CHAPTER 18 PHARMACIST IN GERIATRIC CARE: A CHALLENGING SERVICE*

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1 Health Administrator Vol : XIX Number 1: CHAPTER 18 PHARMACIST IN GERIATRIC CARE: A CHALLENGING SERVICE* Vijay Roy, Rani Varsha** Introduction : Pharmacists are committed to optimizing pharmaceutical therapies for each patient to improve outcomes and reduce costs. They are making significant contributions to the profession through specialized pharmaceutical care. Pharmacists, aided by a comprehensive system employing information technology and clinical best practices work with physicians to identify patients at risk for a given disease state and ensure that optimal drug therapy is received and unnecessary healthcare expenditures are eliminated. Medications are probably the single most important healthcare technology in preventing illness, disability and health in the geriatric population. New products provide pharmacists with valuable tools for promoting quality of life but also confer upon them the more difficult task as well as the greater responsibility of balancing clinical effects to provide the highest possible quality of life for their patients. In a 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 United States. Estimated drug usage, including non-prescription medications, increases this estimate to 50% of all drugs used in the states. Too often, illness in older people are misdiagnosed, overlooked or dismissed as part of the normal aging process, simply because health professionals are not trained to recognize how diseases and drugs affect geriatrics. Making sure every patient must benefit from the pharmacist : Some of the most prevalent diseases of the elderly are : 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 patient? Reduce the variability of prescribing, so that every patient in a skilled nursing facility receives optimal care? Congestive heart failure? Hypertension? Depression? Osteoporosis? Diabetes? Alzheimer s disease? Dementia? Pain management Elders are highly susceptible to medication errors and drug-related problems due to their special needs with medications and uncoordinated care. Further, the side effects of medications in geriatrics often are more severe. Hospital admissions among the elderly due to drug misadventures are six times that of the general population. Use of drugs in the elderly is associated * Adapted with gratefulness from The Pharma Review, October ** Sr. Executive (Pharmacy) Indraprastha Apollo Hospitals, New Delhi and Sarjug Dental College, Darbharsa. 76

2 with increased risk of adverse side effects and morbidity. This is partly because the elderly have more chronic medical conditions and decreased homeostatic reserve. Pharmacotherapy must be individualized, since the elderly are widely variable and drugs must be carefully monitored to minimize risk of poor outcomes. Pharmacist s coordinating and optimizing drug therapy to improve outcomes 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. The ever-increasing elderly population emphasizes the need to better understand drug therapy in the context of the aging process and the unique problems that ensure. In report it was found that 28% of hospitalizations of the elderly are due to adverse drug reactions (17%) and medication noncompliance (11%) respectively. Adverse drug events (ADE s) are among the top five greatest and most preventable threats to the health of the elderly (after CHF, breast cancer, hypertension and pneumonia and approximately 95% of ADE s Are Predictable 4,5. Polypharmacy with elderly Ensuring the appropriateness of an elder patient s drug therapy is paramount. Potentially inappropriate medications put elders at risk for ADE s that could lead to unnecessary morbidity and mortality based on polypharmacy, pharmacokinetics, pharmacodynamics and compliance factors 7. Polypharmacy 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. The tricyclic antidepressants serotonin reuptake inhibitor, antidepressants, benzodiazepines and antipsychotic need to be monitored closely in the geriatric population with regard to falls. Studies have consistently shown a significant association between multiple medication use and risk of falling in the elderly 13. Elderly patients are particularly vulnerable to the sedative effects of psychotropic drugs, resulting in cognitive impairment and motor in coordination with an increased risk of falls and hip fracture. Discomfort, pain or difficulty swallowing medication is a problem faced by many elderly patients. Dysphagia is seen in patients with Parkinson s disease, altered mental status or as a result of a cerebal vascular accident. For an example when a solid dosage form is reduced to a powder (crushed or opened), the surface area is greater and the substance usually dissolves more readily making it more easily absorbed. This may result in an increase in the rate of side effects or toxicity. This is especially true in the elderly with impaired renal or hepatic function Another issue complicating geriatric drug therapy is adherence. Factors that have been shown to increase non-adherence include? Female gender? Lower socioeconomic status? Living alone? Complicated drug regimens? Multiple diseases In a study it was found that 60% of geriatric patients do not take their medications as prescribed and many self medicate as often as once a week. Elderly patients can have some diseases that make adherence to drug therapy difficult, such as;? Conditions that affect vision, e.g. macular degeneration or cataract formation, can make reading prescription labels and medication instruction difficult.? Hearing loss can prevent patients from understanding health care professional instructions and medication information. 77

