PROTOCOL MEDICATION THERAPY ADHERENCE CLINIC · Neurology clinic, MOPD clinic or clinic focusing on specific conditions (e.g. Stroke Clinic, Rehabilitation Clinic, etc.) and patients

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PROTOCOL

MEDICATION THERAPY

ADHERENCE CLINIC:

NEUROLOGY

1st Edition 2019

PHARMACY PRACTICE & DEVELOPMENT DIVISION

MINISTRY OF HEALTH MALAYSIA

First Edition, 2019

Pharmaceutical Services Programme

Ministry of Health Malaysia

Lot 36, Jalan Universiti

46350 Petaling Jaya,

Selangor, Malaysia

© ALL RIGHTS RESERVED

This is a publication of the Pharmaceutical Services Program, Ministry of Health Malaysia.

Enquiries are to be directed to the address below. Permission is hereby granted to

reproduce information contained herein provided that such reproduction be given due

acknowledgement and shall not modify the text.

Pharmaceutical Services Programme

Ministry of Health Malaysia Lot 36, Jalan Universiti, 46350 Petaling Jaya, Selangor, Malaysia

Tel: 603 – 7841 3200 Fax: 603 – 7968 2222

Website: www.pharmacy.gov.my

http://www.pharmacy.gov.my/

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PREFACE

Medication Therapy Adherence Clinic (MTAC) was introduced in

2004 as part of clinical pharmacy services in the Ambulatory Clinic

System, which emphasized on medication management to improve

quality, safety and cost-effectiveness of patient care. Since then,

the service has been expanded and extended to various disciplines

and are available throughout Ministry of Health (MOH) Malaysia‘s

facilities where pharmacists work closely with other health care

providers in providing pharmaceutical care to the patients.

Acknowledging that long-term neurological conditions carry a significant burden

to the individual, families and carers, the government, and to society as a whole, MTAC

Stroke was initiated at Hospital Sultanah Nur Zahirah, Kuala Terengganu. With the

aim to expand the service, this First Edition MTAC Neurology Protocol is developed to

include epilepsy and Parkinson’s disease as part of MTAC Neurology. It outlines the

procedures and documentations during MTAC sessions and serve as a guide to

enable standardization of practice and establishment of MTAC Neurology service

throughout MOH’s facilities.

I would like to congratulate the Neurology Pharmacy Task Force, Pharmacy

Practice & Development Division, MOH for their contributions and commitments to the

publication of this protocol.

Thank you

DR. ROSHAYATI BINTI MOHAMAD SANI

Director

Pharmacy Practice & Development Division

Ministry Of Health Malaysia

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MEMBERS OF PANEL

ADVISORS

Dr Roshayati binti Mohamad Sani

Director of Pharmacy Practice and Development Division, Ministry of Health

EDITORS

Rozita binti Mohamad

Pharmacy Practice and Development Division, Ministry of Health

Nor Hasni binti Haron


Amalina binti Amri


CONTRIBUTORS

Tan Ai Leen

Hospital Kuala Lumpur

Parimala A/P Vijai Indrian

Hospital Tengku Ampuan Rahimah

Ho Chee Wah

Hospital Raja Permaisuri Bainun

Kong Lai San

Hospital Tuanku Ampuan Najihah

Siti Hajar binti Razali

Hospital Sultanah Nur Zahirah

EXTERNAL REVIEWER

Dr Santhi Datuk Puvanarajah

Senior Consultant Neurologist, Hospital Kuala Lumpur

ACKNOWLEDEGEMENTS

This Division would also like to thank those who were involved directly or indirectly in

preparing this Neurology Medication Therapy Adherence Clinic (MTAC) Protocol

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TABLE OF CONTENTS

Overview ................................................................................................................ 1

A. General Objective ............................................................................................ 1

B. Scope of Service ............................................................................................. 1

C. Types of Neurology MTAC ....................................................................................... 2

D. Location and Setting of Service ...................................................................... 2

E. Manpower Requirement .................................................................................. 2

F. Procedure ........................................................................................................ 3

1. Workflow .................................................................................................... 3

2. Patient Selection ................................................................................................... 4

3. Registration ............................................................................................................ 4

4. Appointment and Missed Visit(s) ....................................................................... 4

5. Activities during MTAC Session ......................................................................... 4

6. Documentation ...................................................................................................... 5

G. Outcome Measures .................................................................................................... 6

Section 1: Stroke ................................................................................................... 7

A. Introduction ....................................................................................................... 7

B. Patient Criteria .................................................................................................. 8

C. Specific Monitoring Parameters/Activities ......................................................... 8

D. Education Outline for Stroke Patient ................................................................. 9

E. Outcomes Measures ....................................................................................... 10

F. Discharge Criteria ........................................................................................... 10

Section 2: Epilepsy ............................................................................................. 11

