Drug-related problems among geriatric outpatients at a public sector hospital : an intervention study.

A Prescription Intervention Form (PIF) was used to inform the prescriber about DRP and to make recommendations to change drug therapy to overcome DRP. The most common DRPs were those dealing with drug safety (56.6%); effectiveness of drug therapy (20.8%);.

MOTIVATION FOR THE STUDy

Other studies have shown that 32,000 hip fractures and 16,000 car accidents resulting in injuries are caused by side effects in older patients each year. Drug-related problems (DRPs) are common among older patients in the community and hospitals and are responsible for hospital admissions.

AIMSAND OBJECTIVES OF THE STUDY

RESEARCH ATh1S

STUDY OBJECTIVES

CHARACTERISTICS OF DISEASE IN OLDAGE

PHYSIOLOGICAL SYSTEMS wmCH MAY BE AFFECTED WITH AGEING
DRUG BIOA V AILABILITY AND AGEING

PHARMACOKINETICS

MULTIPLE PATHOLOGY INTHEELDERLY
NON-DIAGNOSIS OF TREATABLE AILMENTS

Renal function is often impaired in the elderly, although there is great variability between patients. 1t12 may be prolonged in the elderly, which should be taken into account when determining the intervals between doses.

Table 2.1 illustrates how physiological systems may be affected with ageing. These physiological changes affect the bioavailabilty of drugs in the elderly patients (Section 2.1.2)

MEDICAL CONDITIONS OR DISORDERS IN GERIATRICS

COMMON DISORDERS IN THE ELDERLY
DISORDERS wmCHPRESENT ATYFICALLYINTHEELDERLY

Bladder control problems are common in the elderly with urge incontinence being the most common type. In the case of the elderly, the primary objectives are to keep the patient asymptomatic.

DRUG-RELATED PROBLEMS IN GERIATRICS

DRUG-RELATED PROBLEMS
CATEGORIES OF DRUG-RELATED PROBLEMS
NUTRITIONAL DRUG-RELATED PROBLEMS

The use of tricyclic antidepressants in the elderly is not recommended due to anticholinergic side effects. Traditional doses of neuroleptics used in elderly patients may be too high and should be reduced.

Table 2.5 Patient "at-risk" groups and associated codes

POLYPHARMACY IN THE ELDERLY

Factors contributing to polypharmacy
Dangers of Polypharmacy

Pressures for increased drug use among the elderly will continue to increase with improved disease diagnosis and the marketing of drugs to treat symptoms and diseases. Use of inappropriate doses (eg, excessive doses of stronger diuretics, which can cause postural hypotension and cause falls in the elderly). The use of multiple medications in the elderly results in iatrogenic disease, drug interactions, and decreased medication compliance.

Although warnings about the use of multiple medications in the elderly are frequently sounded, pressure to prescribe even more drugs will continue in the future.

NONCOMPLIANCE IN THE ELDERLy

Factors relating to Noncompliance in the Elderly
Strategies to improve compliance

It is important that the patient feels that he is actively participating in the care of his health. Make sure the patient understands and accepts the diagnosis and the need for the medication and taking the medication as directed. Tactfully explore whether the patient has the ability to remember to take the medication and ways to improve the patient's memory for taking the medication.

The pharmacist is in a position to know which medicine the patient has been prescribed as well as which OTC.

PRESCRIBING ERRORS IN THE ELDERLy

OVERCOMING PRESCRIBING ERRORS

Using a potentially toxic drug when one with less risk of toxicity would also work (eg, using phenylbutazone in patients with osteoarthritis or rheumatoid arthritis when other nonsteroidal anti-inflammatory drugs would be less dangerous). The most serious consequence of inappropriate prescribing in hospitals is the increase in the number and severity of adverse reactions. In preventing the misuse of geriatric drugs, the physician, pharmacist and patient each play an important role.

Too often, one or both of these critical elements are missing in elderly care.

PRESCRIPTION MONITORING FOR ELDERLY PATIENTS

PRESCRIPTION MONITORING USING PRESCRIBING INFORMATION ALONE
PRESCRIPTION MONITORING CRITERIA

By using bronchodilator prescriptions to identify elderly patients with airway obstruction, pharmacists can reduce unnecessary steroid side effects by ensuring that the patient's response is objectively assessed or monitored (eg, peak velocity of respiratory flow, spirometry, walking distance) and recommending discontinuation of steroids in non-responders. Atrial fibrillation (AF) is a known risk factor for stroke, and this risk is greater in elderly patients. Studies have suggested that III benzodiazepine use in elderly patients is often unnecessary and is associated with decreased cognitive impairment and hospitalization.

