Digital Commons Network^™

Rapamycin Rescues Vascular, Metabolic And Learning Deficits In Apolipoprotein E4 Transgenic Mice With Pre-Symptomatic Alzheimer’S Disease, Ai-Ling Lin, Jordan B. Jahrling, Wei Zhang, Nicholas Derosa, Vikas Bakshi, Peter Romero, Veronica Galvan, Arlan Richardson

Sanders-Brown Center on Aging Faculty Publications

Apolipoprotein E ɛ4 allele is a common susceptibility gene for late-onset Alzheimer's disease. Brain vascular and metabolic deficits can occur in cognitively normal apolipoprotein E ɛ4 carriers decades before the onset of Alzheimer's disease. The goal of this study was to determine whether early intervention using rapamycin could restore neurovascular and neurometabolic functions, and thus impede pathological progression of Alzheimer's disease-like symptoms in pre-symptomatic Apolipoprotein E ɛ4 transgenic mice. Using in vivo, multimodal neuroimaging, we found that apolipoprotein E ɛ4 mice treated with rapamycin had restored cerebral blood flow, blood–brain barrier integrity and glucose metabolism, compared …

Results Of A Health Education Message Intervention On Hpv Knowledge And Receipt Of Follow-Up Care Among Latinas Infected With High-Risk Human Papillomavirus, Maureen Sanderson, Dineo Khabele, Claudine L. Brown, Khalil Harbi, Leah R. Alexander, Ann L. Coker, Maria E. Fernandez, Heather M. Brandt, Mary K. Fadden, Pamela C. Hull

Obstetrics and Gynecology Faculty Publications

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health …

Leadership And Mentorship: Service Leaders As Mentors Of The Followers, Daniel T. L. Shek, Li Lin

Pediatrics Faculty Publications

According to the Hong Kong Institute of Service Leadership and Management, an effective service leader serves as a mentor for his/her followers. Aside from promoting their followers’ professional and personal growth, mentoring also contributes to the development of the service leaders themselves. In this paper, a lecture addressing the concept and functions of mentoring is outlined, along with its relationship with service leadership. The professional and psychosocial functions of mentoring to service leaders and followers and various ways to promote mentoring in service leadership are highlighted. Students are also encouraged to reflect on the potential harmful effects of mentoring on …

A Prospective Analysis Of Factors Associated With Decreased Physical Activity In Patients With Cirrhosis Undergoing Transplant Evaluation, Anna Christina Dela Cruz, Valery Vilchez, Sooyeon Kim, Benjamin Barnes, Abhishek Ravinuthala, Anthony Zanni, Roberto Galuppo, Achuthan Sourianarayanane, Trushar Patel, Erin Colleen Maynard, Malay B. Shah, Michael F. Daily, Timothy L. Uhl, Karyn A. Esser, Roberto Gedaly

Internal Medicine Faculty Publications

BACKGROUND: Physical activity has been associated with improved recovery time after transplantation. Handgrip strength has been related to post-transplant outcomes.

AIM: To evaluate predictors of physical activity and grip strength in cirrhotic patients undergoing liver transplant evaluation.

METHODS: Single center, prospective analysis.

RESULTS: A hundred patients were evaluated (54% male, mean age 53 ± 9). Common etiologies of liver disease were non-alcoholic hepatitis (27%), hepatitis C (22%), and alcoholic liver disease (21%). Mean MELD score was 13.5. Forty one percent had a history of smoking. Ninety-three patients completed the International Physical Activity Questionnaire. The median total physical activity score of …

Distal Insertional Footprint Of The Brachialis Muscle: 3d Morphometric Study, Srinath Kamineni, Abdo Bachoura, William Behrens, Ellora Kamineni, Andrew Deane

Orthopaedic Surgery and Sports Medicine Faculty Publications

Objective. The purpose of this study is to describe the three-dimensional morphometry of the brachialis muscle at its distal attachment to the ulna. Methods. Fifty cadaveric elbows were dissected and the brachialis distal insertion was isolated on the ulna bone and probed with a three-dimensional digitizer, to create a three-dimensional model of the footprint. Measurements and analysis of each footprint shape were recorded and compared based on gender and size. Results. There was significant gender difference in the surface length (P = 0.002) and projected length (P = 0.001) of the brachialis footprint. The shapes …

