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DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 1
Standard of Practice in Geriatric Medicine for Pharmacy Services 1
Geriatric Medicine Standard Working Group* 2
3
Suggested citation: SHPA Geriatric Medicine Standard Working Group (2018). Standard of Practice in 4
Geriatric Medicine for Pharmacy Services. Standard of Practice series. The Society of Hospital 5
Pharmacists Australia (SHPA). 6
7
Preface 8
This Standard is for professional practice and is not prepared or endorsed by Standards Australia. It 9
is not legally binding. 10
This Standard references and relies upon the SHPA Standards of Practice for Clinical Services (1) as 11
the foremost Standard. This Standard may overlap with others and depending on the area of 12
specialty practice it may be advisable to refer to additional Standards of Practice. 13
The use of the word ‘specialisation’ in this standard is in line with the National Competency Standards 14
Framework for Pharmacists in Australia (2) where ‘specialisation’ refers to the scope of practice rather 15
than the level of performance. ‘Specialisation’ of itself does not confer additional expertise. 16
17
Introduction 18
Older People 19
In developed countries the term ‘older people’ usually refers to people aged 65 years and over. In 20
Australia this age is used to determine eligibility for some aged care services. However, 65 years is 21
an arbitrary cut-off and individual people age differently. For many people better healthcare and living 22
standards has delayed the onset of health and physical problems typically associated with ageing, so 23
they remain healthy and active into their 70s or 80s. On the other hand, some people develop 24
geriatric syndromes and frailty in their 50s. Indigenous Australians have a lower average life 25
expectancy than the general population and are eligible for aged care services from the age of 50 26
years. The term ‘older’ is preferred over ‘elderly’, ‘aged’ or ‘geriatric’ when describing a person over 27
65 years of age, as the latter terms carry negative connotations and may lead to generalisations 28
about the health and physical status of the older person. 29
30
Older people constitute a large and growing proportion of the population, making geriatric medicine 31
a rapidly growing specialty. Pharmacists who specialise in geriatric medicine pharmacy practice work 32
in a variety of settings. These include acute and subacute geriatric medicine units, other hospital 33
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 2
units that focus on the care of older people (e.g. psychogeriatric and orthogeriatric units), residential 34
aged care facilities (RACF) and community-based programs (e.g. Transition Care, Hospital Outreach, 35
Home Care). The principles of geriatric medicine and geriatric pharmacy practice are also relevant in 36
other healthcare settings in which older people are managed, for example general medicine units, 37
oncology units and primary care. 38
A central component of geriatric medicine is ‘comprehensive geriatric assessment’ (CGA) (3). CGA 39
provides a comprehensive assessment of the older person’s health and wellbeing, with input into 40
the diagnosis and management plan from multiple disciplines (4). It includes assessment of medical, 41
cognitive, affective, functional and social issues, and development of a management plan that 42
considers the patient’s goals and preferences. Medication review and assessment of patients’ 43
medication management are important components of geriatric assessment, and core roles of the 44
geriatric pharmacist (3, 5). 45
There is a substantial body of published literature demonstrating the clinical and economic benefits 46
of clinical pharmacy services for older people in inpatient, residential care and ambulatory settings. 47
Clinical benefits include: prevention, identification and resolution of adverse drug reactions and 48
other medication-related problems, improved quality of prescribing, enhanced continuity of 49
medication management during care transitions and better medication adherence (5-20). In some 50
patient groups, pharmacist review may reduce unplanned hospitalisations (20). 51
Geriatric medicine pharmacists require specialised knowledge and expertise to contribute effectively 52
to the care of older people because medication management for older patients differs significantly 53
from that of younger adults (Table 1). Geriatric syndromes, many of which may be caused or 54
worsened by medicines or may impact on the older person’s ability to manage their medicines, 55
further complicate medication management. Syndromes that are common in older people include: 56
cognitive impairment (delirium and dementia), incontinence, immobility, falls, frailty, functional 57
impairment and iatrogenic disease. These often have multifactorial aetiologies (including medication 58
reactions) and have a major impact on older peoples’ quality of life. 59
Table 1 How medication management for older people differs from younger adults. 60
• Higher prevalence of multimorbidity and polypharmacy.
• Altered and variable pharmacokinetics and pharmacodynamics.
• Decreased physiological reserve and resilience.
• Increased susceptibility to drug interactions and ADRs.
• Atypical presentation of illness and ADRs.
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 3
• Limited evidence with respect to effectiveness and safety of medications, especially in
multi-morbid and frail older people (due to their exclusion from most clinical trials).
• Variable goals of care, especially in frail individuals and those with limited remaining life
expectancy (e.g. maintaining function and quality of life and avoiding ADRs may be
prioritised over aggressive disease management and achievement of stringent treatment
targets).
• Higher prevalence of impaired functional capacity and cognitive decline, impacting on
patients’ ability to manage complex medication regimens.
• More complex care transitions as a result of polypharmacy, multiple medication changes,
use of pharmacy-packed dose administration aids (DAAs), and transfer to settings in which
medication charts or orders are needed to enable ongoing medication administration (e.g.
residential aged care, community nursing care).
