APTI ijopp - Indian Journal of Pharmacy Practice

Indian J. Pharm. Pract. 1(1), Oct-Dec, 2008APTIRole of Community Pharmacist in the Care of the Elderly* $Tipnis H.P. and Shobha Rani R. Hiremath.$* Medicine Shoppe (India), Mumbai, Al-Ameen College of Pharmacy, Bangalore.*Address for correspondence:pharmacy@ms-india.comijoppAbstractOne of the world's striking trends that have been widely recognized is the aging of its population. The pharmaceuticalcare of the elderly population is of utmost concern in the westernized countries. Even in India, where the average lifeexpectancy is 62.5 years, the aging population is growing. The number of elderly women at any point of time isreported to be more than the number of elderly men. With the advancement of science and medicine, life span andproductive life of an individual has greatly increased. Added to this is the advances made by the pharma industry inproviding affordable modern drugs to control the different diseases. All these factors have contributed to the rise inthe number and percentage of elderly population all over the world and even in India. Elderly are more likely toexperience drug related problems than any other age groups and also the biggest prescription users (40%) than anyother group in the community. Hence, it is necessary and essential to elucidate the role of community pharmacist inthe pharmaceutical care of elderly. Community pharmacist should possess certain basic skills, relearn basicpharmacy practice skills, apply the skills for elderly care and carry out the preventive care, and also develop arational and feasible pharmaceutical care plan (PCP) for the elderly care. As such, community pharmacists thereforecan implement quite a few aspects of PCP in India and give benefit of their knowledge to the patients at large.Key words: Community pharmacist, pharmaceutical care plan, elderly care, geriatric population, non-compliance,quality of life.INTRODUCTIONOne of the world's striking trends that have been widely 8 million living between 75 - 85 years of age, and arerecognized is the aging of its population. In U.S., this growing at double the world average of 4.4 % every year.phenomenon is widely known as the aging of the “Baby The number of elderly women at any point of time isBoomers”. ‘Baby boomers’ is the group of post World reported to be more than the number of elderly men. LifeWar II children, who had grown, had their careers and span and productive life of an individual has now greatlynow retired and living as elderly people. Almost 13 % of increased due to the advancement of science andthe U.S population (35 million) is of the age of 65 years medicine. With eradication of some of the deadlyand above. This population is expected to increase to diseases like polio, small pox, measles, diphtheria and20% (about 70 million) by the year 2020. In the period good control over TB, malaria and leprosy; life span in2010 - 2030, the population of 65 years and older is India has certainly increased. Added to this is theexpected to grow by 75% to over 70 million. The growth advances made by our pharma industry in providingof population among the 'oldest of the old' i.e. 85 years of affordable modern drugs to control hypertension,age and above is of great public concern. During 1995 - diabetes, asthma and other chronic diseases has helped2010, this population is expected to grow by 56 % as millions in our country to extend the life span. All thesecompared with 13 % growth of the population aged 65 - factors have contributed to the rise in the number and84. This means that, a large share of the elderly percentage of elderly population all over the world andpopulation will be over 85 by the year 2020. Even in even in India.India, where the average life expectancy is 62.5 years, the Current health and medication problems with theaging population is growing. There are about 1.5 million elderlyPeople in India, living close to 100 years of age and aboutAlthough there are many age related health problemswith the elderly, some problems are common with thegeriatric population, such asIndian Journal of Pharmacy PracticeReceived on 06/09/2008 Modified on 11/09/2008 HypertensionAccepted on 14/09/2008 © APTI All rights reserved Myocardial infarct (MI)14