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 elderly Drug dose should be reduced in elderly patients because of a general decline in body function with age. Alter in absorption in the elderly include; 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. Because of smaller volume of body water, higher peak alcohol levels are observed in elderly than in young 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. A reduction in phase 1 reactions (oxidation, reduction and hydrolysis) can occur. This results in prolonged elimination half lives of benzodiazepines and certain analgesics (dependent on phase-1 metabolism). This may result in drug accumulation and possible adverse effects Age related physiologic changes affecting drug therapy 21 Table No. 1 Pharmacokinetic Factor Change Clinical Significance Gastrointestinal motility Gastric ph Renal function Serum albumin Total body water Body fat/ Lean body Mass ratio May affect the rate but not the extent of drug absorption No significant change in drug absorption Reduced elimination of renally excreted drugs Decreased protein binding leading to an increased free fraction of drug Decreased volume of distribution Of water soluble drugs Increased volume of distribution of fat soluble drugs 78

4 Selection of pharmaceutical therapy for elderly patients can pose a significant challenge and is determined by three primary factors unique to this group. First, the prevalence of multiple chronic diseases or comorbidity is much higher in older individuals. For example, nearly 40% of the elderly suffer from arthritis plus another serious health condition, such as cardiovascular disease or diabetes. Second, an older body reacts to pharmaceuticals quite differently than a young one due to physiological changes that accompany aging; metabolism rates change, organ function declines and sensitivity to some drugs can be altered. Finally, compared with younger patients, there is generally a wider variation in pharmacological action of a drug across individuals. Taken together, these three factors create the need for flexibility in prescribing for the elderly Comorbidity, or the simultaneous presence of two or more chronic diseases, is common in the elderly and is an important reason why treatment must be tailored to the needs of individual patients. The rate of comorbidity in the elderly population has increased steadily since the early 20 th century. This increase may be attributed to a rise in the number of diagnoses and to increased longevity. As people age, the incidence and impact of comorbidity increase, resulting in a decline in well being and functional abilities. Just as certain individual diseases are more common in the elderly, there are also frequently occurring disease pairs. The simultaneous presence of arthritis and high blood pressure is one such pair common in older people; more than 24% of people older than 60 suffer the effects of both diseases. Such comorbidity requires careful selection of drug therapy to ensure safe and effective drug combinations. The incidence of some common diseases pairs is shown and its potential drug interactions also given in the following table 23 Common disease pairs Table 2 Comorbid disease pair Potential drug-drug Adverse effects interactions Arthritis and High blood NSAIDs + Digoxin Some NSAIDs may increase pressure levels resulting in potentia l Digoxin toxicity NSAIDs + ACE Inhibitors Some NSAIDs may blunt the anti-hypertensive effects of some ACE inhibitors High blood pressure and Thiazides + Insulin Thiazides reduce the effectiveness Diabetes of insulin Arthritis and Diabetes Cortisone + Insulin Harmful increase in blood glucose levels in diabetics Arthritis and Heart Disease NSAIDs + Warfarin With NSAID use, the anti-coagulant (Blood thinning) effect of warfarin may be enhanced Also, there is increased risk of bleeding in the Gl Tract 79

