Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults With Multimorbidity using a systematic review of the literature and consensus. The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision making for clinicians who provide both primary and specialty care to older people with MCCs. A work group of geriatricians, cardiologists, and generalists: (1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; (2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: (3) performed a scoping review to identify evidence‐based, validated tools for carrying out the MCC Actions and Action Steps; and (4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: (1) identify and communicate patients' health priorities and health trajectory; (2) stop, start, or continue care based on health priorities, potential benefit vs harm and burden, and health trajectory; and (3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (http://www.geriatricscareonline.org). J Am Geriatr Soc 67:665–673, 2019.

Patients with dementia experience high rates of polypharmacy, potentially inappropriate medication use, and adverse drug events. There is little guidance for clinicians on how to optimize prescribing for this population. Our objective was to investigate clinician-perceived barriers to and facilitators of optimizing prescribing for people with dementia. Methods: Qualitative study involving semistructured interviews of primary care and specialist clinicians in urban, suburban, and rural settings. Transcripts were analyzed using qualitative content analysis. Results: Interviews were conducted with 12 primary care and 9 specialist clinicians, with a mean (SD) age of 47 (9) and mean (SD) of 14 (10) years in practice. Clinicians cited decisions regarding the following drug classes as particularly challenging: oral anticoagulants, antidiabetic agents, statins, bladder antimuscarinics, and antipsychotics. Perceived enablers of optimizing prescribing included access to interdisciplinary services and guidelines for nondementia illnesses (eg, diabetes) addressing the care of people with dementia. Barriers included the lack of data on efficacy and safety of most medications in people with dementia, difficulty assessing medication effects in an individual patient, and the perception that stopping medications is seen as "giving up." Clinicians used a variety of strategies to discuss risks and benefits of medications with patients and caregivers. Conclusions: Clinicians identified numerous barriers to and some facilitators of optimizing prescribing in people with dementia. More data are needed on the benefits and harms of stopping medications in this population. Research should also test different approaches for supporting informed decision making about medications by people with dementia and caregivers.

Key Points Question Can increasing awareness about deprescribing prior to primary care visits reduce the use of potentially inappropriate long-term medications for individuals with cognitive impairment? Findings In this pragmatic cluster randomized clinical trial of deprescribing education for 3012 older adults with cognitive impairment taking 5 or more medications and their primary care clinicians, patients from intervention clinics and control clinics were taking a similar mean number of medications (6.4 vs 6.5) at 6 months, and similar proportions of patients were taking 1 or more potentially inappropriate medications after 6 months. Meaning Educating patients and clinicians about deprescribing in primary care did not have an effect on the number of long-term medications or percentage of potentially inappropriate medications for older adults taking 5 or more long-term medications; findings suggest such interventions should target older adults taking relatively more medications.

BACKGROUND: Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events. OBJECTIVES: To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing. DESIGN: Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians. PARTICIPANTS: Patients aged ≥ 65 years with claimsbased diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations. APPROACH: We used constant comparison to identify and compare themes between patients, caregivers, and physicians. KEY RESULTS: We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers' expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations. CONCLUSIONS: Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.

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BACKGROUND: It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. OBJECTIVES:To assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. PATIENTS AND METHODS:Retrospective cohort study of adults aged ≥65 with mild cognitive impairment (MCI) or dementia and ≥ 2 additional chronic conditions (N=10698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the Anticholinergic Cognitive Burden (ACB) scale, falls and fall-related injuries. RESULTS:During a median follow-up of 366 days, 63% of the cohort used ≥1 ACB drug; 2015 (18.8%) people suffered a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when Level 2 and Level 3 drugs were used in combination (HR 2.06, CI 1.51, 2.83). Multiple ACB Level 1 drugs taken

Multimorbidity, the coexistence of multiple chronic conditions, is common among all adults receiving healthcare and the norm among older adults. Almost 15 years ago, we raised concerns about the limitations of disease-focused, guideline-based medication prescribing (and the randomized clinical trials that inform such prescribing) for older adults with multimorbidity. 1,2 At that time we noted nine limitations of such care: 1) uncertain applicability of results observed in younger study participants without multimorbidity to older adults with multimorbidity; 2) inadequacy of prescribing based on survival or diseasespecific outcomes for patients with competing risks from multiple diseases and for whom quality-of-life and functional status may take priority over other outcomes; 3) the difficulty of identifying harms or benefits of medications we expect patients to take over many years from trials lasting only a few months to years; 4) lack of attention to potential harms of following individual disease recommendations in the face of multiple coexisting conditions; 5) diminishing amount of benefit, and increasing burden, resulting from adherence to guidelines for multiple conditions; 6) inattention to time to treatment benefit in the context of limited life expectancy; 7) insufficient recognition of tradeoffs between better short term quality-of-life without treatment vs. long term benefits of treatment; 8) risk of drug-drug and disease-drug interactions when following multiple guidelines; and 9) lack of methods for incorporating patients' preferences and priorities into guidelines.

Background Geriatric conditions may influence outcomes among patients receiving implantable cardioverter-defibrillators (ICDs). We sought to determine the prevalence of frailty and dementia among older adults receiving primary prevention ICDs, and to determine the impact of multimorbidity on mortality within one year of ICD implantation. Methods and Results The cohort included 83,792 Medicare patients from the National Cardiovascular Data Registry (NCDR®) ICD Registry™ who underwent first primary prevention ICD implantation between 2006–2009. These data were merged with Medicare analytic files to determine the prevalence of frailty, dementia and other conditions prior to ICD implantation, as well as one-year mortality. A validated claims-based algorithm was used to identify frail patients. Mutually exclusive patterns of chronic conditions were examined. The association of each pattern with one-year mortality was assessed using logistic regression models adjusted for selected patient characteristics. Approximately 1 in 10 Medicare patients with heart failure receiving a primary prevention ICD had frailty (10%) or dementia (1%). One-year mortality was 22% for patients with frailty, 27% for patients with dementia, and 12% in the overall cohort. Several multimorbidity patterns were associated with high one-year mortality rates: dementia with frailty (29%), frailty with COPD (25%), and frailty with diabetes (23%). These patterns were present in 8% of the cohort. Conclusions More than 10% of Medicare beneficiaries with heart failure receiving primary prevention ICDs have frailty or dementia. These patients had significantly higher one-year mortality than those with other common chronic conditions. Frailty and dementia should be considered in clinical decision-making and guideline development.