ADR = adverse drug reaction 61
62
Objectives of the Service 63
The objective of a geriatric medicine pharmacy service is to provide patient-centred care to optimise 64
medication-related outcomes for older people. 65
The pharmacist should work with other members of the multidisciplinary team to ensure that drug 66
therapy for the older person is rational, safe, cost-effective and acceptable to the patient. They 67
should focus on preventing and detecting ADRs, including atypical ADRs such as those that present 68
as geriatric syndromes. When appropriate, the pharmacist should recommend and assist with 69
deprescribing to reduce unnecessary or inappropriate polypharmacy. They should assess patients’ 70
capacity to safely manage and adhere to their medication regimen, and implement strategies to 71
assist patients and carers with this task. Patient and carer education and ensuring continuity of 72
medication management during care transitions are core objectives. 73
74
Scope 75
These standards describe activities consistent with best practice for the provision of clinical 76
pharmacy services for older patients receiving geriatric care or aged care in any setting, including 77
hospitals, residential care facilities, transition care services and in the community. 78
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 4
The scope of services provided by geriatric medicine pharmacists will be dependent on the setting, 79
funding models, the priorities of the organisation and the scope of practice of the individual 80
pharmacist. 81
As well as providing clinical pharmacy services for individual patients, the geriatric medicine 82
pharmacist should be a point of contact for geriatric medicine pharmacy related enquiries from 83
other pharmacists and health professionals within the health or aged care service. The role of the 84
pharmacist in geriatric medicine should also include involvement in development of policies, 85
procedures, guidelines and resources, comment on medicine formulary issues, provision of 86
educational programs and training for pharmacy students, intern pharmacists, postgraduate 87
pharmacists, pharmacy technicians and other healthcare professionals, as well as quality 88
improvement activities and research related to geriatric medication management. 89
90
Operation 91
Access to clinical pharmacy services 92
Older patients in all healthcare settings should have access to a clinical pharmacy service. 93
In hospital inpatient settings, best practice is to provide a comprehensive geriatric medicine 94
pharmacy service in accordance with these standards 7 days a week (1). If a geriatric medicine 95
pharmacy service is not available on weekends and public holidays, the pharmacy department 96
should provide a general clinical pharmacy service on those days to ensure that newly admitted 97
patients are reviewed and discharging patients are reviewed and receive discharge medication 98
counselling and clinical handover (1). 99
For residential and community aged care, a less intensive clinical pharmacy service would be 100
appropriate. 101
Identifying patients who require clinical pharmacist review 102
If a geriatric medicine pharmacy service cannot review all patients, it should target people at 103
greatest risk of adverse medication events. The broad criteria used to determine eligibility for 104
pharmacist services such as Home Medicines Reviews (21) do not effectively identify those at 105
greatest risk (22). The SHPA has developed criteria that may identify at-risk patients more effectively 106
(23). 107
Transitions between care settings and changes to an older person’s care needs are associated with 108
increased risk of adverse medication events and indicate the need for a clinical pharmacist review 109
(Table 2). 110
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 5
Table 2 Examples of transitions that indicate need for clinical pharmacist review of an older person 111
• Admission to hospital
• Discharge from hospital
• Discharge from a Transition Care Program
• Admission to a residential aged care facility (RACF)
• Referral to an Aged Care Assessment Team (ACAT)
• Referral to a home nursing service for medication management
• Admission to a home care package (Australian Government-funded aged care at home)
• Admission to a palliative care service
112
Policies and Procedures 113
Geriatric medicine pharmacists must have knowledge of the following: 114
• Australian Charter of Healthcare Rights (24). 115
• Pharmacy Board of Australia Code of Conduct (25). 116
• National Competency Standards Framework for Pharmacists in Australia (2). 117
• Professional Practice Standards (26). 118
• Legislation, specifically State and Territory Acts and Regulations. 119
These documents provide a framework within which the pharmacist must practice. 120
Guidelines of relevance to geriatric medicine pharmacists are listed in Appendix 1. Resources. 121
Components of a geriatric medicine clinical pharmacy service 122
A summary of the components of a geriatric medicine pharmacy service in different practice settings 123
is provided in Table 3. 124
The range of services provided by a geriatric medicine pharmacist are generally similar to those 125
provided for other patient populations, however the focus or prioritisation of the service may differ. 126
This section of the standards does not describe all clinical pharmacy procedures that form a geriatric 127
medicine pharmacy service. Its purpose is to highlight key differences and procedures as they relate 128
to older patients. 129
Medication history and reconciliation 130
Medication reconciliation is especially important for older patients due to the high prevalence of 131
multimorbidity and polypharmacy, interaction with multiple health services and prescribers, and 132
factors that make history-taking more challenging, such as cognitive impairment and poor health 133
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 6
literacy. Greater time and effort may be required to obtain the best possible medication history in 134
this population. 135
Medication reconciliation should be undertaken on every: 136
• presentation or admission to a health or aged care service (including hospitals, clinics, and 137
residential and community aged care services); 138
• transfer between wards and care settings within an organisation; 139
• transfer between community-based providers (1, 12, 27). 140
Medication reconciliation should also occur whenever handwritten medication charts are re-written 141
and when there are significant changes to a person’s medication regimen (e.g. following a 142
medication review, to ensure that intended medication changes are correctly implemented. 143
Medication review 144
Medication review, referred to as ‘assessment of current medication management’ in the Standard 145
of Practice for Clinical Pharmacy Services (1), is a vital component of health care for older people, 146
especially those who use multiple medications (27-31). 147
An interdisciplinary approach to medication review is recommended, involving the pharmacist, 148
