Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.

The use of information and telecommunication technologies has expanded at a rapid rate, which has a strong influence on healthcare delivery in many countries. Rural residents and communities, however, often lack easy access to healthcare services due to geographical and demographical factors. Telepharmacy, a more recent concept that refers to pharmaceutical service provision, enables healthcare services, such as medication review, patients counseling, and prescription verification, by a qualified pharmacist for the patients located at a distance from a remotely located hospital, pharmacy, or healthcare center. Telepharmacy has many recognizable benefits such as the easy access to healthcare services in remote and rural locations, economic benefits, patient satisfaction as a result of medication access and information in rural areas, effective patient counseling, and minimal scarcity of local pharmacist and pharmacy services. Telepharmacy undoubtedly is a great concept, but it is sometimes challenging to put into practice. Inherent to the adoption of these practices are legal challenges and pitfalls that need to be addressed. The start-up of telepharmacy (hardware, software, connectivity, and operational cost) involves considerable time, effort, and money. For rural hospitals with fewer patients, the issue of costs appears to be one of the biggest barriers to telepharmacy services. Moreover, execution and implementation of comprehensive and uniform telepharmacy law is still a challenge. A well-developed system, however, can change the practice of pharmacy that is beneficial to both the rural communities and the hospitals or retail pharmacies that deliver these services.

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Patients continue to receive medications that are not prescribed as symptomatic treatment despite having a LLE. Very few rigorous studies have been conducted on minimizing preventive medications in patients with LLE, and expert opinion varies on medication optimization at the end of life. A consensus guideline that addresses this gap is of paramount importance.

The accumulation of deficits with increasing age results in a decline in the functional capacity of multiple organs and systems. These changes can have a significant influence on the pharmacokinetics and pharmacodynamics of prescribed drugs. Although alterations in body composition and worsening renal clearance are important considerations, for most drugs the liver has the greatest effect on metabolism. Age-related change in hepatic function thereby causes much of the variability in older people's responses to medication. In this review, we propose that a decline in the ability of the liver to inactivate toxins may contribute to a proinflammatory state in which frailty can develop. Since inflammation also downregulates drug metabolism, medication prescribed to frail older people in accordance with disease-specific guidelines may undergo reduced systemic clearance, leading to adverse drug reactions, further functional decline and increasing polypharmacy, exacerbating rather than ameliorating frailty status. We also describe how increasing chronological age and frailty status impact liver size, blood flow and protein binding and enzymes of drug metabolism. This is used to contextualise our discussion of appropriate prescribing practices. For example, while the general axiom of 'start low, go slow' should underpin the initiation of medication (titrating to a defined therapeutic goal), it is important to consider whether drug clearance is flow or capacity-limited. By summarising the effect of age-related changes in hepatic function on medications commonly used in older people, we aim to provide a guide that will have high clinical utility for practising geriatricians.

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The algorithm captures a range of different clinical scenarios in relation to potentially inappropriate medications, and offers an evidence-based approach to identifying and, if appropriate, discontinuing such medications. Studies are required to evaluate algorithm effects on prescribing decisions and patient outcomes. Geriatr Gerontol Int 2016; 16: 1002-1013.

Aims Older patients with life‐limiting illness (LLI) and limited life expectancy (LLE) continue to receive potentially inappropriate medicines, consequently deprescribing is often necessary. However, deprescribing in this population can be complex and challenging. Therefore, we aimed to investigate the evidence for outcomes of deprescribing interventions in older patients with LLI and LLE. Methods Studies on deprescribing intervention and their outcomes in age ≥65 years with LLI and LLE were searched using PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Google Scholar. Medication appropriateness was primary outcome, while clinical and cost‐related outcomes were secondary. Eligibility, data extraction and quality assessment were followed by a narrative synthesis of data. Results Of 9 studies (1375 participants), 3 reported on primary outcome. One study showed a significant reduction in medication inappropriateness by 34.9% (P < .001) from admission to close‐out, the second achieved 29.4% (P < .001) and 15.1% (P = .003) reduction at 12 and 24 months, respectively. The third reported that their intervention stopped (17.2%) and altered the dose (2.6%) of high‐risk medications. Commonly reported clinical outcomes were mortality (n = 3), quality of life (n = 2) and falls (n = 2). Outcomes in terms of cost were reported as overall cost (n = 2), medication cost (n = 1) and health care expenditure (n = 1). Conclusion Our findings suggest that deprescribing in older patients with LLI and LLE can improve medication appropriateness, and has potential for enhancement of several clinical outcomes and cost savings, but the evidence needs to be better established.