Women With Disabilities: Reproductive Care And Women’S Health, Stephanie Stockburger, Hatim A. Omar

Pediatrics Faculty Publications

Children, adolescents, and women with disabilities experience the same sexual development, pubertal changes, concerns, and desire to reproduce as their typically developing counterparts. However, society has tended to stigmatize women with disabilities as “asexual” and ignore this aspect of their health care. These women are less likely to receive gynecological exams, contraception, and evaluation of sexual dysfunction. Unfortunately, having a disability places women at risk for sexual exploitation and abuse as well as sexually transmitted infections. Therefore, reproductive health care for these women is imperative. A number of barriers to receiving reproductive care exist. However, with proper education and knowledge …

Lipin1 Regulates Skeletal Muscle Differentiation Through Extracellular Signal-Regulated Kinase (Erk) Activation And Cyclin D Complex-Regulated Cell Cycle Withdrawal, Weihua Jiang, Jing Zhu, Xun Zhuang, Xiping Zhang, Tao Luo, Karyn Esser, Hongmei Ren

Saha Cardiovascular Research Center Faculty Publications

Lipin1, an intracellular protein, plays critical roles in controlling lipid synthesis and energy metabolism through its enzymatic activity and nuclear transcriptional functions. Several mouse models of skeletal muscle wasting are associated with lipin1 mutation or altered expression. Recent human studies have suggested that children with homozygous null mutations in the LPIN1 gene suffer from rhabdomyolysis. However, the underlying pathophysiologic mechanism is still poorly understood. In the present study we examined whether lipin1 contributes to regulating muscle regeneration. We characterized the time course of skeletal muscle regeneration in lipin1-deficient fld mice after injury. We found that fld mice exhibited smaller regenerated …

Factors Leading To The Creation, Development, And Maintenance Of Positive Social Relationship, Daniel T. L. Shek, Jocelyn L. Lin

Pediatrics Faculty Publications

In contrast to the manufacturing economy where the focus is primarily placed on the man-machine interface, social relationships are important building blocks in the service economy. Hence, identifyig the factors leading to creation, development, and maintenance of positive social relationships within the context of leadership is an important consideration. In this paper, a lecture covers the nature of social relationships and the related determinants (including trust, care, and respect) are outlined. Through this lecture, students can develop the ability to identify the characteristics and determinants of positive social relationships, appreciate the importance of positive relationships to service leaders, and evaluate …

Albumin Administration In Acute Ischemic Stroke: Safety Analysis Of The Alias Part 2 Multicenter Trial, Michael D. Hill, Renee H. Martin, Yuko Y. Palesch, Claudias S. Moy, Diego Tamariz, Karla J. Ryckborst, Elizabeth B. Jones, David Weisman, L. Creed Pettigrew, Myron D. Ginsberg

Sanders-Brown Center on Aging Faculty Publications

BACKGROUND: Albumin treatment of ischemic stroke was associated with cardiopulmonary adverse events in previous studies and a low incidence of intracranial hemorrhage. We sought to describe the neurological and cardiopulmonary adverse events in the ALIAS Part 2 Multicenter Trial.

METHODS: Ischemic stroke patients, aged 18-83 and a baseline NIHSS ≥ 6, were randomized to treatment with ALB or saline control within 5 hours of stroke onset. Neurological adverse events included symptomatic intracranial hemorrhage, hemicraniectomy, neurological deterioration and neurological death. Cardiopulmonary adverse events included pulmonary edema/congestive heart failure, acute coronary syndromes, atrial fibrillation, pneumonia and pulmonary thromboembolism.

RESULTS: …

Use Of Social Media As A Virtual Community And Support Group By Left Ventricular Assist Device (Lvad) Patients, Bryan Boling, Amanda Hart, Chizimuzo T.C. Okoli, Tamra Halcomb, Peggy El-Mallakh

The VAD Journal

Abstract

Background

Left ventricular assist device (LVAD) patients may benefit from participating in a social support group; however, several factors may limit the availability of these communities. Alternatively, online social support communities may be more accessible for LVAD patients. No studies have examined patterns and reasons for health-related social media use among people with LVADs

Methods

An online survey of patients actively participating in LVAD social media groups was conducted using both multiple choice and open-ended questions.