medical practitioner(s) and aged care or community nurse (27, 29, 30). The patient’s views, concerns 149
and wishes should be central to the review. For patients who are unable to participate in the review, 150
for example due to severe cognitive impairment, their advance care plans should be considered, if 151
available, and their carer or substitute decision-maker (e.g. medical power of attorney) should be 152
involved. 153
For hospital inpatients, medication reviews should occur on admission, during the hospital stay and 154
prior to discharge (1, 32, 33). Medication review on admission should focus on identifying 155
medications and un-treated or under-treated medical problems that may have contributed to the 156
person’s presenting complaints. Subsequent medication reviews provide an opportunity to reassess 157
the benefits and risks of pre-admission medications, ensure appropriateness of new medications, 158
deprescribe unnecessary or inappropriate medications and simplify the discharge medication 159
regimen (34, 35). Medication review is also recommended for older surgical patients as part of pre-160
operative and post-operative assessments (36, 37). 161
In community and residential aged care settings it is recommended that a comprehensive, 162
interdisciplinary medication review occur at least once every 12 months (27, 28, 38). People moving 163
into a RACF should have a comprehensive medication review 4 to 6 weeks after admission. This 164
timing allows the person to adjust to their new environment, with potentially improved nutrition, 165
hydration and medication adherence. It is also an ideal time to reassess the benefits and risks of 166
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 7
long-term medications and develop and implement a deprescribing plan if necessary. Additional 167
reviews should occur when there is a significant change to the patient’s health or medication 168
regimen, and within 5-10 days of discharge from hospital (27, 29, 30, 38). 169
Referral to an aged care assessment team (ACAT) or home nursing service should trigger a 170
medication review since these events indicate a decline in functional capacity which may be related 171
to medications or may impact on the older person’s ability to manage medications (16, 39). 172
173
Whenever possible, medication reviews (in all settings) should include face-to-face discussion 174
between the pharmacist and prescriber(s) to enable efficient and effective communication and 175
decision-making and ensure that potential medication-related problems are addressed. If a face-to-176
face discussion is not possible telehealth is an alternative. Professional practice guidelines and 177
standards for pharmacists relating to the medication review process are listed in Appendix 1. 178
ADR detection and management 179
Iatrogenic disease and prescribing cascades (where a medication is prescribed to manage the 180
adverse effects of another medication) are common in older patients. ADRs may be difficult to 181
detect as a result of atypical presentation (3). 182
ADR should be considered as a potential cause of any new symptom in an older person. Monitoring 183
for ADRs should occur when any new medication is commenced or a dose is increased. Monitoring 184
should also occur following any change to an older person’s medication management that may lead 185
to a sudden increase in medication adherence, such as admission to hospital or a RACF, assistance 186
with medication-taking (e.g. by a home nursing service) or implementation of a DAA. 187
It is also important to monitor for adverse drug withdrawal events when long-term medications are 188
stopped or deprescribed. Adverse drug withdrawal events include recurrence of the original 189
symptom, withdrawal symptoms, or rebound phenomenon (40). 190
Monitoring for ADRs and adverse drug withdrawal events is a shared responsibility involving the 191
prescriber, pharmacist, nurse, and the patient and their carer. 192
Deprescribing 193
Deprescribing attempts to balance the potential for benefit and harm by systematically withdrawing 194
unnecessary or inappropriate medications, with the goal of managing polypharmacy and improving 195
outcomes (40). Deprescribing has become a major focus of geriatric medicine and pharmacy 196
practice, and is especially important for older people with limited remaining life expectancy (41). 197
Since people in their last year of life present to hospital on average two to four times, admission to 198
hospital may be a trigger to discuss end of life care and consider deprescribing in people who are 199
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 8
clearly declining in health (41). Deprescribing should also be considered following admission to a 200
RACF, where the average remaining life expectancy is around two years. 201
Other triggers to consider deprescribing include ADR, high treatment burden, or a decline in 202
functional capacity (which may be indicated by referral to an ACAT, home nursing service or home 203
care package). 204
The rationale for deprescribing decisions should be documented in the patient’s medical record and 205
communicated in clinical handover, including criteria for reintroduction of the medication (40). A 206
plan for follow-up of outcomes is also important. These steps reduce the risk of ADWEs, and allows 207
for the prompt re-introduction of the medication if indicated. 208
Deprescribing decisions should occur as part of a comprehensive medication review and in 209
consultation with the patient and/or their carer or substitute decision-maker. Protocols, algorithms 210
and guidelines for deprescribing are available (42). 211
Regimen simplification 212
Simplification of medication regimens can improve adherence and reduce treatment burden for 213
patients and carers. Simplification may involve medication withdrawal or changes to dose-forms, 214
dose-times and dose-frequencies (34). Regimen simplification should form part of all comprehensive 215
medication reviews for older people. The impact on regimen complexity should also be considered 216
at the time of prescribing, reviewing or dispensing a new medication, because sometimes an 217
alternative medication, dose-form or dose-regimen may be available that will have less impact on 218
the complexity of the patient’s medication regimen. 219
Assessment of patient’s ability to manage medicines 220
Older patients are more likely to have barriers to accurate and safe medication management than 221
younger patients. Barriers include: polypharmacy, cognitive or sensory impairment, reduced manual 222
dexterity and poor health literacy. Assessment of a patient’s (or carer’s) ability to manage and 223
adhere to their medication regimen helps to determine whether a patient needs assistance or 224
medication aids such as medication reminders or a dose administration aid (DAA). 225
Examples of situations where an assessment of a patent’s ability to manage medicines should be 226
considered include: when there has been a change in the patients’ functional capacity (e.g. following 227
