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Biomedical subjects

John Adams

Publications and source records attributed to John Adams.

At least 19 recordsLinked to original sources
PubMed2006

Amygdala dysfunction in men with the fragile X premutation.

Premutation alleles (55-200 CGG repeats) of the fragile X mental retardation 1 (FMR1) gene are associated with autism spectrum disorder in childhood, premature ovarian failure, and the neurodegenerative disorder, fragile X-associated tremor/ataxia syndrome (FXTAS). FXTAS, and perhaps the other clinical presentations among carriers, are thought to be due to toxic gain-of-function of elevated levels of the expanded-repeat FMR1 mRNA. Previous structural MRI studies have implicated the amygdala as a potential site of dysfunction underlying social deficits and/or risk for FXTAS. As a preliminary investigation of this possible association, adult males with the premutation, and male controls matched for IQ, age and education, completed three protocols that probe amygdala and sympathetic function: (i) a functional MRI paradigm that measures brain response to fearful faces; (ii) a fear-potentiated startle paradigm that differentiates responses to fearful faces and fearful non-social images and (iii) measurement of skin conductance level during a brief social encounter. Compared with controls, men with the FMR1 premutation demonstrated diminished brain activation in the amygdala and several brain areas that mediate social cognition while viewing fearful faces. The reduced amygdala activation in the premutation group was significantly associated with self-report of psychological symptoms on the Symptom Checklist-90--Revised. These men also displayed a lack of startle potentiation while viewing fearful faces and showed reduced skin conductance response when greeting an unfamiliar experimenter in comparison with the control group. The current findings may be related to social cognition deficits reported previously in children and adults with the premutation. The aetiology for this dysfunction may be elevated FMR1 mRNA or reduced FMR1 protein that occurs in carriers with higher premutation CGG repeat alleles.

Adult↗
PubMed2006

Paired-associate learning, phoneme awareness, and learning to read.

We report two studies examining the relations among three paired-associate learning (PAL) tasks (visual-visual, verbal-verbal, and visual-verbal), phoneme deletion, and single-word and nonword reading ability. Correlations between the PAL tasks and reading were strongest for the visual-verbal task. Path analyses showed that both phoneme deletion and visual-verbal PAL were unique predictors of a composite measure of single-word reading and of irregular word reading. However, for nonword reading, phoneme deletion was the only unique predictor (and visual-verbal PAL was not a significant predictor). These results are consistent with the view that learning visual (orthography) to phonological mappings is an important skill for developing word recognition skills in reading and that individual differences in this ability can be tapped experimentally by a PAL task.

Awareness↗
PubMed2006

Voxel-based study of structural changes in first-episode patients with bipolar disorder.

BACKGROUND: Although morphometric studies of bipolar disorder (BD) suggest that neurofunctional abnormalities reflect underlying structural changes, it remains unclear whether abnormalities are present at illness onset or reflect disease progression. Previous voxel-based morphometry (VBM) findings suggest that ventrolateral prefrontal cortex (VLPFC) changes develop over time, whereas morphologic abnormalities elsewhere in the anterior limbic network (ALN) are present early in BD. In this study, we used VBM to explore structural brain changes in first-episode bipolar patients. METHODS: First-episode bipolar (n = 33) and healthy (n = 33) subjects underwent magnetic resonance imaging. Images were normalized and compared on a voxel-by-voxel basis. RESULTS: Bipolar subjects showed no change in VLPFC density or volume. We observed increased volume in left thalamus and fusiform and cerebellum bilaterally; increased gray matter density in anterior cingulate and posterior parietal structures; and increased gray matter volume and density in middle/superior temporal and posterior cingulate gyri. No areas of decreased volume or density were observed. CONCLUSIONS: These data indicate that structural changes are absent from VLPFC early in the course of BD. Morphologic abnormalities are present in other portions of the ALN and in structures previously observed to mediate neurofunctional changes in BD, suggesting that dysfunctional neuronal proliferation or pruning may occur in bipolar patients.

Adolescent↗
PubMed2006

Patients' global ratings of their health care are not associated with the technical quality of their care.

