2.9 PHARMACEUTICAL CARE OF THE ELDERLy
2.9.4 PHARMACEUTICAL CARE PROCESS FOR THE ELDERLY
The process of pharmaceutical care begins with taking a comprehensive medical and medication history. With elderly patients, there might be a number of potential problems such as communication, under reporting of events and reliance on caregivers for history.
Pharmacists must develop systems for identifying those most at risk of medication- related problems. Systematic approaches to delivering pharmaceutical care requires
Drug reloted problems among geriatric out-patients at a public sector hospital: An intervention study
individual patient assessment to identify subgroups of patients with defined needs and risk factors that might compromise therapeutic success. Regular monitoring of treatment where possible by direct contact with the patient is required to ensure concordance and appropriate periodic review. To assess whether there were factors, which might increase an elderly patient's risk of experiencing DRPs, a drug regimen review should be conducted. This could be accomplished using a variety of instruments one of, which is the Medication Appropriateness Index refer to ' Prescribing guidelines for geriatric patients' (Appendix 4).
Maintenance of effective patient records is needed to ensure continuity of care over long-term treatment and during shared care between primary and secondary teams.
Information about any functional restrictions affecting sight, hearing, manual dexterity, mobility, memory, comprehension and communication need to be included in the pharmacy record alongside the patient's social circumstances and the availability of domestic support. The medication history is important to ensure continuity of care, avoidance of therapeutic duplication and the prevention of the prescription of drugs, which have previously caused problems.
Pharmaceutical care plans should involve community and hospital pharmacists working to stated goals of symptom control and periods of review. The frequent contact of pharmacists with older patients on long-term medication provides the opportunity for medication review. The purpose of a medication review is to identify any medication-related problems, to ensure that all necessary medicines are taken.
The review enables the pharmacist to provide patient education and to make recommendations to the prescriber where there is an opportunity to rationalise or reduce the number of medicines the patient is required to take. The idea of inviting patients to bring a "brown bag" of their medicines into the pharmacy allows the pharmacist to relate the medications the patient has at home to those they should be taking. Rationalisation therefore also involves the pharmacist helping to encourage patients not to hoard medicines and ensuring safe disposal.
The active participation of patients in drug therapy decisions is increasingly being sought. The prescence of multiple chronic disease states in the older patient
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-7-5---'complicates that decision making process. The patient must be helped to understand what is possible from their drug therapy and to appreciate the limitations on their own rehabilitation and quality of life. The complexity of disease may confuse the assignment of particular symptoms to anyone condition. The complexity of
polypharmacy may be a further confounding factor. Drug therapy that has been prescribed in the past but not recently reviewed may be necessary. Non- pharmacological methods may offer alternative ways of reducing medication and helping to simplify prescribed drug regimens.
The best choice of drug for a particular patient may not be the formulary preferred agent but a second line product with, for example, less dependence on renal elimination, a longer dose interval to enable once or twice daily dosing, perhaps a different colour to enable the patient to differentiate it, or a different form of packaging or administration device that the older patient may seem better to handle.
A period of monitoring may lead to doses being questioned. Perhaps a previously effective dose is now excessive and can be reduced without jeopardising the control of the condition. Treatment failure may be due to the patient not taking their medication within the correct schedule. To "please the doctor", patients often say that they are taking their therapy as prescribed, where it is later revealed they are dutifully collecting repeat prescriptions but hoarding the medication at home.
A continuous record of care makes it possible for the pharmacist to identify change in the level of control of a condition or to recognize DRPs early. Good records are necessary for the delivery of a coherent package of care over a sequence of contacts with the patient and for signs or symptoms in the patient to be linked to medication recently started. A record of the elderly patient's weight and renal function is useful for long-term monitoring and periodic review.
Periodic review of long-term medication in older patients is necessary to confirm satisfactory progress or to reassess need. Monitoring of treatment requires regular inquiry and reassurance to identify any medication-related problems to confirm progress. The inquiry and testing that may be involved in monitoring may be
Drug reloted problems among geriatric out-patients at a public sector hospital.: An intervention study 76
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inconvenient or disturbing, particularly too older patients. It is necessary to arrive at a suitable compromise to provide the necessary reassurance to the patient, the pharmacist and the prescriber. Long term care is about helping patients to maintain their quality of life as they grow older and as they acquire more threats and limitations to their health (Hudson and Boyter, 1997).
Inappropriate medication dosage is one of the most important prescribing problems found with the elderly. This is due to a lack of attention to age-related changes in drug pharmacokinetics and pharmacodynamics, along with the effects of diseases and diminished homeostatic mechanisms on medications (Section 2.1.2.1). Once the drug regimen review is complete, it is important to document the DRPs, develop a therapeutic plan to resolve them, and to establish reasonable therapeutic ends. In some cases, it would be necessary to consult with the elderly patient's physician.
Factors to enhance compliance should be considered when dispensing to elderly patients. Modification of medication schedules to fit in with a patient's lifestyle, easy-to-open caps, easy-to-swallow dosage forms and larger typeface for labels could all be considered. Use compliance aids if available and ensure that suitable containers are marked with clearly legible instructions. Colour coding may be useful.
Guidelines for the delivering of prescription pharmaceutical care in elderly patients appear in the' Prescribing guidelines for geriatrics' (Appendix 4). To complete the pharmaceutical care process, interventions should be documented and the patient's progress monitored (FIP Lisbon Congress, 1994).
Drug reloted problems among geriatric out-patients at a public sector hospital: An intervention study