an acute event such as stroke or delirium), when there are changes to the patient’s medication 228
regimen (especially changes that increase regimen complexity or introduce new dose-forms), or 229
when there are concerns about the patient’s capacity to safely manage their medicines. In 230
residential care, when a resident wants to self-administer medicines an assessment of their capacity 231
must be conducted (27, 30). 232
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 9
Various performance-based instruments exist to assess a patient’s capacity to manage their 233
medications (43, 44). Content of tools is variable, but most include ability to read and explain a 234
dispensing label, open packaging and remove a dose, orientation to time and memory recall (43). 235
Some tools use the patient’s own medication for the assessment, whereas other use a mock 236
medication regimen. The former may be best suited to settings in which the patient’s own 237
medications are available, such as in the patent’s home. The latter may be more feasible in the 238
hospital setting (44). Supervised self-administration of medicines (see next section) can also be used 239
to assess a patients’ ability to manage medicines. 240
An assessment of medication management ability should be performed before implementing a DAA 241
such as a Dosett box, blister pack (e.g. Webster Pak) or sachet system (18). DAAs are not suitable for 242
all patients (6, 18). Sometimes simpler, less costly alternatives may be suitable, such as regimen 243
simplification and use of reminder charts or alarms. Approaches to assessing patients’ suitability for 244
DAAs have been published (6, 18). 245
Self-administration of medicines programs (SAMP) 246
Self-administration of medicines programs (SAMP) are used mainly in sub-acute hospital units and 247
residential care facilities to assess patients’ ability to safely manage their medications, encourage 248
patient participation in their care, provide education and training in medication-taking and identify 249
supports required for ongoing medication management (45, 46). Patients who complete a SAMP 250
may demonstrate better drug knowledge, better adherence and fewer medication errors (47). 251
In hospitals, a SAMP should be considered for patients who plan to self-administer their medicines 252
after discharge and have had significant changes to their medication regimen and/or changes in their 253
functional capacity. In residential care, a SAMP should be conducted when a resident wants to self-254
administer their medicines. SAMP could also be considered in other settings such as people living at 255
home with an aged care package or community nursing support. 256
A SAMP commences with an assessment to determine suitability of the patient for the program, 257
format of medicine supply and to obtain patient consent. Medicines are dispensed with full 258
directions, in the format that the patient will use (original packs or DAA). The patient then 259
administers their medicines with direct nurse supervision. If the patient demonstrates correct 260
administration over several days the program may allow for greater patient independence with 261
regular monitoring. 262
Patients suitable for SAMP are medically stable with a consistent medication profile. Geriatric 263
medicine pharmacists are involved in identifying suitable patients, patient assessment, organising 264
the supply of medicines in the required format, providing education and monitoring outcomes. 265
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 10
Facilitating continuity of medication management on transition between care settings 266
Geriatric medicine pharmacists should provide medicines information to patients, carers and health 267
professionals during transitions of care, ensure ongoing access to medicines, and ensure that 268
medications are able to be safely and accurately administered after a transition of care (1, 32). 269
All older patients who use multiple medicines should be provided with a patient-held medication list 270
(in addition to verbal instructions) (29, 48). At transitions of care the medication list should also 271
include information about medicines that have been recently discontinued. As noted above, 272
patients’ ability to manage their medicines should be assessed, and appropriate medication 273
management strategies and supports implemented. 274
If RACF staff or community nurses will be supporting the patient, they usually require medication 275
administration orders. It is recommended that hospitals provide an interim medication 276
administration chart for all patients discharged to RACFs to avoid medication administration delays 277
and errors upon arrival at the RACF (30). These can be prepared by a pharmacist or hospital medical 278
officer (30). A copy of the interim chart should be provided to the patient’s community pharmacy. 279
When a community pharmacy-packed DAA is used upon discharge from hospital, the packing 280
pharmacy must be provided with information to enable timely and accurate DAA preparation. 281
Provision of discharge medication information to community pharmacists is also important for non-282
DAA users who have had significant changes to their medication regimen in hospital. 283
Patient and carer education 284
Medication information and education should be provided to all older patients, including those using 285
a DAA and patients living in residential care facilities, even if they are not self-administering their 286
medicines. It should include both verbal and written information. For some patients with cognitive 287
impairment or poor literacy, Consumer Medicines Information may be too complex and simpler 288
written materials should be offered. Pharmacists should ensure language used is simple and clear 289
and avoids unnecessary medical terminology. Physical impairments including visual and auditory 290
changes may impair an older person’s ability to receive the message being delivered. Use of 291
appropriate light, colour, font and a lower pitch voice and checking for hearing aids are important 292
when delivering medication information. Speaking slowly, breaking downs tasks and demonstration 293
is necessary in those with cognitive impairment (49). For patients on multiple medications a 294
medication list should be provided, and the patient should be encouraged to keep this up to date. 295
It is recommended that education for inpatients is provided throughout the admission, because 296
delivering a large volume of information at the point of discharge may be overwhelming and 297
ineffective. 298
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 11
Older persons may have third parties managing their medicines (e.g. carer or nurse). Whilst these 299
parties may require medication education, it is important to still involve the patient unless they are 300
unable or have indicated that they do not want to receive education. 301
Interdisciplinary teamwork 302
Interdisciplinary teamwork is at the core of evidence-based models of geriatric medicine. 303