Evidence-based criteria for prescribing monitoring for older patients are listed in the 'Prescribing Guidelines for Geriatric Patients' (Appendix 4).

MONITORING GERIATRIC DRUG THERAPy

Practical considerations in monitoring geriatric drug therapy

Older patients can also take responsibility for their own health through counseling and information about medication administration and the use of OTe medications (Jenner, 1993; Sause, 1996). Older people use more 'over-the-counter' drugs, possibly 40 percent of all daily medications. That is why the healthcare provider plays an important role in monitoring medication use in the elderly.

A challenge for primary care is the recognition of acute illness in the elderly with multiple pathologies and the good management of these complex patients.

PHARMACEUTICAL CARE OF THE ELDERLy

THE PHARMACEUTICAL CARE APPROACH TO MEDICATION IN ELDERLY PATIENTS 71
CHOOSING THE MOST APPROPRIATE DRUG TREATMENT FOR ELDERLY PATIENTS
PHARMACEUTICAL CARE PROCESS FOR THE ELDERLY

Furthermore, unlike most existing pharmaceutical services, the pharmaceutical care process dictates that a written document be generated that captures the drug-related problems, the recommended solutions, and the patient-specific outcomes that actually result from the individualized pharmacotherapy. Regular monitoring of treatment, where possible by direct contact with the patient, is required to ensure compliance and appropriate periodic review. Treatment failure may be due to the patient not taking their medication within the proper schedule.

To complete the pharmaceutical care process, interventions must be documented and the patient's progress monitored (FIP Lisbon Congress, 1994).

INTERVENTION STRATEGIES TO OVERCOMEAND OR MINIMISE DRUG-RELATED

Monitoring adverse drug reactions in elderly patients
Maintaining patient records
Educating elderly patients
Communication regarding the discharge medicines of elderly patients
Clinical Pharmacist Interventions

It is vital that ADRs occurring in the elderly are reported and the data shared with other clinicians. Through the collection and dissemination of ADR information related to elderly patients, advances in appropriate geriatric pharmacotherapy may be a more easily achieved outcome of drug therapy. Caregivers should also be involved in the discharge process and given information about discharge medications.

The clinical pharmacist in a regional hospital has a great opportunity to contribute significantly to an improvement in the quality of health care by providing advice on the appropriate and safe use of drugs.

STUDY DESIGN

IDENTIFICATION OF DRUG - RELATED PROBLEMS

STUDY POPULATION AND SAMPLlNG

SITE OF THE STUDy
THE STUDY POPULATION
SAMPLE SELECTION AND SAMPLING TECHNlQUE

DATA COLLECTION AND MEASUREMENT

RESEARCH INSTRUMENTS
PILOT STUDY
ETIIICAL CLEARANCE

A detailed medication history was obtained from the patient's medical records and by interviewing the patient. The necessary data on the patient were classified into three groups: a) general characteristics of the patient (socio-demographic factors) (b) the patient's diseases, problems or symptoms and. A patient profile is outlined (Appendix I), which enables identification of inappropriate prescriptions (unnecessary drugs and drugs with absolute contraindications (Cl), interacting drugs of clinical importance) and side effects.

During the pilot study, problems were identified and the design and content of the patient profile were adjusted appropriately.

Table 3.1 Elements of an elderly patient profile

DATA PRESENTATION, ANALYSIS AND INTERPRETATION

VARIABLES
DATA CHECKING BEFORE ANAL YSIS
EXPLORATORY DATA ANAL YSIS
SUMMARIZING THE SAMPLE DATA
ESTIMATING THE POPULATION P ARAMETERS
ANALYSIS OF PRESCRIPTION INTERVENTIONS

When any odd values were found, a list of the patient profile numbers of those cases was made. Graphical representations of categorical variables are primarily used to present geriatric study results. By examining the graphical representation of the data, the researcher decided which measures should be used to summarize the geriatric study data.

The most commonly used measure of centrality was the arithmetic mean or average (indicated by x).