Results

Thirty-nine participants (65% male) completed the survey. Participants’ reasons for weekly engagement in online communities were to seek (69.2%) and offer (66.7%) …

Insights Into Alzheimer’S Disease: The Levels Of Signaling Proteins In Brain Of Control Subjects Versus Brain From Subjects With Mild Cognitive Impairment, Georgianne F. Tiu

Kaleidoscope

The purpose of this study was to measure the expression levels of key signaling proteins in brain tissue from subjects with mild cognitive impairment (MCI) compared to control subjects. MCI is considered to be the beginning phase of Alzheimer’s disease (AD). Tumor necrosis factor alpha (TNF-α), nuclear factor kappa beta (NF-κβ), phospho Bad (pBad), and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are four of the proteins that were investigated. Trends of either decreases or increases in protein expression levels in MCI vs. control brain were investigated. Western blot analysis was used in order to identify these trends. These signaling protein levels are …

Inner Synovial Membrane Footprint Of The Anterior Elbow Capsule: An Arthroscopic Boundary, Srinath Kamineni, Abdo Bachoura, Koichi Sasaki, Danielle Reilly, Kate N. Harris, Anthony Sinai, Andrew Deane

Orthopaedic Surgery and Sports Medicine Faculty Publications

Introduction. The purpose of this study is to describe the inner synovial membrane (SM) of the anterior elbow capsule, both qualitatively and quantitatively. Materials and Methods. Twenty-two cadaveric human elbows were dissected and the distal humerus and SM attachments were digitized using a digitizer. The transepicondylar line (TEL) was used as the primary descriptor of various landmarks. The distance between the medial epicondyle and medial SM edge, SM apex overlying the coronoid fossa, the central SM nadir, and the apex of the SM insertion overlying the radial fossa and distance from the lateral epicondyle to lateral SM edge along the …

Sex Differences In Clinical Features Of Early, Treated Parkinson's Disease, Erika F. Augustine, Adriana Pérez, Rohit Dhall, Chizoba C. Umeh, Aleksandar Videnovic, Franca Cambi, Anne-Marie A. Wills, Jordan J. Elm, Richard M. Zweig, Lisa M. Shulman, Martha A. Nance, Jacquelyn Bainbridge, Oksana Suchowersky

Neurology Faculty Publications

INTRODUCTION: To improve our understanding of sex differences in the clinical characteristics of Parkinson's Disease, we sought to examine differences in the clinical features and disease severity of men and women with early treated Parkinson's Disease (PD) enrolled in a large-scale clinical trial.

METHODS: Analysis was performed of baseline data from the National Institutes of Health Exploratory Trials in Parkinson's Disease (NET-PD) Long-term Study-1, a randomized, multi-center, double-blind, placebo-controlled study of 10 grams of oral creatine/day in individuals with early, treated PD. We compared mean age at symptom onset, age at PD diagnosis, and age at randomization between …

Low Neural Exosomal Levels Of Cellular Survival Factors In Alzheimer's Disease, Edward J. Goetzl, Adam Boxer, Janice B. Schwartz, Erin Abner, Ronald C. Petersen, Bruce L. Miller, Olga D. Carlson, Maja Mustapic, Dimitrios Kapogiannis

Sanders-Brown Center on Aging Faculty Publications

Transcription factors that mediate neuronal defenses against diverse stresses were quantified in plasma neural-derived exosomes of Alzheimer's disease or frontotemporal dementia patients and matched controls. Exosomal levels of low-density lipoprotein receptor-related protein 6, heat-shock factor-1, and repressor element 1-silencing transcription factor all were significantly lower in Alzheimer's disease patients than controls (P < 0.0001). In frontotemporal dementia, the only significant difference was higher levels of repressor element 1-silencing transcription factor than in controls. Exosomal transcription factors were diminished 2-10 years before clinical diagnosis of Alzheimer's disease. Low exosomal levels of survival proteins may explain decreased neuronal resistance to Alzheimer's disease neurotoxic proteins.

