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The Pharmacist’s Role In Managing Geriatric patients

Pharmaceutical care in geriatrics

— Medications are probably the single most important healthcare technology in preventing illness, disability and health in the geriatric population.*

— In a recent report, it was estimated that three out of four (75%) of elderly are taking medications. These account for 1/3 of all prescription medications in the world.*

—Pharmacists are the professionals committed to optimizing pharmaceutical therapies for each patient to improve outcomes and reduce costs.*

Definition Of Pharmaceutical Care

Pharmaceutical care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. These outcomes are:-

— Cure of a disease

— Elimination or reduction of patient’s symptoms

—Arresting or slowing of a disease process or preventing a disease or symptom

—Improving quality of life..*

What Is Geriatrics?

—Geriatrics is best described as the branch of medicine that focuses on the health and care of old people. Geriatrics patients  have special health care needs that can make their care complicated.

—Age of Geriatrics  >65years

—More than half of adult age 65 and older have 3 or more medical problems.*

Physiological Changes In The Elderly

An older body reacts to medications quite differently from a young one due to physiological changes that accompany

—aging,

—metabolism rates change,

—organ function decline

—sensitivity to some drugs can be altered.

Age-related physiological changes affects the outcome of drugs therapy.

Diseases Common In Geriatrics

Some of the most prevalent diseases of the elderly are :-

—Congestive heart failure

—Hypertension

— Depression

—Osteoporosis

—Diabetes

— Alzheimer’s disease

—Dementia

—Pain management

Drug Therapy Related Problems In Geriatrics

Geriatrics are highly susceptible to:-

—Medication errors  like wrong drug, wrong dose or dosing intervals

—Drug-related adverse events due to their special needs with medications and uncoordinated care. This is partly because the elderly have more chronic medical conditions and decreased homeostatic reserve

—Non-adherence to drug therapy due to discomfort, pain or difficulty swallowing medication.

—Drug interactions due to poly-pharmacy
Pharmacotherapy must be individualized, since the elderly are widely variable and drugs must be carefully monitored to minimize risk of poor outcomes.

Role Of Pharmacists In Solving Drug Therapy Related Problem

Pharmacist should coordinate and optimize drug therapy to improve outcome by:-

—Reducing costs.

—Targeting patients taking unnecessary multiple prescriptions (often duplicate or triplicate therapies) that can cause serious harm and waste valuable resources.

— Reducing the number of serious at risk for side effects of drugs considered inappropriate for  use in the elderly

— Working with physicians to optimize drug therapies by increasing the use of medications considered to be best for individuals practices

—Providing therapeutic interchange for certain drugs to provide equal or better clinical outcomes.

Poly-pharmacy with Elderly

—   Potentially inappropriate medications put elders at risk for ADE’s that could lead to unnecessary morbidity and mortality based on poly-pharmacy, pharmacokinetics, pharmaco-dynamics and compliance factors.

—      Poly-pharmacy significantly increases the risk of drug-drug interactions.

—      Psychotropic medications have been consistently and significantly associated with an increased risk of falls in the elderly.  E.g The tricyclic antidepressants serotonin reuptake inhibitor, benzodiazepines and antipsychotic need to be monitored closely in the geriatric population with regard to falls.

Example of poly-pharmacy

—Here is a prescription for Mr. L.M age 69 yrs  and admitted in the Male Medical ward with a diagnosis of  Ulcer, He is also a known hypertensive and diabetes patient with history of Asthma

Name: Mr. L.M     Age: 69    Date: 11-03-14

—Rx

-Tab.  Metformin 1g t.d.s  x 1/12

-Tab. Paracetamol 1000mg t.d.s x 5/7

-Tab.  Amlodipine 10mg o.d   x 1/12

-Tab. Bromazepam 3mg nocte x 5/7

-Tab. Chlopheniramine 4mg b.d x 1/52

-Tab. Diclofenac 50mg t.d.s x 1/52

-Tab. Lisinopril 10mg o.d  x1/12

-Tab. Omeprazole 20mg o.d  x 1/52

– Tab. Amiloride 5mg o.d x 1/12

-Tab. HCTZ  25mg b.d x 1/12

-Susp. Gaviscon  15ml PRN x1/52

-Tab. Propranolol  40mg nocte x 1/12

-Seretide 250ug t.d.s  x 1/12

Preferred Prescription:-

—Tab. Amiloride 5mg + Hctz 25mg  o.d x1/12

—Tab. Paracetamol 1g t.d.s x  3/7

—Tab. Metformin 1g t.d.s x 1/12

—Tab. Chlopheniramine 4mg nocte x 1/52

—Tab. Amlodipine  10mg o.d x 1/12

—Tab. Lisinopril 10mg o.d x 1/12

—Susp. Gaviscon 15ml P.R.N

— Seretide 250ug t.d.s  x 1/12

Non-Adherence

Factors that have been shown to increase non-adherence include –

— Side effects

— Female gender

— Lower socio-economic status

— Living alone

—Complicated drug regimens

— Multiple diseases

-About 60% Elderly patients can have some diseases that make adherence to drug therapy difficult, such as:­-

1-Conditions that affect vision*

2- Hearing loss*

3- Arthritis can add to the difficultly of opening medicine bottles.