BACKGROUND: Patient global ratings of care are commonly used to assess health care. However, the extent to which these assessments of care are related to the technical quality of care received is not well understood. OBJECTIVE: To investigate the relationship between patient-reported global ratings of health care and the quality of providers' communication and technical quality of care. DESIGN: Observational cohort study. SETTING: 2 managed care organizations. PATIENTS: Vulnerable older patients identified by brief interviews of a random sample of community-dwelling adults 65 years of age or older who received care in 2 managed care organizations during a 13-month period. MEASUREMENTS: Survey questions from the second stage of the Consumer Assessment of Healthcare Providers and Systems program were used to determine patients' global rating of health care and provider communication. A set of 236 quality indicators, defined by the Assessing Care of Vulnerable Elders project, were used to measure technical quality of care given for 22 clinical conditions; 207 quality indicators were evaluated by using data from chart abstraction or patient interview. RESULTS: Data on the global rating item, communication scale, and technical quality of care score were available for 236 vulnerable older patients. In a multivariate logistic regression model that included patient and clinical factors, better communication was associated with higher global ratings of health care. Technical quality of care was not significantly associated with the global rating of care. LIMITATIONS: Findings were limited to vulnerable elders who were enrolled in managed care organizations and may not be generalizable to other age groups or types of insurance coverage. CONCLUSIONS: Vulnerable elders' global ratings of care should not be used as a marker of technical quality of care. Assessments of quality of care should include both patient evaluations and independent assessments of technical quality.

Aged↗
PubMed2006

Age-related differences in levodopa dynamics in Parkinson's: implications for motor complications.

Treatment-related motor complications in Parkinson's disease have been previously linked to disease-induced pre-synaptic alterations: dopaminergic denervation and changes in dopamine (DA) release patterns. The occurrence of such complications is also known to be partly dependent on the age of disease onset, occurring more frequently in patients with disease onset at a younger age. Using positron emission tomography (PET) and 4-h-long 18F-fluorodopa (FD) scans we have investigated in vivo an age dependence of disease-induced changes in DA turnover as a possible contributing factor to the age-related differences in treatment-related motor complications. We evaluated the relative changes in DA turnover (measured by its direct inverse, effective DA distribution volume--EDV) and DA synthesis and vesicular storage capacity (quantified by the plasma input uptake rate constant Ki) in Parkinson's disease patients as a function of age (n = 27, age range 38-79 years). After correcting for disease severity, a significant negative correlation was found between age and magnitude of disease-induced decrease in EDV and in Ki in the putamen (P < 0.001, P = 0.02, respectively). However, the difference between the disease-induced decrease in EDV and that in Ki also exhibited an age dependence (P < 0.001), indicating a relatively higher disease-induced increase in DA turnover (inverse of EDV) compared with the decrease in DA synthesis and storage rate in patients of younger age compared with older patients. This finding implies that DA turnover in younger-onset patients undergoes a relatively greater alteration and thus likely contributes to a greater imbalance between DA synthesis, storage and release, which could lead to larger swings in synaptic DA levels. It has indeed been suggested on theoretical grounds that such imbalance may contribute to the greater propensity for motor fluctuations. These results provide one possible explanation for the age-dependent occurrence of complications and support the existence of a pre-synaptic contribution to the occurrence of motor complications.

Adult↗
PubMed2006

Results of the National Initiative for Cancer Care Quality: how can we improve the quality of cancer care in the United States?

PURPOSE: In 1999, the National Cancer Policy Board called attention to the quality of cancer care in the United States and recommended establishing a quality monitoring system with the capability of regularly reporting on the quality of care for patients with cancer. METHODS: Using data from a patient survey 4 years after diagnosis and review of medical records, we determined the percentage of stage I to III breast cancer and stage II to III colorectal cancer survivors in five metropolitan statistical areas (MSAs) across the United States who received recommended care specified by a comprehensive set of explicit quality measures. RESULTS: Two thousand three hundred sixty-six (63%) of 3,775 eligible patients responded to the survey, and 85% consented to have their medical records reviewed. Our final analytic sample (n = 1,765) included 47% of the eligible patients. Patients with breast and colorectal cancer received 86% of recommended care (95% CI, 86% to 87%) and 78% of recommended care (95% CI, 77% to 79%), respectively. Adherence to quality measures was less than 85% for 18 of the 36 breast cancer measures, and significant variation across MSAs was observed for seven quality measures. The percent adherence was less than 85% for 14 of the 25 colorectal cancer measures, and one quality measure demonstrated statistically significant variation across the MSAs. CONCLUSION: Initial management of patients with breast and colorectal cancer in the United States seemed consistent with evidence-based practice; however, substantial variation in adherence to some quality measures point to significant opportunities for improvement.

Adult↗
PubMed2006

Comparison of administrative data and medical records to measure the quality of medical care provided to vulnerable older patients.