Indian J. Pharm. Pract. 1(1), Oct-Dec, 2008Classical chest painPeripheral vascular disordersChronic stasis ulcersDeep vein thrombosisChronic illnesses and conditions such as diabetes,arthritis, cardiovascular disorders, dementia, etc.Accompanied by the above problems are also secondarydisorders such asUrinary and fecal incontinenceSleep disturbancesAnxiety followed by depressionDisorders of GITElderly are also more prone to influenza andpneumoniaTheir medication problems are also linked to their healthproblems. Elderly are more likely to experience drug ormedication related problems than any other age groups.Elderly are the biggest prescription users (40%) than anyother group in the community. It is often said that “20%elderly population in a community gives 80%prescription business to retail pharmacy”. Other strikingfacts about the use of medicines by elderly and theproblems arising out of it areNearly 80% of the elderly receive inappropriatetherapyOver treatment is often prescribedElders are more likely to experience drug relatedadverse events (ADEs)By one estimate , nearly 36% of all the ADEs happenwith the elderlyOut of these 36% ADEs, 28% require hospitalizationNon compliance is another big problem with theelderlyOften, non-compliance of the medication regimenleads to sever complications leading tohospitalizationNearly 11% of the non-compliance cases among theold results in hospitalizationThe prescription use by the elders increases with age.For example, between 65-69 years old senior citizenshave 13% prescriptions per year, while those between 70-80 years of age have 15% prescriptions per year.Nearly 82% of the elderly take atleast one drug perday for some disorder or the other.Thus, there is a big challenge and opportunity for acommunity pharmacist to address these drug relatedproblems of the elderly and improve their quality of life.Role of community pharmacist in elderly careEvery community pharmacist is most likely to come incontact with an elderly patient or customer. In somecommunities, this contact may be more frequent than inother communities. For example, if there is a nursinghome nearby or a colony of retired elderly people or in awell to do community where joint families live, thesecontacts are bound to be frequent. It is thereforenecessary that a community pharmacist should befamiliar with the tasks that have to be performed for thecare of the elderly. But before he/she actually startstaking responsibility of the elderly, he/she has to learnsome foundation skills in order to be ready to help theelderly.a) Foundation or Basic skills to be acquired by acommunity pharmacist can be listed as followsFirst of all, he/she must display respect andcompassion for the elderlyLearn to use appropriate and cognitive techniques ininteraction with geriatric patients, their families,their care takers and their health care professionalsTake personal responsibility for an elderly patientand present yourself as assertive professionalLearn to communicate with the elderly in thelanguage and manner by which they will understandclearlyWrite down the important instructions for them insimple and clear languageDemonstrate ethical conduct in all activities relatedto elderly. For example, do not ridicule them or laughat their misunderstanding.b) Relearn basic Pharmacy Practice skills:To do this, a community pharmacist must do thefollowing-Understand major principles of gerontology andgeriatricsDesign and execute investigations of geriatricpharmacy practiceIf possible, attend a short term geriatric residencypharmacy practice program in a nearby hospitalLearn to draw an appropriate pharmaceutical careplan (PCP), with other healthcare professionalsand/or other inter-disciplinary or multi-disciplinaryteamsWork harmoniously with these teamsUnderstand the alternate care settings for geriatricpatients where they can receive pharmaceutical care,like physiotherapy center or a yoga center wherethey can be taught simple exercises of yoga orbreathingUnderstand and learn the use of various assistivedevices for the elderly like wheel chairs, trolleysupport walking, supportive neck and waist belts,15

Indian J. Pharm. Pract. 1(1), Oct-Dec, 2008Neck caps etc.hand knowledge for providing such services.And finally,And ofcourse, he has to interact on regular basis withBe in touch with national and local organizations other healthcare and social service professionalsdoing work in geriatric care(and also with non-healthcare professionals likeclergy, social workers in the hospitals) in planningBe upto date with current geriatric literature and netand providing care for the elderly.Accept evaluation of your work through peer reviewHe also has the responsibility to explain theor through a professional organizationeconomic and financial aspects of providingc) Applying the above skills for elderly care: pharmacy services to the elderly or their kins whoAfter having acquired these basic skills and positioning are close to them.the pharmacy practice skills in place, a community Preventive care for the elderlyPerhaps, the best contribution that a communitypharmacist can now go ahead with applying these skillspharmacist can do in his setting is to give preventive carefor elderly care. What are some of his tasks that he has tofor the elderly. It may not be possible for manydo for elderly care? Here are some of the tasks that he hascommunity pharmacists, especially in India, to