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Malaysian Pharmaceutical Society
5th Pharmacy Scientific Conference
“Responding to new roles & challenges”
Geriatrics: The pharmacists’ role in improving
health outcomes for older people through
quality use of medicines
Andrew Gilbert
University of South Australia
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Overview
In this presentation I will discuss:
Special needs of older people in terms of
medications and medication use
Relevance of considerations of an ageing
population to pharmacists in Malaysia
Practical ways in which pharmacists in hospital and
community will be able to better serve their older
patients
Some of the work my Centre is conducting with the
Australian Government’s Department of Veterans’
Affairs to improve medication management in the
veteran population
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What is the issue?
My story:
The elderly ought to be the main beneficiaries of modern
medicines
However:
“illness caused by medication may be the most significant health
problem among the elderly which is amenable to treatment”
(Beers & Ouslander, 1989)
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
For example
In 1000 Community dwelling patients in the state of
South Australia judged to be at risk of medicationmisadventure
- Mean age 71 years (SD 13 years)
- Mean number of medicines 10 (SD 4)
2,222 medication-related problems identified
81% resolved, well managed or improving after a
collaborative doctor/pharmacist medication review
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What were the medication-related
problems we found?
Need for additional test
Need for additional therapy or medicine
Wrong or inappropriate medicine
Adverse drug reaction/interaction
Unnecessary medication
Wrong dose or regimen
Poor compliance
Poor technique
Out-of-date medication
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Extent of the problem
2.4% of all Australian public hospital
admissions are medication-related
140,000 medication-related admissions
2000/2001
approximately 50% are avoidable
Australian Safety and Quality Report 2002
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Medication-related hospital admissions
(Roughead et al, 2002)
35
All admisions
30
Emergency
admissions
Medical admissions
Percent
25
20
15
Unplanned geriatric
admissions
over 75
10
5
0
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Factors making elderly susceptible to
medication-related problems
Poly-morbidity and consequent polypharmacy
age-related changes in the way the body deals
with medications
the sensitivity of the body to medications
altered homeostasis
types of medicines used
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Poly-morbidity and consequent
polypharmacy
Many older people have multiple chronic medical
conditions.
- 60% of 65yo have 2 chronic conditions
- 80% of 85yo have 4 chronic conditions
Treatment of chronic conditions usually involves a
number of different medications
The likelihood of an adverse drug event rises
exponentially with the number of medicines used.
Diseases themselves can modify drug disposition and
clinical response
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Poly-morbidity and consequent
polypharmacy
Adversely affects the patient’s;
- Ability to safely use the medicines
- Knowledge about medications and conditions
but
polypharmacy can often be useful to reduce the
dose of each drug if effects are additive
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Poly-morbidity and consequent
polypharmacy
In Australia the management of chronic
conditions is being driven by evidence-based
guidelines. These guidelines are;
Nearly always single disease focused
Often miss those at most need who have multiple
chronic conditions
and
Following clinical guidelines inevitably leads to
polypharmacy
Dr JoAnne Epping-Jordan; WHO; 2004 National Disease Management Conference
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Best practice management
Diabetes
Oral hypoglycemic or insulin
ACE inhibitor
Low Dose Aspirin
Lipid Lowering agent
1
2
3
4
ACE inhibitor
Diuretic
B-Blocker
Spironolactone +/- digoxin
5
6
7
CHF
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What are the consequences of moving toward disease
management and guideline driven approaches to medicine in a
population demographic where many people moving into their
sixties and seventies have multiple chronic medical conditions?
There are few data which demonstrate positive outcomes for
older people in this scenario.
Guidelines and disease management program treatment
strategies are not usually derived from data on an elderly cohort
of patients, rarely considered in the context of multiple chronic
conditions and usually require 10-15 year adherence to
demonstrate their positive benefits.
Tinetti M et al, Potential Pitfalls of Disease-Specific Guidelines for Patients with Multiple Conditions. NEJM
2004: 351;2870-2874.