Table 3.3 Suggested data checking procedure

INTERVENTION STRATEGIES

ASSESSMENT OF THE PATIENT COUNSELLING LEAFLET

The pilot study was conducted to allow for refinement of the research instruments, ie. Problems with the wording and clarity of the leaflet and the self-administered questionnaire were identified and these were modified. Unlike the geriatric patients in phase 1 of the study, it was not possible or necessary to apply the inclusion criteria listed in 3.2.3 to this sample population.

After explaining the purpose of the study to the selected patients, consent was obtained from them to participate in the study.

After completing the research instruments, they were distributed to geriatric outpatient clinics in the study itself. Ideally, one of the main intervention strategies would be to introduce routine counseling of all patients in the hospital about their medications. Therefore, it was decided to implement counseling of hospitalized patients in one of the medical departments as a pilot study.

One of the most common and potentially harmful or fatal ADRs is the adverse drug reaction.

PILOT STUDY

Determining the time it took to interview the patients helped establish an average of 15 patients interviewed by a single researcher per day. Drug-related problems were identified in twelve of the elderly patients (92%) interviewed in the pilot study. The pilot study DRPs will not be discussed in detail as this was not the purpose of the pilot study.

The results of the prevalence of DRPs in the pilot study assisted in the statistical determination of sample size.

GENERAL CHARACTERISTICS OF THE GERIATRIC PATIENTS

PATIENT DEMOGRAPIllCS
GERIA1RIC PATIENT'S BACKGROUND AND SOCIO-ECONOMlC
ELDERLY PATIENTS LIFESTYLE OR ACTIVITIES

The education level of the older patients helped determine the literacy level of the population. The following table illustrates the results of older patients' ability to read, write and speak their first language. Healthcare providers play an important role in the supervision and administration of medications to older patients (section 4.7.2).

30.6% of the elderly patients consumed alcohol (Table 4.11), but very few admitted to consuming alcohol daily.

DISEASE PROCESS (ES) OF THE ELDERLY PATIENTS

PRESENT MEDICAL CONDmONS IN ELDERLY PATIENTS
PHYSICAL IMPAIRMENTS OR DISABILITIES AND COGNmVE FUNCTION
PAST MEDICAL msTORY

Prevalence of disease or symptom in elderly patients is a percentage of the total sample population (281). Impaired hearing (could not hear and needed hearing aids) was experienced by 50.5% of the elderly patients and impaired mobility (requiring the use of crutches or a wheelchair) by 59.1%. The majority of patients were female (63.3%) and 49.1% of patients were white in the total sample population.

30.6% and 12.5% of the elderly patients indicated that they had consumed alcohol and smoked cigarettes, respectively.

Figure 4 shows the prevalence of several common chronic conditions in elderly patients in order of frequency

PHARMACOTHERAPY OF THE GERIATRIC PATIENTS

OVERALL PRESCRIBING
NUMBER OF PRESCRIBED DRUGS PER ELDERLY PATIENT
PRINCIPAL DRUG GROUPS PRESCRIBED
USE OF MEDICATIONS OR SUPPLEMENTS OTHER THAN THOSE PRESCRIBED AT
TOTAL NUMBER OF MEDICINES PER GERIA1RIC PATIENT
TOTAL NUMBER OF OTC MEDICINES USED BY GERIA1RIC PATIENTS
DISCUSSION OF DRUG THERAPY IN THE ELDERLY

157 blood and blood organ drugs were prescribed (9.1%) from the total number of drugs prescribed (Table 4.26). Anti-infectives were prescribed only in 8 cases (Table 4.30) and represented only a small percentage (0.5%) of the overall drugs prescribed (Figure 6). They accounted for 79.3% of the total number of drugs acting on the musculoskeletal system and 6.8% (Figure 6) of the total number of prescribed drugs.

Drugs acting on the sensory organs comprised only 2.5% of the total prescribed drugs (Figure 6).

Table 4.23 Number of prescribed drugs per geriatric patient

DRUG RELATED PROBLEMS IN THE GERIATRIC PATIENTs

INCIDENCE OF DRPs IN GERIA1RIC PATIENTS
TYPES OF DRUG RELATED PROBLEMS

The patient had reported this to the prescribing physician at the consultation, and the dose was changed to Prednisone 10 mg daily for one month. A PIF was sent to the prescribing physician to review the patient's treatment and discontinue carbamazepine for reasons listed above. The prescriber taking a more careful medical and medical history of the patient could have prevented this.

In thirteen of the cases listed in Table 4.43, the patient was sent back to the prescriber and medication was prescribed to treat the necessary condition.