Participation in interdisciplinary activities is an effective avenue for pharmacists to build rapport 304
with other clinicians (e.g. medical practitioners, nurses and allied health including occupational 305
therapists, speech pathologists and dieticians) and contribute to patient care. 306
Geriatric medicine pharmacists should routinely participate in interdisciplinary ward rounds and 307
other forums at which decisions about medication management are made, such as team meetings 308
and case conferences. The geriatric medicine pharmacist’s contributions to team discussions should 309
include providing information about current and recent medication use and medication changes, 310
ADR identification, advice about appropriate medication selection, deprescribing and discharge 311
planning. 312
Geriatric medicine pharmacists must be proactive participants in discussions about hospital 313
discharge planning, to ensure that medication management issues are considered and addressed 314
before decisions are made about the discharge destination and support services. 315
Quality use of medicines activities 316
Geriatric medicine pharmacists should lead or contribute to quality use of medicines (QUM) 317
activities, to optimise medication management and patients’ health outcomes in all health and aged 318
care settings. 319
QUM activities can take many forms including (21): 320
• educational activities for health professionals, carers and patients/residents; 321
• continuous quality improvement activities such drug use evaluations; 322
• participation in Medication Advisory Committees; 323
• development of medicine-related policies and procedures; 324
• assisting the organisation to meet and maintain medication management accreditation 325
standards. 326
Recommended Staffing 327
The level of geriatric medicine pharmacy service should be agreed with the health or aged care 328
service provider and the healthcare team, and resourced appropriately to enable delivery of the 329
agreed service. The ideal geriatric medicine clinical pharmacy service and associated pharmacist 330
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 12
staffing ratios for different aged care settings are described in Table 3. These recommendations are 331
based on published evidence (50, 51) consensus guidelines (1, 27-30, 32, 52, 53), and consultation 332
experienced geriatric medicine pharmacists and geriatricians. They assume the pharmacist will be 333
primarily providing clinical services and will have limited or no direct involvement in medication 334
supply functions. 335
Many factors influence the ability of geriatric medicine pharmacists to deliver the clinical services 336
recommended in these standards, such as funding, staffing levels, extent of integration of 337
pharmacists into the multidisciplinary team, education and training of the pharmacist and availability 338
of support staff (e.g. pharmacy technicians, dispensary pharmacists, quality use of medicines 339
pharmacists). In residential and community aged care settings, the size of the service, travel 340
distances required to provide the service and the number and location of medical practitioners will 341
impact on efficiency of the clinical pharmacy service and staffing levels required. 342
Where possible, pharmacy technicians should be employed to support the geriatric medicine clinical 343
pharmacist, because this has been shown to increase the number of patients able to be reviewed by 344
the pharmacist and improve timeliness of review (51). Tasks that can be undertaken by pharmacy 345
technicians are described elsewhere (1).346
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 13
Table 3 Recommended clinical pharmacy services and pharmacist:bed ratios for aged care services 347
Type of care
Acute aged care* Subacute inpatient aged
care
Residential aged care Community aged care^
Average LOS 7-10 days 14-28 days 24 months (8 weeks for
residential Transition Care
Program [TCP] clients)
Variable
Optimal pharmacist:bed ratio 1:20 1:30 1:200 (1:40 for residential
TCP)&&
See footnote%
Optimal clinical pharmacy service
• Medication history and
reconciliation on admission
Yes, within 24 hours Yes, within 24 Yes, within 72 hours** Yes, within 72 hours**
• Medication chart review and
clinical review
Yes, daily Yes, at least 2nd-daily Yes, at least monthly. Yes, at least monthly
• Reconciliation of new dose
administration aid (DAA) packs
with medication orders/charts
when packs are supplied.
DAAs not routinely used
in acute aged care
Yes, if patient is
participating in a self-
administration of
medications program using
DAAs
Yes$ Yes$
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 14
Type of care
Acute aged care* Subacute inpatient aged
care
Residential aged care Community aged care^
• Comprehensive interdisciplinary
medication review
Yes, within 3 days of
admission
Yes, within 7 days of
admission
Yes, within 4-6 weeks of
admission and repeated at
intervals determined by
clinical need (not less than
yearly, and within 5-10
days of returning from an
unplanned hospital
admission)
Yes, within 4-6 weeks of
admission and repeated at
intervals determined by
clinical need (not less than
yearly, and within 5-10
days of returning from an
unplanned hospital
admission)
• Monitoring and review of
deprescribing plan and
outcomes, following a
comprehensive medication
review.
Yes, at least weekly (with
plan for ongoing
monitoring provided in
discharge summary)
Yes, at least weekly (with
plan for ongoing
monitoring provided in
discharge summary)
Yes, at least 4 weekly Yes, at least 4 weekly
• Multidisciplinary ward round
participation
Yes, at least twice-weekly Yes, at least once-weekly Yes (if available) Yes (if available)
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 15
Type of care
Acute aged care* Subacute inpatient aged
care
Residential aged care Community aged care^
• Multidisciplinary team meeting /
case conference participation
Yes, weekly Yes, weekly Yes (if available) Yes (if available)
• Provision of information and
advice to prescribers, nurses and
carers
Yes Yes Yes Yes
• Provision of information to
patients and/or carers about
medication changes
Yes Yes Yes$ Yes$
• Assessment of patients’ ability to
self-administer medications
Yes, if discharge plan is for
patient to manage own
medicines
Yes, if discharge plan is for
patient to manage own
medicines
Yes, if patient wishes to
self-administer medicines
Yes, if patient wishes to
self-administer medicines.
• Self-administration of medicines
program^^
Not routinely used in
acute aged care
Yes, if plan is to manage
own medicines after
discharge
Yes, if patient wishes to
self-administer medicines
Yes, if patient wishes to
self-administer medicines
• Development of a plan for
medication management after
discharge
Yes Yes Yes (residential TCP) Yes
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 16
Type of care
Acute aged care* Subacute inpatient aged
care
Residential aged care Community aged care^
• Discharge prescription review
and reconciliation