A. Introduction ..................................................................................................... 11

B. Patient Criteria ................................................................................................ 11

C. Specific Monitoring Parameters/Activities ....................................................... 12

D. Education Outline for Patient with Epilepsy .................................................... 12

E. Outcomes Measures ....................................................................................... 12


Section 3: Parkinson’s Disease ......................................................................... 14

A. Introduction ..................................................................................................... 14

B. Patient Criteria ................................................................................................ 14

C. Specific Monitoring Parameters/Activities ....................................................... 15

D. Education Outline for Patient with Epilepsy .................................................... 15

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E. Outcomes Measures ..................................................................................................15


References ........................................................................................................... 17

Appendices ..............................................................................................................

Appendix 1(a-d): Medication Therapy Adherence Clinic Neurology (Stroke)

Forms .................................................................................................................. 19

Appendix 2(a-e): Medication Therapy Adherence Clinic Neurology (Epilepsy)

Forms ................................................................................................................. 24

Appendix 3(a-e): Medication Therapy Adherence Clinic Neurology (Parkinson’s

disease) Forms .......................................................................................................... 30

1

OVERVIEW

Medication management of neurologic disorders can be challenging in an

ambulatory care setting, which require close monitoring due to multiple medication

related issues such as complex titration and tapering schedule, use of multiple agents,

unique monitoring parameters and broad range of potential side effects that may be

harmful to the patients. Neurologic conditions are often chronic in nature, thus regular

assessment and review of medication regimen are required.

Clinical pharmacists may be uniquely positioned to assist with the medication

adjustments and monitoring that are often necessary for these conditions. Pharmacist‐

led Medication Therapy Adherence clinics (MTAC) are well established in some areas

of ambulatory care and have been beneficial in treatment aspect of the patient by

improving drug compliance, decreasing inappropriate prescribing and providing

positive therapeutic outcomes by monitoring patients' treatment plans1,2,3,4.

Expansion of clinical pharmacy services in the ambulatory neurology clinic via

Neurology MTAC is a good platform for pharmacist to play their role in extending the

provision of pharmaceutical care to the target group. This protocol will describe MTAC

Neurology, which is currently offered for patients with stroke, epilepsy and Parkinson’s

disease at an ambulatory setting.

A. General Objectives

• To empower patients with knowledge on medications and disease.

• To improve and sustain adherence towards medications.

• To optimize pharmacotherapy in terms of quality, safety and cost-effectiveness.

• To minimize risk of adverse drug reactions and side effects of medications.

B. Scope of Service

Neurology MTAC service will be provided to the patients who are managed in the

Neurology clinic, MOPD clinic or clinic focusing on specific conditions (e.g. Stroke

Clinic, Rehabilitation Clinic, etc.) and patients who fulfil the enrolment criteria.

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Patients can either be referred by health care professionals or selected by

Neurology MTAC pharmacists.

C. Types of Neurology MTAC

Currently, there are three (3) types of Neurology MTAC:

a) Stroke,

b) Epilepsy, and

c) Parkinson’s Disease

Each Neurology MTAC protocol comprises of topics, counselling points and

monitoring parameters for specific disorders. It is important to note that the

selection of topics and the number of MTAC sessions should be tailored to

individual patient’s needs.

D. Location and Setting of Service

The Neurology MTAC service will operate in the clinic area during clinic day.

Subsequent visits can be carried out in either the pharmacy or clinic area

whichever deemed suitable depending on local setting.

E. Manpower Requirement

• Neurology MTAC service shall be provided by trained pharmacist(s).

• A minimum of one pharmacist will be required during MTAC session. However,

the number of pharmacists shall depend on the number of patients scheduled

per day.

• A coordinator should be appointed to facilitate the continuity of the service.

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F. Procedure

1. Workflow

a. Initial Visit

b. Second and Subsequent Visits

No

Yes

Identify Patient

Medication education &

counselling

Communicate

with physician Intervention

Initial assessment

Registration

Documentation

Provide next

appointment date

No

Yes

Patient comes for

MTAC follow-up

Medication education &

counselling

Communicate

with physician Intervention

Follow-up assessment

Documentation

Provide next

appointment date

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2. Patient Selection

Criteria for patient selection will depend on specific neurologic conditions.

Generally, patient with the following criteria will be selected:

a) Patients who is not adhering to their medications

b) Patients with drug-related problem, e.g. sub-optimal drug therapy,

medication overdose, inappropriate drug therapy etc.

