Senior Care Pharmacy

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Senior Care Pharmacy
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Part I--

• Review and discuss the demographics of aging
• Understand the demographics as compared to the
  general population
• Discuss where seniors live (independent vs.
  institutional dwelling)
• Discuss cost of care to the health care system
  (nation)

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Goals and Objectives
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Aging in America

• In 2004, there were 36 million individuals 65
  years and older
• Approximately 12 of US population
• More than 80 million by 2021

85-89
80-84
90-94
95-99
100
75-79
65 to 69
70-74
Source US Census Bureau
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Age
Aging America
85
80
70
Male
Female
60
Baby Boomer Impact
50
40
30
20
10
1
1
2
3
2
3
Population in Millions
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The Senior Market
Nursing homes 1.8 million residents
Other elderly 10.8 million residents
Assisted living 1.8 million residents
Home care 3.5 million beneficiaries
Community-based LTC 8.5 million individuals
NORCs 8.5 million residents
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Rx Use and Seniors

• Elderly account for 42 of total annual Rx
  spending in the US
• 43 billion of 102 billion

US Population
Elderly Rx
Seniors
Non-elderly Rx
Source Families USA/Prime Institute July 2000
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Rx Use and Seniors

• 28.5 Rxs/year - 2000
• 45 increase in utilization since 1992
• Projected 2010 utilization - 38.5 Rxs/year
• 2010 utilization 35 over 2000

SeniorUtilizationRxs/year
Source Families USA/Prime Institute July 2000
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Rx Use and Seniors

• Rx use increases with age
• 65-69 year olds - 13.6 Rxs/year
• 80-84 year olds - 18.2 Rxs/year
• 2 or more ADL supports use 2X the Rxs as those
  without ADL supports
• Seniors in poor health use 6X the Rxs as
  excellent health

Source AARP Issue Brief, 1991
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Seniors Statistics
Source Kaiser/Commonwealth/Tufts-New England
Medical Center 2003 National Survey of seniors
and prescription drugs http//www.kff.org/medicare
/upload/Prescription-Drug-Coverage-and-Seniors-Fin
dings-from-a-2003-National-Survey-Chartpack.pdf
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Safe Prescribing in the Elderly

• Research - include elderly in drug trials
• Diagnosis - is the medication really needed?
• Choice of Medication
• efficacy adverse effects
• drug interactions disease interactions
• cost ease of administration
• quality of life
• Dose - start low, go slow, but dont stop too
  soon
• Therapeutic Endpoints

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Risk Factors forAdverse Drug Reactions

• Polypharmacy
• Female gender
• Small body size
• Hepatic or Renal insufficiency
• Previous ADRs

Source Royal College of Physicians, 1997
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Prevalence of Selected Major Diseases of Aging
in the U.S.
Hypertension 50,000,000 Arthritis
40,000,000 Osteoporosis 10,000,000 Cancer
8,000,000 Stroke 4,000,000 Alzheimers
Disease 4,000,000
Source Compiled by PhRMA 2000
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Chronic Illness and Seniors

• Almost all seniors have at least one chronic
  condition many have multiple conditions
• 35 arthritis
• 50 hypertension
• 32 heart disease
• 16 orthopedic impairments
• 16 diabetes

Source National Center for Health Statistics
2001-2002
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Part II--

• Review and understand the changing
  pharmacokinetics and pharmacodynamics in an
  elderly patient.
• Define and discuss Medication Related Problems
  (MRPs) as they pertain to the elderly.

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The Problem

• A given dose of a given medication produces a
  different, and sometimes unexpected, response in
  an elderly patient compared to a younger patient
  of the same gender and similar body weight.

