A case scenario demonstrates the effectiveness of the
pharmacist’s role in improving patient outcomes.
By Lisa C. Hutchison and Ashley Castleberry
Prescribing medications for elderly patients is complex and challenging. Of the several ways to improve prescribing in this age group, the following methods appear most effective: geriatric-educated healthcare providers; computerized decision support and order entry; clinical pharmacist drug regimen review; geriatric medicine services; multi-disciplinary approaches; or a combination of these efforts (Spinewine et al., 2007).
Three of these methods (clinical pharmacist drug regimen review, geriatric medicine services, multi-disciplinary approaches) are interdisciplinary and require input from different healthcare professionals with geriatric competencies. This article reviews how the pharmacist’s role has evolved into that of an active member of the interdisciplinary team, with the aim to achieve the best possible outcomes in geriatric patients. A three-part case scenario illustrates the practical issues of caring for the older patient.
Medication Use and Misuse in Elders
As the U.S. population ages, problems and issues surrounding drug therapy in older adults will also grow. Drug-related problems account for 10 percent to 30 percent of older adult hospital admissions, and adverse drug events occur in up to 50 percent of these patients while admitted (Spinewine et al., 2007). Many factors contribute to these staggering statistics.
In patients taking multiple prescriptions, only about 5 percent are taking their medications as prescribed (Steurbaut et al., 2010). Barriers such as cognitive impairment, poor drug knowledge, and poor social support can make it difficult to accurately assess an elderly patient’s current medications. Health literacy, cultural differences, fixed budgets, and vision and hearing problems can add to issues with medication use in the elder population (Albanese and Rouse, 2010).
Geriatric Competencies Needed in Healthcare Education
Complexity of care, coupled with inadequacies in the healthcare system, will lead to poor health and quality-of-life outcomes if healthcare providers are not trained in the best methods to meet the health needs of older adults—particularly the most vulnerable. Although all medical schools provide some training in or exposure to geriatrics, only about half of family practice and internal medicine residents indicate that they were prepared to work with geriatric patients. Unfortunately, only about 1.3 percent of U.S. physicians have specialty certification in geriatrics, and it is projected that the United States will need to train nearly 24,000 more geriatricians to care for vulnerable elders by 2030. Furthermore, less than 1 percent of licensed pharmacists are board-certified as geriatric specialists (Institute of Medicine, 2008).
To become a certified geriatric pharmacy specialist, one must be a licensed pharmacist, having practiced a minimum of two years, and successfully complete a certification examination. The examination comprises three sections, which address the following areas:
- patient-specific activities required to identify and resolve potential or actual drug-related problems in older adults;
- knowledge of diseases and syndromes common in elderly patients; and
- the pharmacist’s ability to understand social, economic, and policy issues in geriatric populations (Commission for Certification in Geriatric Pharmacy, 2011).
Medication Mix-Ups in a Patient with Multiple Conditions: Patient Case, Part 1
Kate L., age 75, lives independently in her own home. She has hypertension, osteoarthritis, osteoporosis, gastroesophageal reflux disease, dementia, and a history of stroke. Six months ago she sustained a hip fracture in a fall. During a fifteen-minute routine visit, her primary care physician asks if she has any new problems, and she notes sleeping difficulty, joint pain, and occasional chest pain. The physician checks her blood pressure, recording it at 150/74 mmHg. Her medical record lists the following medications: aspirin, 81mg daily; lisinopril, 5 mg daily; calcium citrate, 600 mg twice daily; Fosamax, 70 mg weekly; Aricept, 10 mg at bedtime; and Protonix, 20 mg daily. The doctor increases her dose of lisinopril and tells her to use over-thecounter (OTC) ibuprofen for pain as needed. She is asked to call if the sleeping difficulty continues, and the clinic arranges for a cardiologist appointment to evaluate the chest pain. She requests additional samples of Aricept and Protonix, but her physician only has Aricept to give her. She is to return for a follow-up visit in three months.