Referral for MTAC between pharmacists will use CP4 form while referral for

MTAC from other health care providers will use standard forms in the facility.

3. Registration

A registry of all MTAC patients must be maintained.

4. Appointment & Missed Visit(s)

a) Appointment

All MTAC appointments shall be scheduled by the MTAC pharmacist using

a suitable tool e.g. calendar, planner, PhIS system etc.

b) Missed visits

Patients shall be contacted by pharmacist or clinic staff if he/she missed

any visit to reschedule the appointment.

5. Activities During MTAC sessions

The following activities will be performed by MTAC Pharmacist during MTAC

session:

a) Initial Visit

• Discussion with patient on:

o Introduction to Neurology MTAC & its objectives

o Anticipated benefits to the patients or caregivers

o Goals for patient

o Patient’s specific drug therapy-related needs

o Patient’s rights and responsibilities in the programme

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• Initial assessment of patient’s baseline on:

o Demographic data

o Medical / medication history

o Social / family history

o Medication knowledge

o Patient’s understanding of medication & adherence

• Counselling and patient education on the topics listed for respective

neurologic conditions (refer to respective modules).

The topics should be delivered at a pace suitable to patient’s knowledge

and understanding.

• Identification of pharmaceutical care issues and communication of

pharmaceutical care plan to the physician.

b) Second & Subsequent Visits

Activities during subsequent visits include managing pharmaceutical care

issues and providing patient education. Subsequent visits shall be

scheduled based on patients’ needs, current health status, other clinic visits

and medication refill appointments.

In cases whereby patients having difficulties or it is impossible for them to

attend the visit (e.g. bedridden due to stroke), the subsequent visits can be

done to the identified caregiver provided the patient medications are fully

managed by them.

6. Documentation

a) All relevant MTAC Forms must be updated during the MTAC sessions and

the record should be kept in the pharmacy department.

b) A copy of relevant forms will then be attached together with the patient’s

case notes.

c) All type of neurologic conditions (strokes / epilepsy / Parkinson’s disease)

will be using the similar assessment forms with additional form for specific

activities for respective disease.

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G. Outcome Measures

The following measures shall be monitored

a) Medications adherence status

b) Medication knowledge

c) Relevant laboratory investigations/ responses to treatment

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SECTION 1: STROKE

A. Introduction

Cerebrovascular accidents (stroke) are the second leading cause of death

worldwide and the third leading cause of disability5. In Malaysia, stroke represents

a major health concern ranking as one of the top 10 reasons for hospitalization and

the third largest cause of death6,7. The National Health and Morbidity Survey

(NHMS) in 2011 reported that the prevalence of stroke in Malaysia is 0.7%

compared to 0.3% in 20068. The number of patients suffering from stroke is

increasing rapidly due to expanding population numbers and aging as well as the

increased prevalence of modifiable stroke risk factors where most of the cases were

preventable9.

The mobility burden for patients, families, and society is considerable. About

thirty-five percent of stroke patients recovered independently at discharge while

54% of survivors suffer due to various degree of physical or cognitive disability,

which may inflict additional social issues affecting the family members in coping

with their daily activities10.

Hypertension (67.0%), diabetes (39.6%), cigarette smoking (25.2%), and

hyperlipidaemia (23.0%) were the commonest risk factors in the Malaysian

population11. Most strokes are preventable where 90% of strokes are linked with 10

modifiable risk factors11. Thus, early awareness of risk factors and modification of

certain behaviours could decrease stroke incidence and prevent stroke

recurrence12. Awareness on recognizing the signs and symptoms of strokes are a

necessity for prompt emergency stroke care can also minimize the chance of getting

stroke, limit the brain damage as well as the level of disabilities it cause13.

The pharmacist as an integral part of health care team can play a significant

role in improving patients’ awareness and knowledge and are in a key position to

tract adherence to drug therapy. A pharmacist involvement can improve disease

and disability prevention, leading to fewer physician visits, decrease the need for

medical treatment, lower health care costs and most important, improve patient’s

quality of life.

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B. Patient Criteria

Patient who has been diagnosed with stroke with the following criteria:

i. Recent first or recurrent stroke event with risk factors.

ii. Patient suspected of having non-adherence towards medication.

iii. Patient who has drug-related problems and suspected adverse drug reactions.

iv. Patient referred by healthcare providers, i.e. specialist, medical officers,

pharmacist, speech therapist.

C. Specific Monitoring Parameter / Activities

i. Patient recovering from recent stroke

Swallowing function

o Review suitability and appropriateness of medication (types, dosage

design, etc.)

o Review handling of medication by patient / caregivers (method and time

of administration time, etc.)

ii. Recurrent stroke prevention

Risk factors of recurrent stroke

o Ensure medications for secondary stroke prevention are given (if not

contraindicated)

o Monitor and optimize risk factor parameters (blood pressure, blood

glucose level, lipid profile, INR).

o Smoking reduction and cessation.