Yes Yes Yes NA
• Preparation and delivery of
discharge medication
information for patient/carer#
Yes Yes Yes NA
• Preparation and delivery of
medication information for
clinical handover (to
community pharmacy, GP,
community nurse, RACF and/or
hospital as applicable)@
Yes Yes Yes Yes
• Referral to post-discharge
medication review service if
patient meets eligibility and risk
criteria&
Yes Yes Yes Yes
• Medication reconciliation after
any care transition (e.g. transfer
Yes Yes Yes$ Yes$
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 17
Type of care
Acute aged care* Subacute inpatient aged
care
Residential aged care Community aged care^
between units, after hospital
discharge)
• Participation in medication
management committees
Yes Yes Yes Yes
• Quality Use of Medicines
activities (e.g. audits, staff
education)
Yes Yes Yes Yes
• Contributing to Medication
policy and procedure
development
Yes Yes Yes Yes
* Acute aged care: Acute medical units for the aged and other acute units with a focus on older people (e.g. orthogeriatric units) 348
^ Community aged care: Formal care provided to the older person in their own home, such as Home Care Packages, community-based Transition Care Programme and 349
home nursing services. 350
&& Pharmacist to bed ratio in RACFs assumes the clinical pharmacist is not involved in reconciliation of new DAA packs with RACF medication administration charts or 351
provision of counselling/education to the patient or substitute decision-maker each time a new medication is dispensed (because these services are the responsibility of 352
the dispensing pharmacy service). If these roles are included, increased pharmacist resource would be needed. The pharmacist resource required will also be affected by 353
the size of the facility, number of medical practitioners, and the model of care (e.g. fewer medical practitioners who attend regularly for ‘ward rounds’ would increase 354
efficiency of the clinical pharmacy service) 355
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% The ratio of pharmacists to patients is variable as a result of variable length of stay within community aged care services and variable travel distances (e.g. metropolitan 356
versus rural). On average, a community-based clinical pharmacist can perform a comprehensive medication review for 2 to 3 patients/day depending on patient complexity 357
and travel distance 358
** If possible, the medication history should be obtained prior to admission (at the patient’s home) as this results in a more accurate history and will reduce the risk of 359
medication charting errors on admission. Reconciliation of the medication chart with the medication history should then occur as soon as possible after admission. 360
$ May be provided by the supplying pharmacy 361
^^ It is usually not feasible for all patients to participate in self-administration of medications program. Patients at highest risk of medication errors should be identified and 362
targeted. 363
# Verbal information, patient medication list (including all current medicines and medicines ceased in hospital) and consumer medicines information if applicable 364
@ Includes contributing medication information to the medical discharge summary, communicating medication changes to the patient’s community pharmacy and/or 365
preparation of an interim residential care medication administration chart. 366
& For example, hospital outreach medication review, HMR or RMMR service, to review medication management and outcomes of medication changes in consultation with 367
GP within 5-10 days of discharge 368
369
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Training and Education (for the service, and of the individual) 370
Training for geriatric medicine pharmacists should be provided by the organisation to improve the 371
pharmacists’ ability to care for older people, and pharmacists should also seek relevant external 372
professional development opportunities. 373
Education, training and professional development can be sourced from professional bodies such as: 374
• SHPA 375
• American Society of Consultant Pharmacy 376
• American Society of Health-System Pharmacists 377
• Universities, e.g. Monash University Geriatric pharmacy practice and Geriatric disease state 378
management postgraduate units 379
Educational material and resource and links to professional development opportunities are provided 380
on the SHPA Specialty Practice Geriatric Medicine stream page on the SHPA eCPD website. For 381
geriatric medicine pharmacists, joining and actively participating in the Geriatric Medicine Stream at 382
the Practice Group level is strongly recommended. 383
Attendance at specialist conferences and educational meetings is encouraged to maintain and 384
update specialist knowledge in geriatric medicine. Relevant domestic conferences include those 385
organised by SHPA, The Australian and New Zealand Society for Geriatric Medicine and The 386
Australasian Association of Gerontology. International conferences in geriatric medicine include 387
those organised by the International Association of Gerontology and Geriatrics, the British Geriatrics 388
Society and the American Geriatrics Society. 389
Credentialing 390
Pharmacists can obtain credentialing in geriatric medicine pharmacy practice by passing the Board of 391
Pharmacy Specialities Geriatric Pharmacy examination. This credential also enables pharmacists to 392
gain accreditation by the SHPA as a provider of Home Medicines Reviews (HMR) and Residential 393
Medication Management Reviews (RMMR). The Australian Association of Consultant Pharmacy 394
(AACP) can also accredit pharmacists to provide HMRs and RMMRs. 395
396
Quality Improvement 397
In addition to quality measures outlined in Chapter 14 of the SHPA Standards of Practice for Clinical 398
Pharmacy Services (1), a geriatric medicine pharmacy quality improvement program should 399
demonstrate that the service is targeting and delivering high quality care for patient groups at 400
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greatest risk for medicine misadventure. The geriatric medicine pharmacist should ensure that the 401
focus is not only on the timeliness of care, but also on the quality of care in line with national or 402
state based indicators. Many of the indicators under discussion nationally and internationally have a 403
medication-related element. 404
Indicators relevant to geriatric medicine pharmacy services include: 405
Australian National QUM indicators e.g. 406
• 3.1 Percentage of patients whose current medicines are documented and reconciled at 407
admission 408
• 5.5 Percentage of patients with a new adverse drug reaction (ADR) that are given written 409
ADR information at discharge AND a copy is communicated to the primary care clinician 410
• 5.9 Percentage of patients who receive a current, accurate and comprehensive medication 411
list at the time of hospital discharge 412
• 6.2 Percentage of patients that are reviewed by a clinical pharmacist within one day of 413
admission (to hospital) 414