BACKGROUND: Administrative data are used to determine performance for publicly reported in health plan "report cards," accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare. METHODS: We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care. RESULTS: Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, kappa = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P < 0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively. CONCLUSIONS: The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.

Aged↗
PubMed2006

The quality of pharmacologic care for adults in the United States.

BACKGROUND: Despite rising annual expenditures for prescription drugs, little systematic information is available concerning the quality of pharmacologic care for adults in the United States. We evaluated how frequently appropriate pharmacologic care is ordered in a national sample of U.S. residents. METHODS: The RAND/UCLA Modified Delphi process was used to select quality-of-care indicators for adults across 30 chronic and acute conditions and preventive care. One hundred thirty-three pharmacologic quality-of-care indicators were identified. We interviewed a random sample of adults living in 12 metropolitan areas in the United States by telephone and received consent to obtain copies of their medical records for the most recent 2-year period. We abstracted patient medical records and evaluated 4 domains of the prescribing process that encompassed the entire pharmacologic care experience: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. A total of 3,457 participants were eligible for at least 1 quality indicator, and 10,739 eligible events were evaluated. We constructed aggregate scores and studied whether patient, insurance, and community factors impact quality. RESULTS: Participants received 61.9% of recommended pharmacologic care overall (95% confidence interval 60.3-63.5%). Performance was lowest in education and documentation (46.2%); medication monitoring (54.7%) and underuse of appropriate medications (62.6%) performance were higher. Performance was best for avoiding inappropriate medications (83.5%). Patient race and health services utilization were associated with modest quality differences, while insurance status was not. CONCLUSIONS: Significant deficits in the quality of pharmacologic care were seen for adults in the United States, with large shortfalls associated with underuse of appropriate medications. Strategies to measure and improve pharmacologic care quality ought to be considered, especially as we initiate a prescription drug benefit for seniors.

Adult↗
PubMed2006

Clinical supervision and burnout: the influence of clinical supervision for community mental health nurses.

AIMS: The aim of this study was to establish the degree to which clinical supervision might influence levels of reported burnout in community mental health nurses in Wales, UK. METHODS: The research instruments used were the Maslach Burnout Inventory and the Manchester Clinical Supervision Scale. At the time of the survey 817 community mental health nurses were reported to work within Wales. Two hundred and sixty (32%) community mental heath nurses working in 11 NHS Trusts responded to the survey. RESULTS: One hundred and eighty-nine (73%) community mental heath nurses had experience of clinical supervision in their present posts and 105 (40%) in their previous posts. The findings from the Maslach Burnout Inventory indicated high levels of emotional exhaustion for 36%, high levels of depersonalization for 12% and low levels of personal accomplishment for 10% of the community mental heath nurses surveyed. Univariate analysis showed that those community mental heath nurses who were younger, male and who had not experienced six or more sessions of clinical supervision were more likely to report cold negative attitudes towards their clients as indicated by higher scores on the depersonalization subscale of the Maslach Burnout Inventory. One hundred and sixty-six community mental heath nurses had experienced six or more sessions of clinical supervision and had completed the Maslach Burnout Inventory. Higher scores on the Manchester Clinical Supervision Scale were also associated with lower levels of measured burnout, with significant negative correlations between the total Manchester Clinical Supervision Scale score and the emotional exhaustion subscale (r = -0.148, P = 0.050) and the depersonalization subscale (r = -0.220, P = 0.003) of the Maslach Burnout Inventory. These findings suggest that if clinical supervision is effective then community mental heath nurses are likely to report lower levels of emotional exhaustion and depersonalization. CONCLUSIONS: The findings from this study suggest that if clinical supervision is effective then community mental heath nurses report lower levels of burnout. Further research is required to determine the long-term benefits of implementing clinical supervision and to determine which other factors have an influence on levels of burnout for this group of nurses. Health service organizations have a responsibility for ensuring that all individual practitioners have access to effective clinical supervision and the Nursing and Midwifery Council could extend the registered nurses personal accountability to include - to seek clinical supervision as and when necessary.

Adult↗
PubMed2006

Evidence of white matter pathology in bipolar disorder adolescents experiencing their first episode of mania: a diffusion tensor imaging study.