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The Explanation

• Pharmacokinetic and/or
• Pharmacodynamic alterations with age

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Pharmacokinetics

• Absorption
• Gastrointestinal (GI)
• Intramuscular (IM)
• Transdermal
• Distribution
• Protein binding
• Metabolism
• Elimination

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PharmacokineticsGI Absorption

• Decreased gastric emptying rate
• Decreased intestinal motility
• Decreased intestinal blood flow
• Decreased intestinal surface area
• Decreased gastric acid output
• Increased gastric pH
• Outcome
• No significant change in quantity absorbed
• Time to onset or peak may be delayed

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PharmacokineticsIM Absorption

• Decreased muscle mass
• Decreased peripheral circulation
• Increased connective tissue
• Outcome
• Possible decreased IM absorption

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PharmacokineticsTransdermal Absorption

• Decreased skin hydration
• Decreased surface lipids
• Decreased peripheral circulation
• Increased keratinization
• Outcome
• Possible decreased absorption from
  transdermal patches

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PharmacokineticsDistribution

• Decreased muscle mass
• Decreased body water
• Decreased cardiac output
• Increased body fat
• Altered regional blood flow
• Altered tissue barriers
• Outcome ? Vd of lipid soluble medications
• ? Vd of water soluble medications

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PharmacokineticsProtein Binding

• Decreased serum albumin
• Decreased protein affinity
• Increased alpha1-acid glycoprotein
• Outcome
• Increased free fraction of highly protein-
• bound medications (ex. Phenytoin)

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PharmacokineticsMetabolism

• Decreased hepatic mass
• Decreased hepatic blood flow
• Outcome
• Phase 1 (oxidation, reduction) decreased
• Phase 2 (conjugation) unchanged
• CYP 450 activity unchanged
• Enzyme induction/inhibition
  controversial

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PharmacokineticsRenal Elimination

• Decreased renal blood flow
• Decreased renal tubular secretion
• Glomerular filtration rate - creatinine clearance
• Stable serum creatinine due to ? muscle mass
• Outcome
• Average renal function of an 80 yr old
• is 50 of a 20 yr old

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Estimating Creatinine Clearance

• Cockcroft-Gault Equation
• CrClmen (140 - Age) x IBW
• Scr x 72
• CrClwomen CrClmen x 0.85
• IBW men 50 kg (2.3 x inches 5 ft)
• IBWwomen 45.5 kg (2.3 x inches 5 ft)

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Pharmacodynamics

• Pharmacodynamic changes are assumed when
• pharmacokinetic changes do not explain
  alterations
• Not as well understood as pharmacokinetics
• More variable than pharmacokinetics
• Changes are seen in
• Numbers of receptors
• Sensitivity of receptors
• Counter-regulatory mechanisms

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Pharmacodynamics - Examples

• Increased receptor sensitivity
• Benzodiazepines, CNS depressants
• Decreased receptor sensitivity
• Beta-adrenergic receptors
• Decreased baroreceptor sensitivity
• Orthostatic hypotension with vasodilators, TCAs,
  antihypertensives

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Pharmacodynamics (cont.)

• Increased risk of tardive dyskinesia and
  parkinsonism with antipsychotics
• Increased sensitivity to anticholinergic effects
• Increased sensitivity to warfarin

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Pharmacodynamics (cont.)

• Increased sensitivity of Na, K-ATPase
• Increased toxicity to digoxin, especially with
  hypokalemia
• Decreased renin and aldosterone levels
• Decreased response to ACE inhibitors and
• beta-blockers
• Increased risk of hyperkalemia with NSAIDs,
• ACE-Inhibitors, and K-sparing diuretics

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Medication Problems of the Elderly

• Pharmacokinetic/Pharmacodynamic issues
• Polypharmacy issues
• Comorbid conditions
• Socioeconomics
• Financial ability to pay for medications
• Sensory/physical impairment
• Cognitive impairment

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"Any symptom in an elderly patient should be
considered a drug side effect until proved
otherwise." J Gurwitz, M Monane, S Monane, J
Avorn Brown University Long-term Care Quality
Letter 1995
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Health Care - Evolving to a Focus on Chronic
Rather than Acute Illness

• "It is now chronic disease that poses a threat
  to our nation's health and economic well-being.

