Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute University of South...
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Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute University of South Australia Malaysian Pharmaceutical Society 5 th 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 Malaysian Pharmaceutical Society 5 th Pharmacy
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Malaysian Pharmaceutical
Society 5 th 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
Slide 3
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 Governments Department of Veterans Affairs to
improve medication management in the veteran population
Slide 4
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)
Slide 5
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 medication- misadventure - 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
Slide 6
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
Slide 7
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
Slide 8
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Medication-related hospital
admissions (Roughead et al, 2002)
Slide 9
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
Slide 10
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
Slide 11
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Poly-morbidity and
consequent polypharmacy Adversely affects the patients; -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
Slide 12
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
Slide 13
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Best practice management
Diabetes Oral hypoglycemic or insulin1 ACE inhibitor2 Low Dose
Aspirin 3 Lipid Lowering agent4 CHF ACE inhibitor Diuretic5
B-Blocker6 Spironolactone +/- digoxin 7
Slide 14
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.
Slide 15
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
Slide 16
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
Slide 17
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia The sensitivity of the body
to medications
Slide 18
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.
Slide 19
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia What medications cause most
problems?
Slide 20
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%
Slide 21
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia The older population The
world health report 2005 The world health report 2005 The world
health report 2005
Slide 22
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia The older population The
world health report 2005 The world health report 2005 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
Slide 23
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.
Slide 24
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Diabetes The world health
report 2005 The world health report 2005 The world health report
2005 20002030 Australia9410001673000 Malaysia9420002479000 How will
pharmacy respond to help both our countries and individuals deal
with this increase in prevalence of chronic diseases?
Slide 25
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
Slide 26
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
Slide 27
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
Slide 28
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Ageing and Medications The
over 65s account for 12% of the population but account for 36% of
total medication expenditure (over $M700/year)
Slide 29
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
Slide 30
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
Slide 31
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
Slide 32
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Veteran Self-reported
Health Problems 19972003 Visual problems 86%92% Arthritis -53%
Depression19%22% Hearing difficulties49%55% Dementia memory loss
16%38% Insomnia/sleep disturbance28%33% Anxiety18%18% Foot/leg
problems that affect mobility19%43% Incontinence 8%15% High blood
pressure38%44% Post Traumatic Stress Disorder 9%13% Department of
Veterans Affairs 2003 Survey of Veterans, War Widows and their
Carers
Slide 33
Quality Use of Medicines and Pharmacy Research Centre / Sansom
Institute University of South Australia Unique Prescription
Medicines 2004 64% DVA Departmental Management Information System
March 2005
Slide 34
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?
Slide 35
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
pharmaco- therapy decisions and to individualise pharmaco- therapy,
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
Slide 36
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
Slide 37
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
Slide 38
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
Slide 39
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 poly- morbid 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
Slide 40
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?
Slide 41
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?
Slide 42
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
Slide 43
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