Procollagen C-Endopeptidase Enhancer Protein 2 (Pcpe2) Reduces Atherosclerosis In Mice By Enhancing Scavenger Receptor Class B1 (Sr-Bi)-Mediated High-Density Lipoprotein (Hdl)-Cholesteryl Ester Uptake, Ricquita D. Pollard, Christopher N. Blesso, Manal Zabalawi, Brian Fulp, Mark Gerelus, Xuewei Zhu, Erica W. Lyons, Nebil Nuradin, Omar L. Francone, Xiang-An Li, Daisy Sahoo, Michael J. Thomas, Mary G. Sorci-Thomas

Pediatrics Faculty Publications

Studies in human populations have shown a significant correlation between procollagen C-endopeptidase enhancer protein 2 (PCPE2) single nucleotide polymorphisms and plasma HDL cholesterol concentrations. PCPE2, a 52-kDa glycoprotein located in the extracellular matrix, enhances the cleavage of C-terminal procollagen by bone morphogenetic protein 1 (BMP1). Our studies here focused on investigating the basis for the elevated concentration of enlarged plasma HDL in PCPE2-deficient mice to determine whether they protected against diet-induced atherosclerosis. PCPE2-deficient mice were crossed with LDL receptor-deficient mice to obtain LDLr^-/-, PCPE2^-/- mice, which had elevated HDL levels compared with LDLr^-/- mice with similar …

Calcium Channel Blockers, Progression To Dementia, And Effects On Amyloid Beta Peptide Production, Mark A. Lovell, Erin Abner, Richard Kryscio, Liou Xu, Shuling X. Fister, Bert C. Lynn

Sanders-Brown Center on Aging Faculty Publications

Previous epidemiologic studies suggest that antihypertensive drugs may be protective against cognitive decline. To determine if subjects enrolled in the University of Kentucky longitudinal aging study who used antihypertensive drugs showed diminished progression to dementia, we used a 3-parameter logistic regression model to compare the rate of progression to dementia for subjects who used any of the five common categories of antihypertensive drugs to those with similar demographic characteristics but who did not use antihypertensives. Regression modeling showed that subjects who used calcium channel blockers (CCBs) but not the other classes of antihypertensives showed a significant decrease in the rate …

Ferritin Levels In The Cerebrospinal Fluid Predict Alzheimer's Disease Outcomes And Are Regulated By Apoe, Scott Ayton, Noel G. Faux, Ashley I. Bush, Charles D. Smith, Greg A. Jicha, Peter A. Hardy, Partha Sinha, Elizabeth Oates, Gary Conrad, Alzheimer's Disease Neuroimaging Initiative

Neurology Faculty Publications

Brain iron elevation is implicated in Alzheimer's disease (AD) pathogenesis, but the impact of iron on disease outcomes has not been previously explored in a longitudinal study. Ferritin is the major iron storage protein of the body; by using cerebrospinal fluid (CSF) levels of ferritin as an index, we explored whether brain iron status impacts longitudinal outcomes in the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort. We show that baseline CSF ferritin levels were negatively associated with cognitive performance over 7 years in 91 cognitively normal, 144 mild cognitive impairment (MCI) and 67 AD subjects, and predicted MCI conversion to AD. …

Plasma Tnf-Α And Soluble Tnf Receptor Levels After Doxorubicin With Or Without Co-Administration Of Mesna-A Randomized, Cross-Over Clinical Study, John Hayslip, Emily Van Meter Dressler, Heidi L. Weiss, Tammy J. Taylor, Mara D. Chambers, Teresa Noel, Sumitra Miriyala, Jeriel T. R. Keeney, Xiaojia Ren, Rukhsana Sultana, Mary Vore, D. Allan Butterfield, Daret St. Clair, Jeffrey A. Moscow

Markey Cancer Center Faculty Publications

PURPOSE: Chemotherapy-induced cognitive impairment (CICI) is a common sequelae of cancer therapy. Recent preclinical observations have suggested that CICI can be mediated by chemotherapy-induced plasma protein oxidation, which triggers TNF-α mediated CNS damage. This study evaluated sodium-2-mercaptoethane sulfonate (Mesna) co-administration with doxorubicin to reduce doxorubicin-induced plasma protein oxidation and resultant cascade of TNF-α, soluble TNF receptor levels and related cytokines.