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Age-related changes in the way the
body deals with medications
Changes in pharmacokinetics
Absorption
Distribution
Hepatic metabolism
Renal clearance
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Age-related changes in the way the
body deals with medications
Changes in pharmacodynamics/receptor sensitivity
Unpredictable
Need to individualise therapy and dose regimen
Changes in homeostatic mechanisms
blood pressure
Posture and body sway
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
The sensitivity of the body to
medications
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Types of medicines used
Low therapeutic index drugs
- Digoxin, lithium carbonate, methotrexate
Drugs to which older people are known to
be more sensitive;
- Trimethaprim+sulphamethazole,
antihypertensives, antidepressants,
vasodilators, NSAIDs, H2 receptor
antagonists,anticholinergics.
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What medications cause most
problems?
ADRs reported from Australian hospitals data
(Roughead et al 2002)
12
Antineoplastics
Anticoagulants
10
Opioids
Percent
8
6
NSAIDs
Glucocorticoids
4
Antihypertensives (excluding
beta blockers and diuretics)
Cardiac glycosides
2
Antipsychotics
0
Penicillins
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
In the community setting
Main medication groups involved
– Cardiac medications (39% of ADRs)
– CNS medications (27%)
– Musculoskeletal (12%)
At the level of medication class
– ACE inhibitors accounted for 14% of all ADRs
– antidepressants 11%
– NSAIDs 10%
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
The older population The world health report 2005
Popluation by age group; Malaysia and Australia (2003)
3000000
2500000
Australian Population
1500000
Malaysian Population
1000000
500000
5t
o9
15
-1
9
25
-2
9
35
-3
9
45
-4
9
55
-5
9
65
-6
9
75
-7
9
85
-8
9
95
-9
9
0
<1
Population
2000000
Age Group
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
The older population The world health report 2005
Life expectancy at age 60
Malaysia
– Males 10.9 years
Females 12.0 years
Australia
– Males 16.9 years
Females 19.5 years
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
The dominant causes of hospital
admissions and of death in Malaysia
Pre-1970's : infectious diseases; malaria, cholera,
typhoid and tuberculosis
Post-1980 : cardiovascular diseases, cancer,
stroke, accidents, chronic pulmonary
diseases and other chronic diseases
Source: Ministry of Health, Malaysia 1996.
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Diabetes The world health report 2005
Australia
2000
941000
2030
1673000
Malaysia
942000
2479000
How will pharmacy respond to help both our
countries and individuals deal with this
increase in prevalence of chronic diseases?
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Ageing in Australia
Those over 60 make up about 16.5% of the
Australian population. (Malaysia 6.7%)
Less than 10% reside in residential aged-care
accommodation
Most older people lead active lives
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Ageing in Australia
Factors influencing well-being of elderly
Loss of independence (financial, social)
Diminished social support (loss of spouse)
Discounted role
Complex poly-morbidity
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Health concerns for elderly
Loss of cognitive abilities/mental health
Loss of independence
Chronic pain
Negative perceptions and stereotyping
Loneliness/isolation
Reduced physical capabilities
Injury/safety
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Ageing and Medications
The over 65’s account for 12% of the
population but account for 36% of total
medication expenditure
(over $M700/year)
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Ageing in Australia
Surveys among elderly people indicate:
26% taking 5 or more medications
concurrently
89% taking one or more medication
33% taking one or more non-prescription
medications
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Ageing in Australia
Medicines for;
•blood pressure
•other cardiovascular problems
•infections
•arthritis
•asthma
•sleep problems/anxiety
•general poor health
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What does the veteran population
look like?
Veteran Treatment population by age
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Veteran Self-reported Health
Problems
1997
Visual problems
86%
Arthritis
Depression
19%
Hearing difficulties
49%
Dementia memory loss
16%
Insomnia/sleep disturbance
28%
Anxiety
18%
Foot/leg problems that affect mobility
19%
Incontinence
8%
High blood pressure
38%
Post Traumatic Stress Disorder
9%
Department of Veterans’ Affairs 2003 Survey of Veterans, War Widows and their Carers
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
2003
92%
53%
22%
55%
38%
33%
18%
43%
15%
44%
13%
Unique Prescription Medicines 2004
Unique RPBS Items
1 to 5
6 to 10
11 to 15
16 to 20
21 to 25
26 Plus
Total
Number of Veterans
84,967
95,562
70,403
38,835
18,581
14,182
322,530
Percentage of Rx Population
26.34 %
29.63 %
21.83 % 64%
12.04 %
5.76 %
4.40 %
100.00 %
DVA Departmental Management Information System – March 2005
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
What should we, as pharmacists, do?