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D. Education Outline for Stroke Patient

No. Visit Education

1. First Visit Brief overview about stroke and stroke subtypes

Stroke risk factors

Stroke symptoms

Specific discussion on drugs as secondary prevention of

stroke (indication, role of each drug and adverse effects

o Antiplatelet (for ischemic stroke and transient

ischemic attack (TIA))

o Lipid lowering therapy

o Antihypertensive drug

o Anticoagulant for cardio-embolic stroke

Therapeutic goal for main parameters: blood pressure,

glucose level, LDL and INR.

2. Second Visit Education on risk factors (hypertension, diabetes

mellitus, atrial fibrillation, ischemic heart disease,

hyperlipidaemia, smoking cessation (if applicable),

alcohol consumption (if applicable), etc.)

3. Third Visit Stroke complication and prevention

4. Forth Visit Benefit of exercise

Basic nutrition and diet control

5. Subsequent

Visit

How to maintain therapeutic goals and long term plan

Revision of treatment goals

Specific drug counselling

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E. Outcome Measures

The following shall be monitored and assessed during MTAC visits:

i. Risk factors of recurrent stroke (blood pressure, blood sugar profile, lipid

profile).

ii. Adherence towards medications for chronic illnesses.

iii. Medication knowledge (DFIT score).

iv. Other laboratory parameters e.g. renal profile, liver function test etc.

F. Discharge Criteria

Patient who fulfilled two (2) of the following criteria can be discharged from MTAC

service:

i. Medication knowledge evaluation is satisfactory (DFIT > 80%) and no changes

in treatment regime for at least two (2) visits.

ii. Therapeutic goals have been achieved, all pharmaceutical issues have been

resolved and no further monitoring is needed.

iii. Discharged or transferred out to other facilities.

iv. Default two (2) consecutive appointments despite being contacted (effort must

be made to contact patient / caregiver by telephone call) or patient requests to

exit MTAC service.

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SECTION 2: EPILEPSY

A. Introduction

An epileptic seizure is defined as a transient occurrence of signs and / or

symptoms due to abnormal excessive or synchronous neuronal activity in the brain

while epilepsy is a disorder of the brain characterised by an enduring predisposition

to generate epileptic seizures that is, a seizure is an event and epilepsy is the

disease involving recurrent unprovoked seizures14,15. Epilepsy is responsible for an

enormous amount of suffering, affecting some 50 million people of all ages16. The

estimated proportion of the general population with active epilepsy at a given time

is between 4 and 10 per 1000 people and about 5 million new cases occur each

year16. Epilepsy is universal and the most common serious neurological disorder,

which accounts for 0.5% of the global burden of disease16.

Epilepsy can be associated with profound physical, psychological and social

consequences, and its impact on a person’s quality of life can be greater than that

of some other chronic conditions16. In many parts of the world, people with epilepsy

and their families suffer from stigma and discrimination and the risk of premature

death in people with epilepsy is up to three times higher than for the general

population16.

Epilepsy is treatable where 70% of patients could respond to treatment with

appropriate use of cost-effective anti-seizure medicines16. Failure to comply with

drug regimens is prevalent amongst patients with epilepsy and the consequence of

this, is often an increased risk of further seizures17. Further implementation of

educational programs for people with epilepsy would help to improve levels of

compliance thereby reducing the risk of unnecessary and preventable seizures.

B. Patient Criteria

Patient who has been diagnosed with epilepsy with the following criteria:

i. Newly diagnosed / newly initiated with antiepileptic medications.

ii. Requires changes in antiepileptic medications.

iii. Patient with drug-related problems and suspected adverse drug reactions.

iv. Patient with adherence problems towards antiepileptic medications.

v. Patient with uncontrolled seizure.

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C. Specific Monitoring Parameters/ Activities

i. Seizure Control: Seizure Diary (seizure profile, fit frequency and trigger of

seizures)

ii. Therapeutic Drug Monitoring (Phenytoin, Carbamazepine, Sodium Valproate,

Phenobarbitone)

D. Education Outline for Patient with Epilepsy

No. Visit Education

1. First Visit Brief overview on epilepsy and types of epilepsy

Treatment of epilepsy

Side effects of medications

Importance of adherence to antiepileptic

Management during and after seizure

Seizure diary

2. Second and

subsequent

visits

Review seizure diary & adherence

Other suggested additional info:

o Further explanation on medications (according to

types of medications)

o Complications of seizure attack

o Antiepileptics in pregnancy (if relevant)

E. Outcome Measures

The following measures shall be monitored and assessed during MTAC visits:

i. Adherence towards antiepileptic medications.

ii. Frequency and duration of seizure.

iii. Medication knowledge (DFIT score).

iv. Therapeutic Drug Monitoring of antiepileptic medications.

v. Other laboratory parameters e.g. renal profile, liver function test etc.