ACOVE 3 quality indicators (Assessing the care of vulnerable elders, RAND Corp, USA) e.g. 415
• ALL vulnerable elders should have an annual drug regimen review 416
• IF a vulnerable elder is prescribed a drug, THEN the prescribed drug should have a clearly 417
defined indication 418
• IF a vulnerable elder is prescribed an ongoing medication for a chronic medical condition, 419
THEN there should be documentation of response to therapy 420
Standard 14 (Medication Review) of the Pharmaceutical Society of Australia’s Professional Practice 421
Standards may be used to assess the quality of pharmacist medication review services.(26) 422
There are also numerous sets of indicators of appropriate prescribing for older people that could 423
potentially be used as a measure of the quality of care provided to geriatric medicine patients 424
(Appendix 1). 425
426
Research 427
Further information on research can be found in Chapter 11 of the SHPA Standards of Practice for 428
Clinical Pharmacy Services (1). 429
Geriatric pharmacists should contribute to the generation of new knowledge and evidence related to 430
medication management for older people. This may include investigating problems with medication 431
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use and evidence-practice gaps, developing and testing new approaches to improve medication use 432
or delivery of pharmacy services, and evaluating novel treatments. Research Ethics Committee 433
approval should be sought where applicable. It is advisable to establish an interdisciplinary research 434
team, including consumer representation, to ensure the research is relevant to key stakeholders. 435
Where applicable, core outcome sets for trials aimed at improving medication use in older people 436
should be used (54-57). 437
Presentation and publication of research is important to support the development of geriatric 438
medicine pharmacy practice and drive improvements in medication use and safety. Studies should 439
be designed and conducted with this in mind, to ensure the findings are publishable. 440
External funding enables larger and more complex studies to be conducted. The SHPA National 441
Translational Research Collaborative (NTRC) funds research grants, practitioner grants and 442
educational grants. Grants may also be available from other organisations such as the Australian 443
Association of Gerontology and various charitable trusts with an interest in aged care. 444
Acknowledgements 445
This Standard of Practice has been produced with expert consensus from the Geriatric Medicine 446
Practice Standards Working Group: Rohan Elliott (Chair), Alex (Ho Yin) Chan, Gauri Godbole, Ivanka 447
Hendrix, Lisa Pont, Dana Sfetcopoulos, John Woodward, with support from Courtney Munro, Lead 448
Pharmacist Specialty Practice, SHPA. 449
The SHPA additionally wish to acknowledge the substantive work of Rohan Elliott, Mary Etty-Leal 450
and John Woodward of the former SHPA Committee of Specialty Practice in Geriatric Medicine on a 451
previous draft of this Standard. 452
453
References 454
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6. Elliott RA. Appropriate use of dose administration aids. Australian Prescriber. 2014;37(2):46-468 50. 469
7. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A 470 comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a 471 randomized controlled trial. Arch Intern Med. 2009;169(9):894-900. 472
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10. Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a 480 collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, 481 controlled trial. J Am Geriatr Soc. 2007;55(5):658-65. 482
11. Zermansky A, Petty DR, Raynor DK, Freemantle N, Vail A, CJ. L. Randomised controlled trial of 483 clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in 484 general practice. British Medical Journal. 2001;323(7325):1340-3. 485
12. Hanlon JT, Weinberger M, Samsa GP, Schmader KE, Uttech KM, Lewis IK, et al. A Randomized, 486 Controlled Trial of a Clinical Pharmacist Intervention to Improve Inappropriate Prescribing in 487 Elderly Outpatients With Polypharamcy. The American Journal of Medicine. 1996;100:428-38. 488
13. Lipton HL, Bird JA. The Impact of Clinical Pharmacists' Consultations on Geriatric Patients' 489 Compliance and Medical Care Use: A Randomized Controlled Trial. The Gerontologist. 490 1994;34(3):307-15. 491
14. Roberts M. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 492 52 nursing homes. Br J Clin Pharmacol. 2000;51:257-65. 493
15. Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric 494 medication advisory service in residential aged care: a randomised controlled trial of case 495 conferencing. Age Ageing. 2004;33(6):612-7. 496
16. Elliott RA, Martinac G, Campbell S, Thorn J, Woodward MC. Pharmacist-led medication review 497 to identify medication-related problems in older people referred to an Aged Care Assessment 498 Team: a randomized comparative study. Drugs Aging. 2012;29(7):593-605. 499
17. O'Sullivan D, O'Mahony D, O'Connor MN, Gallagher P, Gallagher J, Cullinan S, et al. Prevention 500 of Adverse Drug Reactions in Hospitalised Older Patients Using a Software-Supported 501 Structured Pharmacist Intervention: A Cluster Randomised Controlled Trial. Drugs Aging. 502 2016;33(1):63-73. 503
18. Etty-Leal MG. The role of dose administration aids in medication management for older 504 people. Journal of Pharmacy Practice and Research. 2017;47(3):241-7. 505
19. Elliott RA, Tran T, Taylor SE, Harvey PA, Belfrage MK, Jennings RJ, et al. Impact of a pharmacist-506 prepared interim residential care medication administration chart on gaps in continuity of 507 medication management after discharge from hospital to residential care: a prospective pre- 508 and post-intervention study (MedGap Study). BMJ Open. 2012;2(3):8. 509
20. Jokanovic N, Tan EC, van den Bosch D, Kirkpatrick CM, Dooley MJ, Bell JS. Clinical medication 510 review in Australia: A systematic review. Res Social Adm Pharm. 2016;12(3):384-418. 511
21. Pharmaceutical Society of Australia. Guidelines for pharmacists providing Residential 512 Medication Management Review (RMMR) and Quality Use of Medicines (QUM) services. 513 Pharmaceutical Society of Australia Ltd.; 2011. 514
22. Elliott RA, Lee CY. Poor uptake of interdisciplinary medicine reviews for older people is a 515 barrier to deprescribing. BMJ. 2016;353:i3496. 516
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23. The Society of Hospital Pharmacists Australia (SHPA). SHPA Fact Sheet: Risk factors for 517 medication-related problems Fact sheets & position statements: SHPA; 2015 [Available from: 518 https://www.shpa.org.au/fact-sheets-position-statements. 519
24. Australian Charter of Healthcare Rights [press release]. 2008. 520 25. Pharmacy Board of Australia. For Pharmacists Code of Conduct. March 2014 ed2014. 521 26. Pharmaceutical Society of Australia. Professional Practice Standards Version 5. Deakin West 522
ACT 2600.2017. p. 116. 523 27. National Institute for Health and Care Excellence (NICE). Managing medicines in care homes. 524