Daniel Perry, Alliance for Aging Research, 1999
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Medication-Related Problems

• Undesirable event experienced by a patient
• Involves or is suspected to involve drug therapy
• Actually or potentially interferes with a desired
  patient outcome

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Symptoms ofMedication-Related Problems

• Confusion
• Depression
• Delirium
• Insomnia
• Parkinsons-like symptoms

• Incontinence
• Weakness or lethargy
• Loss of appetite
• Falls
• Changes in speech

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Seven Categories of Medication-Related Problems

• Medical condition that requires new or additional
  drug therapy
• Patient taking unnecessary drug given present
  condition
• Wrong drug for patients medical condition
• Correct drug, dose too low
• Correct drug, dose too high
• Adverse drug reaction
• Patient not taking drug correctly

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Reasons Seniors are at Greater Risk for
Medication-Related Problems

• Multiple chronic diseases
• Multiple prescribers
• Multiple medications
• Types of medications prescribed
• Under-representation in clinical trials,
  particularly those over age 75
• Shortage of trained professionals in geriatric
  pharmacotherapy

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28 of hospitalizations of the elderly are due to
Adverse Drug Reactions (17) and Non-Compliance
(11)
Source Arch Intern Med, April 1990
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Adverse Drug Events and Seniors

• Incidence in high risk seniors (5 Rxs)
• 35 experienced ADE
• 95 of ADEs were predictable
• 63 required physician intervention
• 10 required ER visit
• 11 required hospitalization

Source Hanlon, JAGS, 1997
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Common geriatric issuesImpact of medications
ADLs/IADLs Behavior Cognition Dehydration Delirium
Falls Incontinence
Involvement in activities Nutrition Mood Psychosoc
ial well-being Pressure sores Psychotropic
medication use
These are the areas of greatest concern to the
patient!
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High-Risk Potential Drug Interactions

• Highly protein-bound drugs
• Drugs metabolized by CYP 450 system
• Enzyme inducers or inhibitors

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Barriers to medication adherence

• Lack of understanding or misinterpretation of
  directions
• Sensory impairments
• Drug regimen interferes with daily activities
• Drug regimen is too complex
• Lack of understanding why the medication is
  important or the goals of therapy
• Doesnt believe the medication will work or is
  even necessary

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Economic Impact of Disease
128 billion
Heart Disease
104 billion
65 billion
100 billion
92 billion
30 billion
100 billion
Source PhRMA 1997
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Part III--

• Discuss what consultant pharmacists have done to
  reduce medication-related problems in long-term
  care (ie. Fleetwood Project results)
• Prospective vs. Retrospective review
• Understand the pharmacists work up of drug
  therapy
• Discuss key issues in the evolution of senior
  care pharmacy

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Medication-Related Problem (MRP) Costs in Nursing
Facilities

• Without Consultant Pharmacists
• 7.6 billion
• With Consultant Pharmacists
• 4.0 billion
• Estimated total savings from Pharmacists 30-day
  retrospective review
• 3.6 billion

Source BootmanL, et al, Analysis of
Drug-related Morbidity and Mortality in Nursing
Facilities Arch Internal Medicine Oct 1997
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The Senior Care Pharmacy Imperative

• MRPs impact on quality of life
• MRPs increase cost
• MRPs in seniors - 50 preventable
• MRPs 100 Billion in Direct Medical Costs
• Purchasers want to reduce the cost of MRPs

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Pharmacist Workup of Drug Therapy

• Patient needs
• Demographics and Background
• Medical conditions/Problem list
• Allergies and Alerts
• Medication record
• Indication, goals of therapy, progress
• Review of systems
• MRPs to be resolved or prevented
• Care Plan
• Follow-up evaluation

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Key Issues in Senior Care Pharmacy Practice

• The evolution continues
• Retrospective drug regimen review had an impact
• Pharmacists proved themselves
• Prospective drug regimen review
• Certification in Geriatric Pharmacy

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Fleetwood Project Research Initiative

• Estimate the cost of medication-related morbidity
  and mortality in U.S. nursing facilities
• Assess the impact of Consultant Pharmacist
  services on health care costs and outcomes
• Develop and demonstrate a model of prospective
  drug regimen review

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Fleetwood Project Phase I

• First Pharmacoeconomic study to quantify the cost
  of medication-related problems in nursing
  facilities
• Quantify the value of Consultant Pharmacists
  services

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Fleetwood Phase I ResultsConsultant Pharmacist
DRR . . .