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F. Discharge criteria


service:





iii. No seizure attack after stopping antiepileptic for at least two (2) visits.

iv. Discharged or transferred out to other facilities.

v. Defaults two (2) consecutive appointments despite being contacted (effort must


exit MTAC service.

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SECTION 3: PARKINSON’S DISEASES (PD)

A. Introduction

Parkinson’s disease (PD) was described by James Parkinson in his monograph

1817, “An Essay on the Shaking Palsy”. PD is a neurodegenerative disease, which

involves degeneration of dopaminergic neurons at basal ganglia and causes

movement disorder symptoms.

PD has a worldwide prevalence of approximately 0.3% in general population

over age of 40. This also suggests that there are about 7.5 million people who suffer

from PD worldwide18,19. The prevalence of PD is increasing over age whereby ratio

is 41:100,000 for 40-49 years old to 1900:100,000 for 80 years old and above18.

When PD progress or in advanced PD, motor fluctuation and dyskinesia are the

main complications especially in those who are treated with levodopa. There are as

many as 40% of levodopa-treated PD patients who experience motor fluctuation

and dyskinesia after being treated for 4-6 years20. The incidence of motor fluctuation

and dyskinesia is estimated to be about 10% per year after initiating levodopa21.

More than 80% of patients will experience motor fluctuation and dyskinesia, 10

years after initiating levodopa20.

Pharmacist in Neurology MTAC may help PD patients who suffer from motor

fluctuation complications through better management of medications and

subsequently improve their quality of life.

B. Patient Criteria

Patient who has been diagnosed with Parkinson’s disease with the following criteria:

i. Newly diagnosed and initiated with medication.

ii. Patient suspected of having non-adherence towards medication.

iii. Patient who has drug-related problems and suspected adverse drug reactions.

iv. Patient on levodopa therapy with motor fluctuation and dyskinesia.

v. Patient referred by healthcare providers, i.e. specialist, medical officers,

pharmacist.

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C. Specific Monitoring Parameter / Activities

i. Patient Education

For all recruited patients.

ii. Individualized dose adjustment of levodopa therapy

For patient who has potential for uncontrolled movement, or

For patient on levodopa with motor fluctuation and dyskinesia.

Based on patient’s motor diary (24 hours chart describing time at which ON,

OFF and dyskinesia occur) and basic physical test.

Patient with poor cognitive impairment will be referred to physician due to

possible inaccuracy of information on the ON, OFF and dyskinesia.

D. Education Outline for Patient with Parkinson’s Disease

No. Visit Education

1. First Visit Brief overview on Parkinson’s disease and signs and

symptoms

Treatment goal for Parkinson’s disease

Medication used for treatment of Parkinson’s disease

and their mechanism

Side effects of medication

Food interaction with levodopa therapy

2. Second and

subsequent

visits

Review patient’s response on treatment

Management of motor fluctuation, dyskinesia and

wearing off in levodopa therapy

E. Outcome Measures

The following shall be monitored and assessed during each MTAC visit:

i. Signs and symptoms of progressiveness of Parkinson symptoms (bradykinesia,

tremor and rigidity, swallowing function)

ii. History of falls

iii. Patient’s response after initiation / adjustment of a particular medication regime

iv. Recent alteration in diet (protein intake) and time of medication intake (before

or after meal)

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v. Medication knowledge (DFIT score) and adherence towards medications for

Parkinson’s disease.

F. Discharge Criteria


service:





iii. Discharged or transferred out to other facilities.

iv. Default two (2) consecutive appointments despite being contacted (effort must


exit MTAC service.

In cases where discharged patient require continuation of MTAC service due to

progression of the Parkinson’s disease, patient may continue MTAC follow-up by

using previous registration.

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REFERENCES

1. You L.X., et al. (2015). Impact of pharmacist-managed Diabetes Medication

Therapy Adherence Clinic (DMTAC) in government health clinics. Malaysian

Journal of Pharmaceutical Sciences, Vol. 13, No. 1, 43–51.

2. Thanimalai S., Shafie A. A., Hassali M. A., & Sinnadurai J. (2013). Comparing

effectiveness of two anticoagulation management models in a Malaysian tertiary

hospital. International Journal of Clinical Pharmacy, 35(5), 736–743.

doi:10.1007/s11096-013-9796-6.