apply theto do to practice elderly care:skills stated above for the elderly care. Many may not beFirst of all, he has to identify the seniors in his or even come in contact with other healthcarecommunity who may have high risk for medication professionals and work out a combined or collaborativerelated problemsprogram for elderly care. But atleast they can giveHe has to formulate potential solutions to resolve preventive care to help elderly patients in theirand prevent these medication related problems community. This will not only prevent mishaps with theProvide ongoing medication therapy monitoring andelderly, but also prevent some emergency situations. Alsoit will help to prevent adverse drug events (ADEs),assessment to the elderly patientsmedication errors and problems arising out of selfObtain detailed medication histories of the elderlymedication among elderly.patients by interviews to know their medication Some of the guidelines for preventive care are as follows:related problemsTeach the elderly proper use of accessories likeApply knowledge of geriatric pharmacotherapy to walking stick, rolling walker, neck collars, waistcare for older patients and make the support belts etcrecommendations for appropriate, effective and safeAlso teach them how to prevent falls in home and insurroundings. If possible visit their homes andmedication therapy (remember older patients areinspect their bathrooms and toilet blocks to see ifoften over-prescribed).proper supporting bars/handles are installedEngage in verbal and written communications with Regularly check weights of the elderly and assesselderly patients and also with other healthcare weight gain or lossprofessionalsTake medication review of all their prescribed drugsDevelop and demonstrate sensitivity to social and and other auxiliaries like vitamins, dietarypsychological aspects of aging process to supplements, herbal medicines that they take onunderstand their impact on medication use. For their own.example, older people often feel that the drugs are Monitor compliance of medicationnot doing any better for them, then why to take so In your setting, set up screening program for the elderlymany drugs. A community pharmacist has to for the followingimpress on them that the drugs are indeed working o Vision Screeningfor better and revive their faith in the medicineso Screening for hearing problemsA community pharmacist also has to observe,o Screening for cognitive impairment (i.e. mentalunderstand and appreciate the medication useprocess in different settings of elderly careperception, memory, judgement, reasoning etc)A community pharmacist also has to understand the o Screen for urinary incontinencescope of pharmacy services (administrative and o Screen for increased risk from fall in home orclinical) needed for elderly patients and develop first outside16

Indian J. Pharm. Pract. 1(1), Oct-Dec, 2008o Screen for blood pressureo Screen for diabetes and for control of diabeteso Screen for dementiao Screen for depressiono Screen for height and weight and assess BMIo Screen for osteoporosis by BMD test. Other highend screening can be done with the help of a localpolyclinico Oral health screeningo Colorectal cancer screeningo Mammography for breast cancero Cervical cancer screeningo Prostrate cancer screeningo Lipid profile screeningBesides these, a community pharmacist must also set upeducational programs for the elderly through distributionof simple medical literature on hypertension, diabetes,asthma, osteoporosis etc. Set-up lectures by someexperts, film shows, VCD programs in a community hall.These educational programs can be focused on varioustopics such as appropriate medication use, rational use ofdrugs, prevention of medication errors, diseaseprevention and various topics on nutrition and diet etc.The best place to start such educational programs is thesenior citizen's clubs, where you can get a captiveaudience. Community pharmacists should thereforedevelop a good rapport with such clubs and organizationsof the elderly and participate in their activities on regularbasis.Pharmaceutical care for the elderlyPharmaceutical care has been well defined in manyarticles as “Responsible provision of drug therapy for thepurpose of achieving definite outcomes that improves apatient's quality of life”. Community pharmacists havean excellent opportunity to provide pharmaceutical careand services to the elderly in their settings. There is alsoample evidence that pharmaceutical care can benefit theelderly patients. However, the community pharmacistsmust have a pharmaceutical care plan (PCP) in theirhands which aims to communicate, promote complianceand concordance with treatment (that the elderly arereceiving) and achieve specified therapeutic outcomes.PCP has great potential to not only reduce drug relatedproblems of the elderly, but