OBJECTIVE: Previous diffusion tensor imaging findings have supported suggestions that bipolar disorder is characterized by subtle white matter changes. The chronic nature of the study population, however, has limited interpretation of these findings. In this study the authors utilized diffusion tensor imaging to study white matter tracts of adolescents in their first episode of mania to address whether abnormalities are present in early bipolar disorder. METHOD: Eleven medication-naive adolescents in their first episode of mania and 17 healthy subjects underwent diffusion tensor imaging scans. Fractional anisotropy and trace apparent diffusion coefficients of prefrontal and posterior regions of interest were compared between groups. RESULTS: Bipolar adolescents showed significantly decreased fractional anisotropy only in superior-frontal white matter tracts. Trace apparent diffusion coefficients did not significantly differ in any regions examined. CONCLUSIONS: These findings suggest that prefrontal white matter abnormalities are present early in bipolar disorder and may consist largely of axonal disorganization. The presence of changes in young first-episode patients also suggests that white matter pathology may represent an early marker of bipolar disorder.

Adolescent↗
PubMed2005

Quality of care for hypertension in the United States.

BACKGROUND: Despite heavy recent emphasis on blood pressure (BP) control, many patients fail to meet widely accepted goals. While access and adherence to therapy certainly play a role, another potential explanation is poor quality of essential care processes (QC). Yet little is known about the relationship between QC and BP control. METHODS: We assessed QC in 12 U.S. communities by reviewing the medical records of a randomly selected group of patients for the two years preceding our study. We included patients with either a diagnosis of hypertension or two visits with BPs of >or=140/90 in their medical records. We used 28 process indicators based on explicit evidence to assess QC. The indicators covered a broad spectrum of care and were developed through a modified Delphi method. We considered patients who received all indicated care to have optimal QC. We defined control of hypertension as BP < 140/90 in the most recent reading. RESULTS: Of 1,953 hypertensive patients, only 57% received optimal care and 42% had controlled hypertension. Patients who had received optimal care were more likely to have their BP under control at the end of the study (45% vs. 35%, p = .0006). Patients were more likely to receive optimal care if they were over age 50 (76% vs. 63%, p < .0001), had diabetes (77% vs. 71%, p = .0038), coronary artery disease (87% vs. 69%, p < .0001), or hyperlipidemia (80% vs. 68%, p < .0001), and did not smoke (73% vs. 66%, p = .0005). CONCLUSIONS: Higher QC for hypertensive patients is associated with better BP control. Younger patients without cardiac risk factors are at greatest risk for poor care. Quality measurement systems like the one presented in this study can guide future quality improvement efforts.

Age Factors↗
PubMed2005

Need for eye care among older adults with diabetes mellitus in fee-for-service and managed Medicare.

OBJECTIVE: To compare rates of need for eye care among Medicare beneficiaries with network-model Medicare+Choice (MC) and fee-for-service (FFS) health insurance. METHODS: Cross-sectional study of a random sample of MC and FFS community-dwelling Medicare beneficiaries with diabetes who are older than 65 years of age in Los Angeles County. Study ophthalmologists masked to the participants' type of health insurance performed standardized dilated eye examinations and indicated the need for ophthalmic care during the next 6 months. To evaluate the association between type of insurance and need for treatment, we constructed logistic regression models adjusted for participant sociodemographic and clinical characteristics. RESULTS: The 311 MC and 107 FFS respondents reported comparable rates of eye care provider visits and preexisting eye diseases. However, on masked clinical examination, MC respondents were more likely to have diabetic retinopathy, visually significant cataract, glaucoma, or suspected glaucoma than FFS participants (68% vs 46%, P<.001). In multivariate analyses, persons enrolled in MC were significantly more likely than FFS participants to require further treatment during the next 6 months (42% vs 24%, P = .01). CONCLUSIONS: Data from standardized study ophthalmic examinations suggest high rates of unrecognized and untreated eye diseases among Medicare beneficiaries enrolled in both FFS and MC and significantly higher rates of need for care among MC participants.

Aged↗
PubMed2005

Predictors of overall quality of care provided to vulnerable older people.

