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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

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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

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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)

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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

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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medicine Adverse drug reaction/interaction Unnecessary medication Wrong dose or regimen Poor compliance Poor technique Out-of-date medication

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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

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Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute University of South Australia Medication-related hospital admissions (Roughead et al, 2002)

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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

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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

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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

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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

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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

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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.

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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

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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

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Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute University of South Australia The sensitivity of the body to medications

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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.

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Quality Use of Medicines and Pharmacy Research Centre / Sansom Institute University of South Australia What medications cause most problems?

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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%

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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

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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

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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.

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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?

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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?

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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

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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

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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

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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

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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

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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?

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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?

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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

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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