3. Mubashra B., Adliah M.A., Mohd M.B., & Norlaila M. (2016). Impact of a

pharmacist-led diabetes mellitus intervention on HbA1c, medication adherence

and quality of life: A randomised controlled study. Saudi Pharmaceutical Journal

Volume 24, Issue 1, January 2016, Pages 40-48.

4. Alrasheedy A.A., Hassali M.A., Wong Z.Y., & Saleem F. (2017). Pharmacist-

managed medication therapy adherence clinics: The Malaysian experience. Res

Social Adm Pharm. 2017 Jul - Aug;13(4):885-886.

5. Walter J., Oyere O., Mayowa O., & Sonal S. (2016). Stroke: A global response is

needed. Bull World Health Organ. 2016 Sep 1;94(9):634-634A.

6. Statistics on Causes of Death, Malaysia, 2018, Department Of Statistics Malaysia.

7. Health Facts 2018, Planning Division Health Informatics Centre, Ministry of Health

Malaysia.

8. MOH Malaysia. National Health and Morbidity Survey 2011 Report: Institute of

Public Health.

9. Katan, M., & Luft, A. (2018). Global burden of stroke. Seminars in Neurology,

38(02), 208–211.

10. Annual Report of the Malaysian Stroke Registry 2009-2016.

11. Dr Martin J O’Donnell, et al. “Global and regional effects of potentially modifiable

risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-

control study,” The Lancet, 2017; 388: 761-775.

12. Chin Y.Y., Sakinah H., Aryati A., & Hassan B.M. (2018). Prevalence, risk factors

and secondary prevention of stroke recurrence in eight countries from South, East

and Southeast Asia: a scoping review. MMed2, Med J Malaysia Vol 73 No 2 April

2018.

https://www.sciencedirect.com/science/article/pii/S1319016415000614#!




https://www.sciencedirect.com/science/journal/13190164/24/1

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13. Díez-Tejedor E. & Fuentes B. (2004). Acute care in stroke: the importance of early

intervention to achieve better brain protection. Cerebrovasc Dis. 2004;17 Suppl

1:130-7.

14. International Leagues Against Epilepsy

15. Consensus Guidelines on Management of Epilepsy 2017, Malaysian Society of

Neuroscience.

16. WHO https://www.who.int/news-room/fact-sheets/detail/epilepsy

17. Malek N., Heath C. A., & Greene J. (2016). A review of medication adherence in

people with epilepsy. Acta Neurologica Scandinavica, 135(5), 507–515.

18. Pringsheim T., Jette N., Frolkis A., & Steeves T.D. (Nov 2014). The prevalence of

Parkinson’s disease: A systematic review and meta-analysis. Mov Disord. 29 (13):

1583-90.

19. Ross GW, Abbot RD (Nov 2014). Living and dying with Parkinson’s disease. Mov

Disord 29 (13):1571-3

20. Ahlskog J.E. & Muenter M.D. (2001). Frequency of Levodopa-related dyskinesia

and motor fluctuations as estimated from the cumulative literature. Movement

disorder: official journal of movement disorder society 16 (3), 448-458, 2001.

21. Marsden C.D. & Parkes J.D. (1977) Success and problems of long-term levodopa

therapy in Parkinson’s disease. Lancet 1977;1:345-9.

https://www.who.int/news-room/fact-sheets/detail/epilepsy

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Appendix 1a

MEDICATION THERAPY ADHERENCE CLINIC

NEUROLOGY (STROKE)

Patient Name: MRN:

Stroke Subtype:

ADL:

Dependent / Independent

Caregiver’s Name & Contact No:

Address:

Risk Factor □ Hypertension

□ Diabetes Mellitus

□ Hyperlipidemia

□ Atrial Fibrillation

□ Smoking

□ Others:

Date of MTAC Recruitment

Date of MTAC Visit 1.

2.

3.

4.

5.

6.

7.

8.

Date of Discharge

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Appendix 1b


NEUROLOGY (STROKE)

Patient Name : Gender : M / F

MRN / ID NO : Race : M / C / I / Other _____

Age : Allergy :

Diagnosis :

Assessment

Social History Family History

Smoking :

Alcohol Intake :

Pregnancy :

Drug Abuse :

Education Level:

Diet & Lifestyle :

Yes (___Sticks/day) /

No / Ex-smoker / Passive

smoking

Yes ( amount ______) /

No / Ex-alcoholic

Yes (______ trimester) /

No / Planning to get

pregnant

Yes (_________) / No

Primary / Secondary /

Tertiary

Marital status :

Family history of

illness :

No. of Children :

Lives with :