OBJECTIVES: Prior research shows that the quality of care provided to vulnerable older persons is suboptimal, but little is known about the factors associated with care quality for this group. In this study, the influences of clinical conditions, types of care processes, and sociodemographic characteristics on the quality of care received by vulnerable older people were evaluated. DESIGN: Observational cohort study. SETTING: Two senior managed care plans. PARTICIPANTS: Three hundred sixty-two community-dwelling patients aged 65 and older identified as vulnerable by the Vulnerable Elder Survey (VES-13). MEASUREMENTS OUTCOME VARIABLE: patients' observed-minus-expected overall quality score. PREDICTOR VARIABLES: types of care processes, types and number of clinical conditions, sex, age, VES-13 score (composite score of function and self-rated health), income, education, mental health status, and number of quality indicators triggered. RESULTS: Patients whose conditions required more history-taking, counseling, and medication-prescribing care processes and patients with diabetes mellitus received lower-than-expected quality of care. A greater number of comorbid conditions was associated with higher-than-expected quality of care. Age, sex, VES-13 score, and other sociodemographic variables were not associated with quality of care. CONCLUSION: Complexity, vulnerability, and age do not predispose older persons to receive poorer-quality care. In contrast, older patients whose care requires time-consuming processes such as history taking and counseling are at risk for worse quality of care and should be a target for intervention to improve care.

Aged↗
PubMed2004

Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.

BACKGROUND: The Veterans Health Administration (VHA) has introduced an integrated electronic medical record, performance measurement, and other system changes directed at improving care. Recent comparisons with other delivery systems have been limited to a small set of indicators. OBJECTIVE: To compare the quality of VHA care with that of care in a national sample by using a comprehensive quality-of-care measure. DESIGN: Cross-sectional comparison. SETTING: 12 VHA health care systems and 12 communities. PATIENTS: 596 VHA patients and 992 patients identified through random-digit dialing. All were men older than 35 years of age. MEASUREMENTS: Between 1997 and 2000, quality was measured by using a chart-based quality instrument consisting of 348 indicators targeting 26 conditions. Results were adjusted for clustering, age, number of visits, and medical conditions. RESULTS: Patients from the VHA scored significantly higher for adjusted overall quality (67% vs. 51%; difference, 16 percentage points [95% CI, 14 to 18 percentage points]), chronic disease care (72% vs. 59%; difference, 13 percentage points [CI, 10 to 17 percentage points]), and preventive care (64% vs. 44%; difference, 20 percentage points [CI, 12 to 28 percentage points]), but not for acute care. The VHA advantage was most prominent in processes targeted by VHA performance measurement (66% vs. 43%; difference, 23 percentage points [CI, 21 to 26 percentage points]) and least prominent in areas unrelated to VHA performance measurement (55% vs. 50%; difference, 5 percentage points [CI, 0 to 10 percentage points]). LIMITATIONS: Unmeasured residual differences in patient characteristics, a lower response rate in the national sample, and differences in documentation practices could have contributed to some of the observed differences. CONCLUSIONS: Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.

Cross-Sectional Studies↗
PubMed2004

Profiling quality of care: Is there a role for peer review?

BACKGROUND: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. METHODS: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. RESULTS: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16-0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. CONCLUSIONS: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses.

Acute Disease↗
PubMed2004

The quality of pharmacologic care for vulnerable older patients.

BACKGROUND: Although pharmacotherapy is critical to the medical care of older patients, medications can have considerable toxicity in this age group. To date, research has focused on inappropriate prescribing and policy efforts have aimed at access, but no comprehensive measurement of the quality of pharmacologic management using explicit criteria has been performed. OBJECTIVE: To evaluate the broad range of pharmacologic care processes for vulnerable older patients. DESIGN: Observational cohort study. SETTING: 2 managed care organizations enrolling older persons. PATIENTS: Community-dwelling high-risk patients 65 years of age or older continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. MEASUREMENTS: Patients' receipt of care as specified in 43 quality indicators covering 4 domains of pharmacologic care: 1) prescribing indicated medications; 2) avoiding inappropriate medications; 3) education, continuity, and documentation; and 4) medication monitoring. RESULTS: Of 475 vulnerable older patients, 372 (78%) consented to participate and had medical records that could be abstracted. The percentage of appropriate pharmacologic management ranged from 10% for documentation of risks of nonsteroidal anti-inflammatory drugs to 100% for avoiding short-acting calcium-channel blockers in patients with heart failure and avoiding beta-blockers in patients with asthma. Pass rates for quality indicators in the "avoiding inappropriate medications" domain (97% [95% CI, 96% to 98%]) were significantly higher than pass rates for "prescribing indicated medications" (50% [CI, 45% to 55%]); "education, continuity, and documentation" (81% [CI, 79% to 84%]); and "medication monitoring" (64% [CI, 60% to 68%]). LIMITATIONS: Fewer than 10 patients were eligible for many of the quality indicators measured, and the generalizability of these findings in 2 managed care organizations to the general geriatric population is uncertain. CONCLUSIONS: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.

Aged↗