METHODS: Thirty-two evaluable patients were randomized using a crossover design to receive mesna or saline in either the first or second cycle of doxorubicin in the context of a standard chemotherapy regimen for either non-Hodgkin lymphoma or breast …

Closed Head Injury In An Age-Related Alzheimer Mouse Model Leads To An Altered Neuroinflammatory Response And Persistent Cognitive Impairment, Scott J. Webster, Linda J. Van Eldik, D. Martin Watterson, Adam D. Bachstetter

Sanders-Brown Center on Aging Faculty Publications

Epidemiological studies have associated increased risk of Alzheimer's disease (AD)-related clinical symptoms with a medical history of head injury. Currently, little is known about pathophysiology mechanisms linked to this association. Persistent neuroinflammation is one outcome observed in patients after a single head injury. Neuroinflammation is also present early in relevant brain regions during AD pathology progression. In addition, previous mechanistic studies in animal models link neuroinflammation as a contributor to neuropathology and cognitive impairment in traumatic brain injury (TBI) or AD-related models. Therefore, we explored the potential interplay of neuroinflammatory responses in TBI and AD by analysis of the temporal …

Detection Of Phlpp1Α/Β In Human And Mouse Brain By Different Anti-Phlpp1 Antibodies, Travis C. Jackson, Hülya Bayir, Milos D. Ikonomovic, Keri Janesko-Feldman, Zaichuan Mi, Tianyan Gao, Edwin K. Jackson, Patrick M. Kochanek

Markey Cancer Center Faculty Publications

Pleckstrin homology domain and leucine rich repeat protein phosphatase 1 (PHLPP1) is a member of the serine/threonine family of phosphatases. It has been studied in organs including brain, heart, pancreas, adipose, breast, and prostate. Human PHLPP1 encodes two splice variants - PHLPP1α (~140-150 kDa) and PHLPP1β (~180-190 kDa). Commercial antibodies are widely used to characterize PHLPP1 proteins in cells/tissues. Here we validate five different antibodies to detect PHLPP1α/β by Western blot using PHLPP1 WT/KO mice. All antibodies recognize PHLPP1β in brain. Only a single antibody (Cosmo Bio Co) detects PHLPP1α (~145-150 kDa). The other four antibodies detect a non-specific signal …

Getting The Right Scan: Evidence Based Radiology For Hospitalists, Erich C. Maul Do, Mph

Erich C. Maul DO MPH

No abstract provided.

Menthol Cigarette Smoking And Obesity In Young Adult Daily Smokers In Hawaii, Alyssa Marie M. Antonio, Pebbles Fagan, Faith D. Hamamura, Ian Joseph N. Lagua, Jenny Liu, Devin J. Park, Pallav Pokhrel, Thaddeus A. Herzog, Ian Pagano, Kevin Cassel, Angela Sy, Dorothy Jorgensen, Tania Lynch, Crissy Kawamoto, Carol J. Boushey, Adrian Franke, Mark S. Clanton, Eric T. Moolchan, Linda A. Alexander

Health, Behavior & Society Faculty Publications

This study investigates 1) the relationship between menthol cigarette smoking and obesity and 2) the association of body mass index with the nicotine metabolite ratio among menthol and non-menthol daily smokers aged 18–35 (n = 175). A brief survey on smoking and measures of height and weight, carbon monoxide, and saliva samples were collected from participants from May to December 2013 in Honolulu, Hawaii. Multiple regression was used to estimate differences in body mass index among menthol and non-menthol smokers and the association of menthol smoking with obesity. We calculated the log of the nicotine metabolite ratio to examine differences …

Syphilis: The Forgotten Sexually Transmitted Disease. A Brief Case Report, Amy Burnett, Hatim A. Omar

Pediatrics Faculty Publications

Syphilis has declined significantly over the last 30 years. Due to that success, many physicians no longer have the skills to recognize its symptoms. We present a case of syphilis as a demonstration of this fact.

Effective Youth Suicide Prevention: Evidence From Kentucky, Dessi Slavova, Hatim A. Omar

Pediatrics Faculty Publications

In 2013, Suicide was the second leading cause of death among U.S. young adolescents (15-19 years of age), accounting for 18.4% of all deaths in this age group. According to a nationally representative study on the lifetime prevalence of adolescent suicidal behaviors, 12.1% of U.S. adolescents experience suicidal ideation, 4.0% develop a plan, and 4.1% attempt suicide. The same study estimated that approximately 60% of young people with a suicide plan will attempt suicide, and most of the adolescents who subsequently make an attempt do so within the first year after the onset of ideation.