Single / Married /

Divorced / Widowed

Alone / Family

Members / Nursing

Homes / Others

Medical History

Comorbidities:

Surgical History:

Diagnostic Test:

Medication History

Past Medication History (and indication):

Non-Prescription Medication

(includes herb/ vitamin/ supplement &

reasons of taking):

21

Current Medication

DFIT Score: Level of adherence:

22

Appendix 1c

STROKE RISK FACTOR EVALUATION & MEDICATION REVIEW

Date: Visit No:

Medication D F I T Remark

Score (%) D = Dose, F = Frequency, I = Indication, T = Method of Administration

Control of Risk Factor

Risk Factors Status Comment

i. Hypertension Control/Uncontrolled,

ii. Diabetes Mellitus Control/Uncontrolled

iii. Hyperlidemia Control/Uncontrolled

iv. Smoking Yes / No

v. INR (if applicable) ____ (Target:_____)

Complications

□ Aspiration Pneumonia

□ Urinary Tract Infection

□ Bedsore

□ Seizure

□ Upper GI Bleeding

□ Depression

□ Recurrent stroke

□ Others: ___________

Pharmaceutical Care Issue

Pharmacist Intervention

Outcome/Plan

Pharmacist Name & Signature

23

Appendix 1d

Laboratory Values

Visit

Date

BP (mmHg)

PR (bpm) 60-100

RR (bpm) 12-18

Lipid Profile

T. Chol (mmol/l) <5.2

TG (mmol/l) 0.6-2.3

LDL (mmol/l) <1.8

HDL (mmol/l) >1.7

Renal Profile

Urea (mmol/l) 2.8-7.2

Na (mmol/l) 133-145

K (mmol/l) 3.3-5.1

SrCreatinine (umol/l) 45-84

CrCl (ml/min)

Liver Profile

T. Protein (g/L) 55-82

Albumin (mg/dl) 35-50

ALP (u/l) 30-120

ALT(u/l) <34

AST (u/l) <37

T. Bilirubin (umol/l) <21

Full Blood Count

WBC (x103/uL) 4-11

Hb (g/dL) 13.5-18

Platelet (x103/uL) 150 - 450

Cardiac Enzymes

CK (u/l) 24-195

LDH (u/l) <247

AST (u/l) <45

Coagulation Profile

PT 10.6-15.0 sec

APTT 26-42 sec

INR

Blood Sugar Profile

FBS (mmol/l) 4-6

RBS (mmol/l) 6-8

HbA1c <6.5%

Others

Weight (kg)

24

Appendix 2a


NEUROLOGY (EPILEPSY)

Patient Name: MRN:

Diagnosis:

ADL:



Address:



2.

3.

4.

5.

6.

7.

8.

Date of Discharge

25

Appendix 2b


NEUROLOGY (EPILEPSY)



Age : Allergy :

Diagnosis :

Assessment


Smoking :

Alcohol Intake :

Pregnancy :

Drug Abuse :

Education Level:

Diet & Lifestyle :



smoking


No / Ex-alcoholic



pregnant

Yes (_________) / No


Tertiary

Marital status :

Family history of

illness :

No. of Children :

Lives with :

Single / Married /

Divorced / Widowed

Alone / Family

Members / Nursing

Homes / Others

Medical History

Comorbidities:

Surgical History:

Diagnostic Test:

Medication History




reasons of taking):

26

Current Medication


27

Appendix 2c

EPILESY EVALUATION & MEDICATION REVIEW

Date Visit No

Medication D F I T Remark

Score (%) D = Dose, F = Frequency, I = Indication, T = Method of Administration

Seizure Control (since last visit)

Description of seizure

Trigger Factor

Latest TDM result

Adherence status

Any adverse

effect(s) of AED?

Pharmaceutical Care Issue

Pharmacist Intervention

Outcome/Plan:

Pharmacist Name & Signature

28

Appendix 2d

Laboratory Values

Visit

Date

BP (mmHg)

PR (bpm) 60-100

RR (bpm) 12-18

Lipid Profile


TG (mmol/l) 0.6-2.3

LDL (mmol/l) <1.8

HDL (mmol/l) >1.7

Renal Profile


Na (mmol/l) 133-145

K (mmol/l) 3.3-5.1


CrCl (ml/min)

Liver Profile



ALP (u/l) 30-120

ALT(u/l) <34

AST (u/l) <37


Full Blood Count

WBC (x103/uL) 4-11

Hb (g/dL) 13.5-18

Platelet (x103/uL) 150 - 450

Cardiac Enzymes

CK (u/l) 24-195

LDH (u/l) <247

AST (u/l) <45

Coagulation Profile

PT 10.6-15.0 sec

APTT 26-42 sec

INR

Blood Sugar Profile

FBS (mmol/l) 4-6

RBS (mmol/l) 6-8

HbA1c <6.5%

Others

Weight (kg)

29

Appendix 2e

Therapeutic Drug Monitoring Assay Result

Date & Time of

sampling Medication Therapeutic Range

Expected Range

(based on calculation) Measured Level TDM Recommendation

30

Appendix 3a


NEUROLOGY (PARKINSON’S DISEASE)

Patient Name: MRN:

Diagnosis:

ADL:



Address:

Diet Normal / Vegetarian



2.