In these cases providing patients with “pre filled pill boxes” for each day and bold written medication schedule may limit barriers to patient adherence

Dosing Of Drugs In The Elderly

Drug dose should be reduced in elderly patients because of a general decline in body function with age such as

— delayed gastric emptying,

— decreased splanchnic blood flow,

— elevated gastric pH and

— impaired intestinal motility
Although the rate of drug absorption is rarely affected. The lean body mass decreases and body fat increases by almost 100% in elderly persons as compared to adults. Volume of distribution of a water soluble drug may decrease and that of a lipid soluble drug like diazepam increases with age.

— Drugs that are highly bound to albumin (e.g warfarin, phenytoin) may have a greater free concentration because albumin is decreased in the elderly.

—Age related changes in hepatic and renal function greatly alters the clearance of drugs. Serum creatinine may not be a good predictor of renal functions, as creatinine production declines with age.

—Decline in cardiac output with age results in decrease of renal perfusion by 40% to 50%. Due to progressive decrease in renal function, the dosage regimen of drugs that are predominantly excreted unchanged in urine should be reduced in elderly patients.

Dosing Of Drugs In The Elderly

Common Disease Pairs And Drug-Drug Interactions

Pharmacist Role & Responsibilities In Geriatric Care

—Elder patient-care activities using a consistent approach that reflects the philosophy of pharmaceutical care.

—Design, recommend, monitor and evaluate patient specific pharmacotherapy for geriatric patients.

—Build the information base needed to design a medication therapy regimen for a geriatric patient

—Provide medication-use education to geriatric patients and their caregivers

—Consider non-drug alternatives which includes: physical exercise, physical therapy, counseling and relaxation techniques.

— Written instruction, information leaflets, special containers for appropriate use of medication

—Assure the adjustment of the dose is made carefully. Always follow the well known adage “start low and titrate slow”

—Document pharmaceutical care activities provided for geriatric patients appropriately.

—Provide programs that center on disease prevention and wellness promotion in a geriatric population

—Provide in-service education to physicians, nurses and other practitioners serving geriatric patients

—Participate in the medication-use evaluation (MUE) programe in the care of geriatric patients

—Develop a proposal for a new geriatric pharmacy service

— Provide instruction to pharmacy technicians, pharmacy students and pharmacy aides

Benefits Of Geriatric Patients From Pharmacist

—Pharmacist by his professional knowledge and skill can provide a unique service with a mankind approach towards geriatric care.

—Help  prescribers choose the best clinical therapy for each individual patient.

—Offer guidance on how to switch from one drug to another in the way most beneficial to the Patients.*

— Reduce the variability of prescribing, so that every patient in a skilled nursing facility receives optimal care.

Conclusion

—  Geriatrics are a specialized group of patients that require an understanding of their peculiarity to comprehensively evaluate drug regimens in this population and recommend dosage modifications where appropriate.

—  Pharmacists  are essential participants of geriatric health care systems, and are valued for the practice of pharmaceutical care for the elder population.

—In their role as medication therapy experts, pharmacists should take responsibility for their patient’s medication-related  needs; ensure that their medications are most appropriate,  most effective, safe and are used correctly to improve outcome of the health of elderly patients.

References

—Avorn J “Medication use and the elderly :current status and opportunities”; Health Affairs, 2014 spring.

—Hanlon JT, Schmader KE , Koronkowski MJ, et al. Adverse drug events in high risk older patients, J Am Geriatric Soc. 2012; 45(8), 9458.

—Wilcox SM, Himmelstein, Inappropriate drug prescribing for the community-dwelling elderly, JAMA 2014; 272, 292-296.

— Tregaskis BF, Stevenson IH, Pharmacokinetics in old age. Br.Med Bulletin 2010; 46, 9-21.

— Lamy PP, Physiological changes due to age :pharmacodynamic changes of drug action and implications of therapy, Drugs Aging 2013; 1,385-404.

— Steinweg KK, The changing approach to falls in older people : a systematic review and meta-analysis II, Cardiac and analgesic drugs,J Ann Intern Med 2009; 47(1), 40-50.

— Helper, D.D. & Strand, L.M., Opportunities and Responsibilities in Pharmaceutical care, Am. J. Pharm. Educ., 53,7S-15S(2014).

— Amr A Hassan, Geriatric care and the role of pharmacist, “Professional Pharmacist “ May/July 2014, Vol.IV P.No.2-4.

— Why the Elderly Need Individualized Pharmaceutical Care; www.npcnow.org/resources

 

—Vijay Roy, Pharmacis’t role in new era of prescription auditing July Aug’2012, The Indian Journal of Hospital Pharmacy, Vol XLII,P.No.142-44

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