Kate goes to the community pharmacist to fill her new prescription for 10 mg daily of lisinopril. The pharmacist reviews her prescription profile and discovers she is not filling the Protonix as scheduled. The pharmacist then spends five minutes counseling Kate to replace her current lisinopril 5 mg tablets with the new dose and not duplicate this prescription. The pharmacist asks her how she is taking the Protonix. Kate explains that she only takes one capsule about three times a week because it is so expensive. The pharmacist counsels her to discuss this prescription with her doctor.
The Interdisciplinary Team Intervenes: Patient Case, Part 2
Kate L.’s daughter comes to visit from another state and arranges an evaluation at a local geriatrics clinic. In addition to seeing the geriatrician, Kate is evaluated by a nurse, a social worker, and a certified geriatric pharmacy specialist (CGP). The geriatrician evaluates her new complaint of chest pain; the nurse evaluates her risk of falls and discovers a new complaint of dizziness; the social worker evaluates the cost of her medications not covered by her Medicare Part D plan (particularly the Fosamax and Protonix); and the CGP discovers she is also taking OTC Tylenol PM, but, because of its cost, has never filled the Fosamax prescription. Also, the pharmacist learns that Kate only takes one calcium tablet daily, frequently forgets aspirin, takes the Protonix three times a week because of the cost, and will likely not fill her prescription for Aricept once her samples run out. Each team member spends thirty minutes with Kate and her daughter for a total of two hours.
The interdisciplinary team meets to discuss findings and develop a plan for further evaluation and care. The team decides Kate needs to have Protonix and Fosamax changed to the generic-therapeutic equivalents of omeprazole and alendronate, in addition to having an evaluation of her Medicare Part D plan to ensure she is on the best plan for her regimen. The new chest pain is most likely from her gastroesophageal reflux, so routine use of omeprazole may alleviate this complaint. However, she needs to take the recommended dose of calcium citrate, and vitamin D should be added to effectively treat osteoporosis, along with the alendronate. The Tylenol PM should be discontinued to decrease dizziness and reduce her risk of falls. The recently recommended OTC ibuprofen should be replaced with OTC acetaminophen to avoid increased risks for gastrointestinal bleeding and increased blood pressure. Finally, Kate should be switched to enteric-coated aspirin and counseled on the risks and benefits of each medication to encourage adherence. The team identifies who is responsible for each action item. This meeting takes about thirty minutes.
Positive Outcomes from Proper Adherence: Patient Case, Part 3
Over the next two months, Kate L. makes the changes planned by her geriatric interdisciplinary healthcare team. The chest pain subsides, her joints ache less, and she is able to develop a system to help her adhere to her medication regimen at home. She tells her friends at church about the clinic and several make appointments. However, the clinic is growing full, and it takes one friend two months to get in as a new patient. She also mentions the clinic to her sister in another state. Unfortunately her sister is unable to find a geriatric clinic within sixty miles of her home. Kate asks her CGP for suggestions. The CGP identifies a community pharmacist located near Kate’s sister who can provide medication therapy management services and work with her sister’s physician.
Interdisciplinary Teams, Geriatric-Trained Healthcare Providers, and Coordinated Care
The use of an interdisciplinary team with geriatric competency is necessary to best manage the complex and challenging healthcare of older adults, including drug therapies. To be successful, the team must share a common understanding of its overall purpose. In geriatric healthcare, that purpose would be to achieve optimal health outcomes for the geriatric patient. To best define what those health outcomes are, the team must first establish care goals with the patient and the patient’s family or caregivers. While each team member must have specific professional roles as determined by team and patient needs, all team members should contribute to leading the team when necessary. There must be effective communication between team members and those outside the team. When conflict develops, the team must have strategies to resolve issues (Flaherty, Hyer, and Fulmer, 2011).