3.

4.

5.

6.

7.

8.

Date of Discharge

31

Appendix 3b


NEUROLOGY (PARKINSON’S DISEASE)



Age : Allergy :

Diagnosis :

Assessment


Smoking :

Alcohol Intake :

Pregnancy :

Drug Abuse :

Education Level:

Diet & Lifestyle :



smoking


No / Ex-alcoholic



pregnant

Yes (_________) / No


Tertiary

Marital status :

Family history of

illness :

No. of Children :

Lives with :

Single / Married /

Divorced / Widowed

Alone / Family

Members / Nursing

Homes / Others

Medical History

Comorbidities:

Surgical History:

Diagnostic Test:

Medication History




reasons of taking):

32

Current Medication


33

Appendix 3c

PARKINSON’S DISEASE EVALUATION & MEDICATION REVIEW

Date: Visit No

Disease Control

Motor

symptoms

□ Bradykinesia

□ Tremor

□ Fall (time: ___)

□ Swallowing difficulty

□ OFF

□ ON

□ Others: ______

Non-Motor

symptoms

Medication

Adverse Effect

Levodopa

□ Dyskinesia

□ Hallucination

□ GI symptoms

□ Delayed-ON

(___ minutes)

□ OFF

□ Others: ______

Dopamine

Agonist

□ Hallucination

□ Obsessive behaviour

□ Insomnia

□ Orthostatic

hypotension

Headache

□ Others:_____

Anti-

cholinergic

□ Tremor

□ Dry mouth

□ Urinary retention

□ Hallucination

□ Blurred vision

□ Others:_____

Pharmaceutical

Care Issue

Pharmacist

Intervention

Outcome/Plan

Pharmacist Name

& Signature

34

Appendix 3d

D = Dose, F = Frequency, I = Indication, T = Method of Administration * 2012 consensus Guidelines for the treatment of Parkinson's disease

Date: PATIENT’S ‘ON & OFF’ CHART

MEDICATION D F I T Morning (AM) Afternoon (PM) Evening (PM)

00-01

01-02

02-03

03-04

04-05

05-06

06-07

07-08

08-09

09-10

10-11

11-12

12-13

13-14

14-15

15-16

16-17

17-18

18-19

19-20

20-21

21-22

22-23

23-00

Score (%)

STATUS Morning (AM) Afternoon (PM) Evening (PM)

Date of recording: _________ 00-01

01-02

02-03

03-04

04-05

05-06

06-07

07-08

08-09

09-10

10-11

11-12

12-13

13-14

14-15

15-16

16-17

17-18

18-19

19-20

20-21

21-22

22-23

23-00

ASLEEP

OFF

ON without dyskinesia

ON with non-troublesome dyskinesia

ON with troublesome dyskinesia

Pharmacist’s note:

35

Appendix 3e

Laboratory Values

Visit

Date

BP (mmHg)

PR (bpm) 60-100

RR (bpm) 12-18

Lipid Profile


TG (mmol/l) 0.6-2.3

LDL (mmol/l) <1.8

HDL (mmol/l) >1.7

Renal Profile


Na (mmol/l) 133-145

K (mmol/l) 3.3-5.1


CrCl (ml/min)

Liver Profile



ALP (u/l) 30-120

ALT(u/l) <34

AST (u/l) <37


Full Blood Count

WBC (x103/uL) 4-11

Hb (g/dL) 13.5-18

Platelet (x103/uL) 150 - 450

Cardiac Enzymes

CK (u/l) 24-195

LDH (u/l) <247

AST (u/l) <45

Coagulation Profile

PT 10.6-15.0 sec

APTT 26-42 sec

INR

Blood Sugar Profile

FBS (mmol/l) 4-6

RBS (mmol/l) 6-8

HbA1c <6.5%

Others

Weight (kg)

Documents

PROTOCOL MEDICATION THERAPY ADHERENCE CLINIC · Neurology clinic, MOPD clinic or clinic focusing on specific conditions (e.g. Stroke Clinic, Rehabilitation Clinic, etc.) and patients