5 Pharmacist role & responsibilities in geriatric care could involve :? Elder patient-care activities using a consistent approach that reflects the philosophy of pharmaceutical care and that is performed with the efficiency and depth of experience characteristic in geriatric practice.? 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? Design pharmacotherapeutic regimens for geriatric patients? Provide medication-use education to geriatric patients and their caregivers? Consider non-drug alternatives including physical exercise, physical therapy, counseling and relaxation techniques.? Written instruction, information leaflets, special containers, special packaging 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? Ensure continuity of pharmaceutical care for geriatric patients as they move among alternate care setting? Document pharmaceutical care activities provided for geriatric patients appropriately? Provide programs that center on disease prevention and wellness promotion in a geriatric population provide concise, applicable and timely responses to requests for drug information geriatric patients and their health care providers? Provide inservice education to physicians, nurses and other practitioners serving geriatric patients? Participate in the medication-use evaluation (MUE) program 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? Perform prospective and retrospective financial and clinical outcomes analysis Conclusion A solid understanding of these issues is necessary to comprehensively evaluate drug regimens in this population and recommend dosage modifications where appropriate. Tailoring a drug regimen based on the individual s clinical response requires ongoing assessment. Pharmacists specializing in elder care pharmacy practice are essential participants in the health care systems, recognized and valued for the practice of pharmaceutical care for the elder population and people with chronic illness. In their role as medication therapy experts, pharmacists table responsibility for their patient s medication-related needs; ensure that their medications are most appropriate, the most effective the safest possible and are used correctly; identify, resolve and prevent medication related problems that may interfere with the goals of therapy. Pharmacist s manage and improved drug therapy and improve the quality of life geriatric patients and other individuals residing in a variety of environments, including nursing facilities, sub acute care and assisted living facilities, psychiatric hospitals, hospice programs and in home and communitybased care. Pharmacists can provide a variety of small but important services to make taking prescription medication easier for the elder patient. Furthermore a prudent clinical monitoring of drug therapy by a pharmacist can limit adverse drug reactions and polypharmacotherapy due to a prescribing cascade. 80

6 References 1. Avorn J Medication use and the elderly : current status and opportunities ; Health Affairs, 1995 spring. 2. Murphy J Senate, Committee on aging, Washington Post; May Stein DJ, Variability of serum phenytoin concentration in nursing home patients, Arch Intern Med. 1990; 150(40), Competition and cost of hospital care, JAMA 1987; (258) 15, Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older patients, J Am Geriatr Soc. 1997; 45(8), Gurwitz J, Monane M, et al. Brown University Long-term Care Quality Letter, Wilcox SM, Himmelstein, Inappropriate drug prescribing for the community-dwelling elderly, JAMA 1994; 272, Tregaskis BF, Stevenson IH, Pharmacokinetics in old age. Br.Med Bulletin 1990; 46, Lamy PP, Physiological changes due to age : pharmacodynamic changes of drug action and implications of therapy, Drugs Aging, 1991; 1, Feely J, Coakley D, Altered pharmacodynamics in the elderly, Clin Geriatr Med 1990; 6, Monane M. Avorn J, Medications and falls: causation, correlation and prevention, Clin Geriatr Med 1996; 12(4), 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 1994; 47(1), Leipzig RM, Cumming RG, Tinatti ME Drugs and falls in older people :a systematic review and meta-analysis II, Cardiac and analgesic drugs, J Am Geriatrics Society 1999; 47(1), Rubenstein LZ, Josephson KR, Robbins AS, Falls in the nursing home, Ann Intern Med (6), Macdonald JB, The role of drugs in falls in the elderly, Clin Geriar Med 1985; 1(3), Goodman LS, Goodman and Gilman s The Pharmacological Basis of Therapeutics, 7 th ed. New York MacMillan, 1980:1-7, Levy RA, Therapeutic inequivalence of pharmaceutical alternates, Amer Pharm 1985; April: Osol A, Remington s Pharmaceutical Sciences, 17 th ed. Eaton, PA: Mack; 1985: , , Jacknowitz Al, Swallowing tablets and capsules correctly, US Pharm 1985; October, D M Brahmankar, Sunil B Jaiswal, Text book of Biopharmaceutics and Pharmacokinetics, Amr A Hassan, Geriatric care and the role of pharmacist, Professional Pharmacist May/ July 2005, Vol.IV P.No Guralnik JM, LaCroix A, Everett D, Kovar M, Aging in the eighties: The prevalence of comorbidity and its association with disability, National Center for Health Statistics 1989; 170; Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, et al. Functional status and well being of patients with chronic conditions, JAMA 1989; 262: (7)

7 Why the Elderly Need Individualized Pharmaceutical Care; resources 27. Vijay Roy, Puneet Gupta, Shouryadeep Srivastava, Medication Errors: Causes and Prevention, Aug 2005, The Pharma Review, Vol.3,P.No Vijay Roy, Pharmacis t role in new era of prescription auditing July Aug 2005, The Indian Journal of Hospital Pharmacy, Vol XLII, P.No