Geriatric care teams are typically made up of the patient, physician, nurse, social worker, and pharmacist. The team can be extended as necessary to include family members or significant others, physical or occupational therapists, dieticians, speech pathologists, psychologists, and psychiatrists, as well as physician extenders such as nurse practitioners or physician assistants. Effective team communication in the form of updating and sharing medical records, regularly scheduled venues for discussing the patient, a forum to address team issues, and a way to communicate outside the team is key for teams to function well.
Teams can function in multiple settings. For hospital settings, “acute care of the elderly” (or ACE) teams typically work together to facilitate effective care and discharge of elderly patients, including the reduction of iatrogenic complications. Usually each discipline evaluates the patient for acute issues and communicates either through the medical record or on patient rounds to combine assessments and treatment plan recommendations into the final care plan.
In long-term-care settings, teams function to set care goals and implement rehabilitation services. While staff at the nursing home may meet routinely, the physician, consultant pharmacist, and other disciplines may communicate primarily through the medical record or individually to the staff.
In the ambulatory setting, clinics and doctors’ offices have traditionally been staffed with nurses and physicians. However, for geriatric care, social workers are also considered essential. The patient-centered medical home further embraces the team concept and, if involving geriatric patients, will likely include pharmacists because of the high prevalence of drug-related problems and the need for frequent discussions concerning medication use and adherence (Flaherty, Hyer, and Fulmer, 2011; Martin et al., 2010).
The Pharmacist’s Traditional Role
Traditionally, the role of a pharmacist included compounding and dispensing medications safely and effectively. Their expertise in nonprescription drugs, medication devices, and counseling, coupled with easy accessibility to the public, made the pharmacist a quick reference for medication use (Albanese and Rouse, 2010). Encouraging compliance to medication regimens was another aspect of the profession.
Pharmacists were not paid for cognitive services, nor were they held responsible for their recommendations by means of documentation or monitoring; therefore, they did not have a personal stake in the outcomes of their patients (Wiedenmayer et al., 2006). The traditional pharmacist’s main focus was product management. Because of their isolated practice site at community pharmacies and focus on products, pharmacists were not usually identified as a vital member of the healthcare team.
In recent decades, the pharmacy profession has shifted focus. The World Health Organization notes that the emerging role of the pharmacist as a healthcare provider involves him or her participating in patient care as a caregiver, communicator, decision maker, teacher, life-long learner, leader, manager, and researcher (Wiedenmayer et al., 2006). These roles go far beyond the pharmacist’s traditional role.
These new pharmacist roles emerged along with the concept of “pharmaceutical care.” As defined by the American Society of Hospital Pharmacists (ASHP) in 1993, pharmaceutical care is “the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life” (American Society of Hospital Pharmacists, 1993). This statement shifts the focus of treatment to definite outcomes (cure disease, eliminate or reduce symptoms, stop or slow disease progression, prevent disease and symptoms) and makes the pharmacist responsible for these outcomes. The pharmacist is responsible for identifying, resolving, and preventing medication-related problems such as untreated indications, improper drug selection, inadequate dosing, toxic dosing, adverse drug reactions, interactions, and medication use without indication (American Society of Hospital Pharmacists, 1993). The pharmacist is, therefore, an accountable member of the healthcare team.
Pharmacists: Vital Members of the Geriatric Care Team
Pharmacists offer a variety of services as a member of an interdisciplinary team. They make recommendations in many areas, including dosing and administration, current guidelines for treatment, approved and off-label indications, adverse drug reactions, drug interactions, intravenous drug compatibility, drug monitoring, and duplications (Albanese and Rouse, 2010). By interacting with other members of the healthcare team, pharmacists are able to enhance patient care by contributing to the decisionmaking process (Albanese and Rouse, 2010). With the added responsibility of documenting services provided, pharmacists gain a personal stake in patient outcomes. Plus, the pharmacist team member can help to educate other team members regarding appropriate medication use, new drugs, and issues to address with elderly patients. This serves to prevent common adverse drug events and streamline care.