• Improves optimal therapeutic outcomes by 43
• Saves 3.6 billion annually in costs from avoided
  Medication-Related Problems
• 7.6 billion without consultant pharmacists
• 4 billion with consultant pharmacists

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Fleetwood Project Phase II

• Feasibility study to compare outcomes associated
  with the federally-mandated retrospective DRR to
  prospective DRR
• Formalize pharmaceutical care planning in
  high-risk elderly patients
• Prospective screening to identify patients at
  high risk for Medication-Related Problems

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Fleetwood Project Phase IIResults

• Allowed pharmacists greater input into clinical
  decision-making and interventions
• Enhanced interaction with patients and families
• Improved communication with the interdisciplinary
  team
• Greater job satisfaction
• Improvement in pharmacy workflow efficiency

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Fleetwood Project Phase III

• Pharmacist-sensitive outcomes
• National implementation of the Fleetwood Model to
  identify, prevent, and resolve MRPs
• ASCP Foundation will train pharmacists in the
  Fleetwood Model
• Evaluation of pharmacists impact on health
  outcomes and health care costs

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Part IV--

• How senior care pharmacists can extend what
  they've done in LTC to the much larger and
  rapidly growing community dwelling/healthy
  seniors.
• Adult care facilities
• Community dwelling seniors
• Adult day care programs
• P.A.C.E programs

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Why Senior Care Pharmacy?

• Modern medicines may be the most important health
  care technology in preventing illness,
  disability, and death in the geriatric population
  (Avorn 1995)
• Persons aged 65 represent about 13 of
  population yet consume 30-40 of all Rx and OTC
  medications.
• Older persons at greater risk for and experience
  a disproportionate share of MRPs
• 50 or more of MRPs are preventable

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Senior Care Pharmacy Thru Pharmaceutical Care for
Seniors

• A practice in which the pharmacist takes
  responsibility for a patients medication-related
  needs and is held accountable for this commitment
• Ensures that patients medication therapy is
  appropriate, most effective available, safest
  possible, and is used as indicated
• Accomplished by identifying, resolving, and
  preventing MRPs that interfere with achieving
  therapeutic goals and producing positive outcomes

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Senior Care PharmacyA Golden Opportunity

• Unmet need
• Someone will do it
• Not driven by regulation
• You have to go out and get it it wont come to
  you

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Senior Care Pharmacist Description

• Senior care pharmacists have specialized
  knowledge in geriatrics, geriatric
  pharmacotherapy, and the unique
  medication-related needs of the senior
  population, which they apply in the provision of
  pharmaceutical care.
• Senior care pharmacy practice is unique in
  that it is population rather than site specific.

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Senior Care PharmacyHow will you get there?

• Knowledge and skills
• Tools
• Environment

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Knowledge and Skills

• Geriatrics
• Geriatric pharmacotherapy
• Special medication-related needs of seniors
• Gerontology

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Useful Tools

• www.ascp.com
• Geriatric Curricular Resources
• www.ascpfoundation.org
• MDS MedGuide
• Screening/Assessment Forms
• Geriatric Depression Scale
• AIMS, DISCUS
• MMSE
• Geriatric texts
• Geriatric Dosage Handbook
• Pharmaceutical Care Handbook

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Where are Senior Care Pharmacists?

• Area Agencies on Aging
• Home Care
• Senior centers
• Adult day care
• Home health
• Support groups (patients/caregivers)
• Social Workers
• Case/Care Managers
• Long-distance care-giving services

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Todays OpportunityTomorrows Imperative

• 200 billion problem to impact
• Roughly 35 million person market

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Senior Care PharmacyPractice Characteristics

• Service (people) business
• Decisions focus on patient
• Patient care generates revenue
• Success measured as patient outcomes
• Documentation supports patient care
• Follow-up determined by risk and benefit of
  medication therapy and needs of patient

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ASCPs Vision

• The senior population realizes improved quality
  of care and quality of life through the provision
  of pharmaceutical care
• Senior care pharmacists are recognized and valued
  for their care of patients
• Senior care pharmacists are professionals,
  essential in healthcare systems
• ASCP is the acknowledged leader in senior care
  pharmacy practice