Work within a Quality Use of medicines framework
Judicious use
is medication necessary?
Appropriate
If medication best option what is the best
medicine considering other medications and
other conditions?
Safe and effective
Is the pharmaco-therapy individualised and
does the patient have the knowledge and skill to
use their medicines safely and effectively?
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
How would this work in practice?
In hospitals:
– Pharmacists as members of Drug and Therapeutics
Committees
– Pharmacists in the wards to participate in pharmacotherapy decisions and to individualise pharmacotherapy, monitor outcomes of pharmaco-therapy
– Pharmacists involved in patient medication review on
admission and discharge
– Pharmacists involved in patient medicines education
and training
– Pharmacists involved in liaison services between the
hospital and the community or aged care setting to
which their patient is returning to ensure continuity of
care
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
How would this work in practice?
In hospitals
Plus
–
–
–
–
–
ADR reporting
Safety and Quality activities
Educational activities for doctors, nurses etc
Specialised practice TDM, cytotoxic preparation
etc
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
How would this work in practice?
In aged-care
As for the hospital setting
In Australia community pharmacists provide these services
to aged-care facilities
Aged-care facilities are required by legislation to have a
contract with a pharmacy for these services
Major difference is the residents will be in your care
for a long time, not sort episodes as in the hospital.
Preventing and resolving medication-related problems is a
major focus
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
How would this work in practice?
In the community setting
As per hospital and aged care
Additional considerations because your patients will be;
–
–
–
–
self administering medicines,
making choices about when and whether to take them
Mixing them with non-prescription and traditional medicines
Seeing other doctors and pharmacists
This requires greater attention to checking and reviewing at risk
patients at each visit. Providing medilists and keeping good
patient records in your practice is the key to the success of this
style of practice
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Key pointers for practice:
Is preventing or resolving medication-related problems a possible role
for pharmacists in Malaysia?
Pharmacists role in aged-care
Pharmacists role in medication review
Understand, interpret and relay to doctors and patients the basis of
evidence-based treatment guidelines and their applicability in the polymorbid older person
Individualising medication therapy for the elderly; medication choice,
dose, monitoring
Documentation of ADRs in both the community and hospital setting
Pharmacy care for older people in any setting (aged-care, community,
hospital) is an important aspect of pharmacy practice and requires
attention to a range of clinical (eg individualisation of therapy) and
systems (eg recording and reporting ADRs) roles.
A key role for pharmacists will be to work with doctors and nurses to
provide pharmaceutical care as part of the overall chronic disease care
plan developed with the doctor
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Case study
Mrs Tan (75year old, regular customer in your
pharmacy). Asks to see the pharmacists
because of frequent dizzy spells.
What would you do?
• Sell her a product?
• Provide advice and send her home?
• Send her to the doctor?
• Do a medication review?
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Mrs Tan
Current medications
Ramipril 5mg m
started 18/10/05
Frusemide 40mg m
started 20/02/02
Metformin 500mg bd started many years ago
What is a likely cause of the dizziness
Now what would you do?
• Sell her a product?
• Provide advice and send her home?
• Send her to the doctor?
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Mrs Tan
Actions
1.
Document the review on a patient file
2.
Provide advice and send home
3.
If no better in two to three days go back to your
doctor
4.
Write your comments on a referral note for her to
take to the doctor with her
5.
Ask her to report back to you in two to three days
and add outcome to your patient file
6.
Make a note on her file to offer assistance with any
other issues at each visit
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia
Key points
The increasing prevalence of older patients
with multiple chronic diseases adds to the
complexity of medication management.
Medication management is a key component
of chronic disease management.
Collaborative medication reviews are a key
medication management strategy.
Patient records and good documentation is
critical to pharmaceutical care for your older
patients
Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute
University of South Australia