Today’s pharmacist involved with interdisciplinary geriatric healthcare also provides pharmaceutical care directly to the patient. In most states, pharmacists can enter collaborative practice agreements to manage drug therapy of patients under the supervision of a physician. For example, a pharmacist can use the results of laboratory testing for cholesterol or prothrombin to adjust the dose of statins or oral anticoagulants under a collaborative practice agreement. This can be done as part of a physician’s office practice, in a hospital or nursing home setting, or at the local pharmacy. In each setting, providing pharmaceutical care involves gathering patient information, assessing that information, prioritizing problems, developing an action plan to solve problems, and communicating and documenting this process (Jones, 2003). Involving the interdisciplinary team in the pharmaceutical care process improves the amount of information gathered, strengthens the assessment and prioritization, and increases the chances that an appropriate plan will be developed and executed.
Optimizing drug therapy for older patients is the pharmacist’s focus on the interdisciplinary team, and is accomplished either through dispensing medications and counseling patients on their proper use, or in an emerging role where they provide care through medication therapy management, selecting the best medication and dose for the patient, assuring patient understanding of the drug regimen, monitoring for drug response, and reporting outcomes. Today’s pharmacist may accomplish these steps through providing recommendations to the interdisciplinary team or by performing the prescribing and monitoring as a physician extender. Either process would optimally involve communication with the team prior to implementing the patient’s care plan and reporting back to the team to discuss the outcomes and determine if adjustments are necessary (American Society of Hospital Pharmacists, 1993). Our case illustrates how a pharmacist with additional training and expertise in geriatric pharmaceutical care, working in tandem with other healthcare professionals, can identify and resolve potential and actual drug-related problems to improve care for a geriatric patient.
Challenges with Interdisciplinary Care
In addition to the paucity of healthcare professionals with specific geriatric training, financial barriers limit the availability of geriatric interdisciplinary care clinics. Medicare does not directly pay for the increased numbers of healthcare professionals and the time required for interdisciplinary evaluation and management. Cost savings from avoiding drug-related adverse events make such programs viable in healthcare systems where costs for both ambulatory and acute care are bundled. Therefore, the general availability of such model programs is, at present, limited (Boult et al., 2009).
Programs of All-inclusive Care of the Elderly (PACE), managed care organization geriatric programs, and geriatric evaluation clinics within the Department of Veterans Affairs are examples where geriatric interdisciplinary care has been shown to be effective and financially viable. The patient-centered medical home model and the Patient Safety and Clinical Pharmacy Collaborative offer options that will provide justification and funding for such programs and allow the healthcare system to ramp up interdisciplinary care for elderly patients in the outpatient setting. This is crucial considering the increasing geriatric patient population (Patient Safety and Clinical Pharmacy Services Collaborative, 2011).
Pharmacists Are Key Team Members
Medication use in older adults is complex and challenging. The current healthcare workforce is inadequately prepared, in both entry-level competency and in numbers of geriatric specialists, to care for the growing numbers of vulnerable elderly patients. The interdisciplinary team is one successful method of optimizing the prescribing of medications for the geriatric patient. The pharmacist, as an integral member of the interdisciplinary geriatric healthcare team, works to improve outcomes related to medications. Under a collaborative practice agreement, the roles that the pharmacist fulfills as a member of the interdisciplinary healthcare team may range from the traditional (as a dispenser of drugs) to the emerging (as a prescriber of drugs). Newer practice models using the interdisciplinary team with geriatric competencies, such as the patient-centered medical home, should be pursued with vigor.
Lisa C. Hutchison, Pharm.D., M.P.H., is a professor in the Department of Pharmacy Practice, and an associate professor in the Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock. She can be contacted at email@example.com.
Ashley Castleberry, Pharm.D., is a pharmacy resident and clinical instructor in the Department of Pharmacy Practice, University of Arkansas for Medical Sciences.
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Editor’s Note: This article is taken from the Winter 2011-2012 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Medications and Aging.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.