to improve their quality oflife and overall reduce the expenditure on drugs. Theclinical skills of the pharmacists have to be used tomanage the medication therapy of the elderly. This willrationalize the use of human resources in a communityhealthcare team and reduce the work load of the generalpractitioners (GP) in the community.The next big question is how to develop a rational andfeasible pharmaceutical care plan (PCP)? Following aresome steps that can be taken to develop such a PCP:First of all, establish a good relationship with thepatient and his doctorCollect relevant information on patient like diseasestate, drugs that he is receiving, clinical tests data etc.All this has to be done by working with his GP andthe patient himselfIdentify drug related (potential) problems among thedrugs he is receiving. Prioritise them in decliningorder, with the most likely first on the listSome of the drug related problems can beo Failure to receive the drug by the patiento Untreated indicationo Improper drug selectiono Not receiving proper dosageo May be even receiving an overdose of the drugo Adverse drug reaction due the medication thatthe patient is receivingo Drug-Drug interactions (DDI) from among thedrugs written in the prescription for which thereis no indicationEstablish therapeutic goals for each drug relatedproblemIdentify feasible alternative treatment, even withherbal medicinesSelect the best pharmaceutical solution, i.e. bestpossible drug, best suitable formulation of the drugand the best suitable doseFinally, get an agreement with the GP of the patientand the patient himselfImplement and monitor the planFollow up the plan and measure the outcomesContinue to update the PCP, with the patient's GPand study the outcome.The community pharmacist will have to educate thepatients and their caretakers about the PCP and themedicines that are recommended. He will also have toassist the patients and the caretakers about the need ofcompliance and provide them with compliance aids suchas dose boxes, reminder charts and even send them SMSat appropriate times to ensure compliance. He shouldgive his contact numbers and arrange for his personalvisits to patients' home. The outcome can be measured byClinical parameters like measurement of bloodpressure, fasting blood sugar, total cholesterol etc. Inchronic illness, measurement of creatinine and bloodUrea can be done17

Indian J. Pharm. Pract. 1(1), Oct-Dec, 2008Other simpler methods are, patients' own assessment pharmaceutical care issues in individual patients in aof well being their role in the therapyhospital setting. International Journal of Risk andCorrect response of patient to the questions asked Safety in Medicine 2006; 18(2): 99-105.about the therapy.4. Lau E, Dolovich LR. Drug-related problems inAlthough pharmaceutical care plan is a new concept in elderly general practice patients receivingIndia, some of the aspects of PCP can easily be followed pharmaceutical care. Int. J. Pharm. Pract.by a community or hospital pharmacist are information 2005;13(3):165-77.about the patients, indications, medicines that he is 5. Roughead EE, Semple SJ, Vitry AI. Pharmaceuticalreceiving, possible drug-drug interactions within his care services: A systematic review of publishedprescribed drugs, and most important of all, the over studies, 1990 to 2003, examining effectiveness inprescribed drugs and unnecessary drugs. Compliance is a improving patient outcomes. Int. J. Pharm. Pract.big problem in India and community pharmacists can 2005;13(1):53-7.play a big role here. Most of the failures of positive 6. Lam A. Senior care clerkship: An innovativetherapeutic outcomes arise from non-compliance form collaboration of pharmaceutical care and learning.India. Community pharmacists therefore can implement Consult. Pharm. 2005;20(1):55-60.quite a few aspects of PCP in India and give benefit of 7. Crealey GE, Sturgess IK, McElnay JC, Hughes CM.their knowledge to the patients at large.Pharmaceutical care programmes for the elderly:economic issues. Pharmacoeconomics. 2003;REFERENCES: 21(7):455-65.1. Mandavi, Tiwari P and Kapur V. Inappropriate drug 8. Penna RA. Pharmaceutical care. American Journalprescribing identified among Indian elderly of Health-System Pharmacy 1999.hospitalized patients. International Journal of Risk 9. Ross Division. American Academy of Familyand Safety in Medicine 2006; 19: 111-116. Physician. Abbott laboratories 2001.2. Mandavi and Tiwari P. Profile of pharmacotherapy in 10. Tiwari P. Niper Report Pharmacy Practice Divisionelderly Indian patients: Preliminary findings. 2006.International Journal of Risk and Safety in Medicine 11. Tipnis HP and Rani Shobha RH. Community2006; 18(3): 151-157. Pharmacy. Career Publications 2008.3. Tiwari P and Sukhpreet. An investigational study of 12. Aging. India Today, 2007 July 30.18