Malaysian Pharmaceutical Society

1

• Malaysian Pharmaceutical Society
• 5th 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

2
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

3
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)

4
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

5
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• Out-of-date medication

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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

7
Medication-related hospital admissions (Roughead
et al, 2002)
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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

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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

10
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

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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

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Best practice management

• Diabetes
• Oral hypoglycemic or insulin 1
• ACE inhibitor 2
• Low Dose Aspirin 3
• Lipid Lowering agent 4
• CHF
• ACE inhibitor
• Diuretic 5
• B-Blocker 6
• Spironolactone /- digoxin
  7

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• 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 3512870-2874.

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Age-related changes in the way the body deals
with medications

• Changes in pharmacokinetics
• Absorption
• Distribution
• Hepatic metabolism
• Renal clearance

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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

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The sensitivity of the body to medications
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Types of medicines used

• Low therapeutic index drugs
• - Digoxin, lithium carbonate, methotrexate
• Drugs to which older people are known to be more
  sensitive
• - Trimethaprimsulphamethazole,
  antihypertensives, antidepressants, vasodilators,
  NSAIDs, H2 receptor antagonists,anticholinergics.

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What medications cause most problems?
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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

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The older population The world health report 2005
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The older population 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

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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.

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Diabetes The world health report 2005

• 2000 2030
• Australia 941000 1673000
• Malaysia 942000 2479000
• How will pharmacy respond to help both our
  countries and individuals deal with this increase
  in prevalence of chronic diseases?

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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

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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

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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

27
Ageing and Medications
The over 65s account for 12 of the population
but account for 36 of total medication
expenditure (over M700/year)
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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

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Ageing in Australia

• Medicines for
• blood pressure
• other cardiovascular problems
• infections
• arthritis
• asthma
• sleep problems/anxiety
• general poor health

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What does the veteran population look like?
Veteran Treatment population by age
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Veteran Self-reported Health Problems

• 
  1997 2003
• Visual problems 86 92
• Arthritis - 53
• Depression 19 22
• Hearing difficulties 49 55
• Dementia memory loss 16 38
• Insomnia/sleep disturbance 28 33
• Anxiety 18 18
• Foot/leg problems that affect mobility 19 43
• Incontinence 8 15
• High blood pressure 38 44
• Post Traumatic Stress Disorder
  9 13

Department of Veterans Affairs 2003 Survey of
Veterans, War Widows and their Carers
32
Unique Prescription Medicines 2004
64
DVA Departmental Management Information System
March 2005
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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?

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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

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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

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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

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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

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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

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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?

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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?

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Mrs Tan

• Actions
• Document the review on a patient file
• Provide advice and send home
• If no better in two to three days go back to your
  doctor
• Write your comments on a referral note for her to
  take to the doctor with her
• Ask her to report back to you in two to three
  days and add outcome to your patient file
• Make a note on her file to offer assistance with
  any other issues at each visit

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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