These findings support the importance …

Female Athlete Triad Review, Hannah Harrison, Hatim A. Omar

Pediatrics Faculty Publications

This article defines the female athlete triad and discusses long-term consequences for adolescents and women symptoms related to the triad. The pillars of the female athlete triad consist of menstruation disruption, decreased bone mineral density, and disordered eating (energy availability). We will discuss the problems that can arise from each of the three pillars of the female athlete triad and the relationships among them. There are different treatments for the triad based on the needs of the individual and new treatments are being researched. Finally, the need for more informed coaches, parents, and medical professionals is discussed.

Self-Cutting And Suicide In Adolescents, Donald E. Greydanus, Hatim A. Omar

Pediatrics Faculty Publications

Deliberate self-harm (DSH) is a common and typically secret phenomenon in adolescents, especially females that involves two main features—self-derogation and negative emotionality. Causes of non-suicidal self-injury include attempts to get help from professionals, express disgust or self-anger, resist suicidal thoughts, and correct episodes of dissociation. DSH is associated with eating disorders and alcohol abuse, as well as other illict drug abuse. Fortunately, most self-cutters are not at high risk for eventual suicide; however, all those with DSH histories should be carefully assessed for suicide as well as offered comprehensive management. Programs for prevention of suicide should be implemented for adolescents …

Disability And Suicide, Divya Nagraj, Hatim A. Omar

Pediatrics Faculty Publications

We provide a systematic review of suicide among adolescents with physical disabilities, intellectual disability and learning disability. A search was performed of English articles published prior to December 2014 in the PubMed database for studies examining suicide, suicidal behavior and suicidal ideation among adolescents with and without varied disabilities. Nine studies were retrieved, of which two studies examined adolescent populations with physical disabilities, three looked at suicide in adolescents with intellectual disability and four studies examined adolescents with learning disabilities. There were consistent results to prove that these adolescents with special needs had an increased tendency to commit suicide and …

Primary Care Providers’ Knowledge And Experience With Pediatric Acute Watery Diarrhea And Hemolytic Uremic Syndrome, Krista Marie Cassel

DNP Projects

The purpose of this capstone is to investigate the potential for hemolytic uremic syndrome (HUS) risk reduction in children through the evaluation of current evidence as well as pediatric primary care providers' knowledge and experience with children at risk for HUS. The goals of this capstone are to 1) evaluate the current literature to determine best practice for prevention of HUS, 2) assess primary care provider knowledge of HUS and experience with children with acute watery, and 3) develop a guideline for the initial management and referral of these children at risk for HUS.

Measuring Providers’ Adherence To The American Diabetes Association Screening Recommendation For Prevention Of Diabetic Nephropathy, Whitney R. Munroe

DNP Projects

Purpose: The purpose of this study was to evaluate provider adherence to the ADA’s recommendation for an annual screening urinary albumin excretion level to check for the presence of microalbuminuria. A secondary objective was to assess for adequate treatment (i.e. ACE inhibitor or ARB prescription) in those patients with microalbuminuria present.

Methods: A retrospective chart review was conducted on 60 randomly selected patients seen within a primary care practice in an urban university setting between January 1^st, 2014 and December 31^st, 2014. Inclusion criteria included age ≥ 18 years and an active diagnosis of type 2 …

Polypharmacy Practice Inquiry Project, Mary T. Skinner

DNP Projects

“The impending crisis, which has been foreseen for decades, is now upon us.The nation needs to act now to prepare the health care workforce to meet the care needs of older adults.” Institute of Medicine.

Given the rising tide of people over the age of 65, taking multiple medications or polypharmacy is a becoming more prevalent in older adults. Unfortunately, there are many negative consequences associated with polypharmacy. Specifically, this burden has been associated with greater health care costs and an increased risk of adverse drug events, drug-interactions, medication non-adherence, reduced functional capacity and multiple geriatric syndromes including cognitive impairment. …