using the Medication Falls Risk Assessment Tool (MFRAT). Methods. An assessment was administered to students prior to MFRAT use and after MFRAT use. The assessment consisted of 10 medication regimens for various chronic conditions (50 distinct drug choices with 30 correct answers and 20 distractors), and students were to identify fall risk increasing drugs (FRIDs). Using a flipped-classroom approach, students viewed an online presentation on FRIDs and then participated in instructor guided, in-class application of the MFRAT using student-collected data from an actual patient case. Students completed medication therapy management (MTM) documentation. The assessment data for students who had previously used the MFRAT (experienced) were analyzed separately from first time users (inexperienced). Results. Three assessment scores were evaluated: number correct (maximum 30; higher score is better), number of distractors (maximum 20; lower score better), and a combined total score (maximum 50; higher score better). In inexperienced users (n=104), pre- and post-assessment means improved significantly for correct score (24.9 vs 29.5) and total score (39.4 vs 44.3). Among experienced users (n=10), pre- and post-assessment means improved significantly for correct responses (27.3 vs 29.7), distractors (7.0 vs 3.5), and total score (40.3 vs 46.2). Conclusion. The ability of both pharmacy students who had used the MFRAT previously and those who had not to correctly identify FRIDs increased on the post-assessment.

Nebulized Fentanyl for Dyspnea in a Hospice Patient with True Allergy to Morphine and Hydromorphone.

An 86-year-old white female was admitted to hospice care with lung cancer. Even with optimal medical management, she suffered from dyspnea and required opioid therapy. However, the patient had a true morphine and hydromorphone allergy. She was administered nebulized fentanyl for symptomatic relief of dyspnea with good effect and she did not experience any allergic response.

Use of Compounded Dextromethorphan-Quinidine Suspension for Pseudobulbar Affect in Hospice Patients.

BACKGROUND: Pseudobulbar affect (PBA) consists of unprovoked and uncontrollable episodes of laughing and/or crying. In end-of-life situations, PBA symptoms can be especially distressing to family and friends during an already heightened emotional time. Although a commercial product combining dextromethorphan and quinidine (DMQ) is FDA approved for use in PBA, many hospice patients are unable to swallow any solids or semisolids. An alternative formulation for these patients is needed. OBJECTIVE: We present here two cases in which we used a compounded DMQ suspension successfully to treat PBA symptoms in the weeks before the patients' death. DESIGN: A retrospective chart review was completed on the two cases where the DMQ suspension was used. A description of the DMQ suspension formula is described. SETTING/SUBJECTS: Both patients were under the care of a hospice program; one in home care and one in a skilled nursing facility. MEASUREMENTS: Episodes of PBA symptoms were summarized in a narrative of the patients' symptom relief. RESULTS: Both patients tolerated the administration of the DMQ suspension and there were noted improvements in PBA symptoms. CONCLUSIONS: DMQ suspension is an effective alternative for PBA symptoms in patients who cannot swallow oral solid medication.

Students Use "STAMP-OUT" Program to Advance Seniors' Knowledge of Drug Misuse.

This program assessed the impact of student presentations on 30 seniors and sought to improve their knowledge of prescription drug misuse and abuse. The six pharmacy students used the ASCP Foundation's "STAMP Out Prescription Drug Misuse and Abuse Tool Kit." Information presented to senior audiences included descriptions of drug misuse and abuse and preventive measures to uphold medication safety. Students assessed seniors' prior knowledge about the topics through audience participation. Afterwards, a self-assessment quiz was given that examined participants' learning about safe medication practices. Before the presentation, only 36% of participants recognized the difference between prescription drug misuse and abuse. The self-assessment quiz results showed that following the three presentations, all 30 participants received perfect scores: The results showed an improvement in knowledge after attending the student presentations. This program demonstrates advancement of the pharmacy profession through educating seniors on proper medication use to prevent drug abuse and improve medication safety. ABBREVIATION: OTC = Over-the-counter, UB SPPS: University at Buffalo School of Pharmacy and Pharmaceutical Sciences.

Very-high-dose methadone with minimal toxicity and inadequate pain control in a hospice patient with cancer.

A case is reported of a 48-year-old Caucasian male who was admitted to hospice care with metastatic cancer of the larynx. The patient required very high methadone doses and experienced little opioid toxicity. The pharmacodynamics and pharmacokinetics of methadone are discussed in the context of this patient experience.

Morphine and hydromorphone-induced hyperalgesia in a hospice patient.

Opioids including morphine and hydromorphone are widely used for control of moderate to severe pain and dyspnea in hospice and palliative care patients. Accumulation of the active morphine-3-glucuronide (M3G) and hydromorphone-3-glucuronide (H3G) metabolites is one proposed mechanism for the development of neuroexcitatory effects including allodynia and opioid-induced hyperalgesia (OIH). We report the case of a 43-year-old female hospice patient with metastatic non-small cell lung cancer who initially developed allodynia following morphine administration and again following administration of hydromorphone. The allodynia resolved both times following the discontinuation of the opioid and rotation to a different opioid regimen. Potential opioid-induced neuroexcitatory treatment options include opioid rotation to an agent with inactive metabolites, use of adjuvant pain medications for opioid-sparing effects, management of undesired symptoms (e.g., myoclonus), or increasing opioid clearance with intravenous (IV) fluids. Although the incidence is not well defined in the literature, hospice and palliative care clinicians should suspect OIH in patients with allodynia and/or hyperalgesia, especially when repeated dose escalations do not improve analgesia or pain escalates following opioid dose titration.

A national survey of hospice administrator and pharmacist perspectives on pharmacist services and the impact on medication requirements and cost.

Symptom management at the end of life relies heavily on medications. For this reason, pharmacists are an ideal addition to the interdisciplinary hospice team (IDT). The aim of this study is to characterize the utilization of pharmacists in hospices from the hospice administrator and pharmacist perspectives and to determine the impact utilization has on per diem medication requirement and costs. Surveys were sent to 2824 hospice administrators and 658 pharmacists to obtain their perceptions on what clinical, administrative, and dispensing services were being performed. Responses were returned by 9.4% of administrators and 12.6% of pharmacists. The majority of administrators and pharmacists reported a mix of clinical, administrative, and dispensing responsibilities. Medication requirements and costs were not significantly impacted as the administrator's perception of pharmacist clinical, administrative, or dispensing time increased from 0% to 100%.

Mindful parenting decreases aggression and increases social behavior in children with developmental disabilities.

Research shows that after training in the philosophy and practice of mindfulness, parents can mindfully attend to the challenging behaviors of their children with autism. Parents also report an increased satisfaction with their parenting skills and social interactions with their children. These findings were replicated and extended with 4 parents of children who had developmental disabilities, exhibited aggressive behavior, and had limited social skills. After mindfulness training, the parents were able to decrease aggressive behavior and increase their children's social skills. They also reported a greater practice of mindfulness, increased satisfaction with their parenting, more social interactions with their children, and lower parenting stress. Furthermore, the children showed increased positive and decreased negative social interactions with their siblings. We speculate that mindfulness produces transformational change in the parents that is reflected in enhanced positive behavioral transactions with their children.