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Am Geriatr Soc. 2007;55 Suppl 2:S373-82. 527 29. Australian Pharmaceutical Advisory Council. Guiding principles for medication management in 528
the community. Canberra: Commonwealth of Australia; 2006. 529 30. Department of Health and Ageing. Guiding principles for medication management in 530
residential aged care facilities. Canberra: Commonwealth of Australia; 2012. 531 31. Hilmer SN, editor Outcome Statement: National Stakeholders’ Meeting on Quality Use of 532
Medicines to Optimise Ageing in Older Australians. National Stakeholders’ Meeting: Quality 533 Use of Medicines to Optimise Ageing in Older Australians; 2015 03/08/2015. 534
32. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in 535 medication management. Canberra: Commonwealth of Australia; 2005. 536
33. Australian Commission on Safety and Quality in Health Care, NSW Therapeutic Advisory Group 537 Inc. National Quality Use of Medicines Indicators for Australian Hospitals. Sydney; 2014. 538
34. Elliott RA. Reducing medication regimen complexity for older patients prior to discharge from 539 hospital: feasibility and barriers. J Clin Pharm Ther. 2012;37(6):637-42. 540
35. McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised 541 older patients receiving multiple medications. Intern Med J. 2016;46(1):35-42. 542
36. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), 543 American Geriatrics Society (AGS). ACS NSQIP® /AGS BEST PRACTICE GUIDELINES: Optimal 544 Preoperative Assessment of the Geriatric Surgical Patient. 2012. 545
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38. Royal Pharmaceutical Society (RPS). The Right Medicine: Improving Care in Care Homes. 2016. 549 39. Elliott RA, Lee CY, Beanland C, Vakil K, Goeman D. Medicines Management, Medication Errors 550
and Adverse Medication Events in Older People Referred to a Community Nursing Service: A 551 Retrospective Observational Study. Drugs Real World Outcomes. 2016;3(1):13-24. 552
40. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 553 2016;91:115-34. 554
41. Hardy JE, Hilmer SN. Deprescribing in the Last Year of Life. Journal of Pharmacy Practice and 555 Research. 2015;41(2):146-51. 556
42. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 557 2016;91:115-34. 558
43. Elliott RA, Marriott JL. Review of Instruments used in Clinical Practice to Assess Patients’ 559 Ability to Manage Medications. Journal of Pharmacy Practice and Research. 2010;40(1):36-41. 560
44. Elliott RA, Marriott JL. Standardised assessment of patients' capacity to manage medications: 561 a systematic review of published instruments. BMC Geriatr. 2009;9:27. 562
45. Tran T, Elliott RA, Taylor SE, Woodward MC. A Self-Administration of Medications Program to 563 Identify and Address Potential Barriers to Adherence in Elderly Patients. The Annals of 564 pharmacotherapy. 2011;45(2):201-6. 565
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47. Richardson SJ, Brooks HL, Bramley G, Coleman JJ. Evaluating the effectiveness of self-568 administration of medication (SAM) schemes in the hospital setting: a systematic review of 569 the literature. PLoS One. 2014;9(12):e113912. 570
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597
598
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Appendices
Appendix 1. Resources for geriatric medicine pharmacy practice
Recommended texts
• Australian Medicines Handbook Aged Care Companion
Discretionary texts
• ABC of Geriatric Medicine. Cooper N, Mulley G, Forrest K, eds. BMJ Books, Blackwell
Publishing Ltd 2009 (basic introductory text)
• Essentials of clinical geriatrics. 7th ed. Kane RL, Ouslander JG, Abrass IB, Resnick B. McGraw-
Hill, 2013 (intermediate text)
• Current diagnosis and treatment: geriatrics. 2nd ed. Williams BA, Chang A, Ahalt C, et al, eds.
McGraw-Hill Lange, 2014 (intermediate text)
• Brocklehurst's textbook of geriatric medicine and gerontology. 8th ed. Fillit HM, Rockwood K,
Young JB, eds. Elsevier Science; ScienceDirect 2016 (comprehensive text)
Guidelines and standards
• Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in
medication management. Canberra: Commonwealth of Australia; 2005
• Australian Pharmaceutical Advisory Council. Guiding principles for medication management in
the community. Canberra: Commonwealth of Australia; 2006
• Department of Health and Ageing. Guiding principles for medication management in
residential aged care facilities. Canberra: Commonwealth of Australia; 2012
• Guidelines for pharmacists providing Residential Medication Management Review (RMMR)
and Quality Use of Medicines (QUM) services. Pharmaceutical Society of Australia 2011.
• Guidelines for pharmacists providing Home Medicines Review (HMR) services. Pharmaceutical
Society of Australia 2011
• Guidelines for pharmacists providing dose administration aids (DAA) services. Pharmaceutical
Society of Australia 2017
• Quality standards and practice principles for senior care pharmacists. American Society of
Consultant Pharmacists 2016
Indicator sets for identifying potentially appropriate prescribing for older people
• Beers criteria 2015
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 26
• STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert
doctors to Right Treatment) criteria
• STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life
expectancy): consensus validation
• Polypharmacy Guidance, Realistic Prescribing. Scottish Government Polypharmacy Model of
Care Group. https://www.therapeutics.scot.nhs.uk/wp-
content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
Geriatric medicine journals
• Age and Ageing
• Australasian Journal on Ageing
• Drugs and Aging
• JAGS: Journal of the American Geriatrics Society
• Geriatric Therapeutics Review section in JPPR
Useful websites
American Geriatrics Society (AGS)
• Guidelines and
recommendations
http://www.americangeriatrics.org
Australian and New Zealand Society for
Geriatric Medicine (ANZSGM)
• Position statements
http://www.anzsgeriatric medicine.org/
British Geriatrics Society (BGS)
• Good practice guides, clinical
guidelines
http://www.bgs.org.uk
Coalition for Quality in Geriatric
Surgery
• Guidelines for pre- and peri-
operative care
https://www.facs.org/quality-programs/geriatric-coalition
American Society of Consultant
Pharmacy (ASCP)
https://www.ascp.com/articles/geriatric-
pharmacotherapy
DRAFT prepared 12.12.2018. Property of The Society of Hospital Pharmacists Australia 27
• Key geriatric pharmacy
references and Geriatric
curriculum guide
The ultimate guide for pharmacists
working in care homes. Royal
Pharmaceutical Society (UK) 2016
https://www.rpharms.com/resources/ultimate-guides-
and-hubs/ultimate-guide-to-working-in-care-homes
Polypharmacy Guidance (NHS
Scotland)
http://www.polypharmacy.scot.nhs.uk/
Deprescribing.org
• Guidelines and algorithms for
deprescribing
https://deprescribing.org/
Geriatric medicine podcasts
MDTea
GeriPal
SHPA Contact Details
Address for Correspondence The Society of Hospital Pharmacists of Australia PO Box 1774
Collingwood, Victoria 3066, Australia. Email: [email protected]