The Role of Pharmacist in: Elderly & their Carers

Shahan Ullah PhD Pharmacy Practice

Department of Pharmacy Quaid-I-Azam University Islamabad

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Introduction to Elderly

Living conditions of Elderly

Introduction to Carers

Problems Associated with Elderly

Main Reasons of Sub-Optimal Outcomes due to Incorrect use of medicines in Elderly

Conclusion and References

Non- Pharmaceutical Approach / Guidance to Geriatrics and Geriatric Carers

Pharmaceutical Approach to elderly and their Carers

Why Elderly approach Pharmacist?

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Britain Friendly Societies Act, “Any

age after 50” [2]

Introduction to Elderly

MYTHS

Incompetent/Incapable of

Making Decisions

Defining elderly

Anthropological Study by WHO

[1]

ChronologyElderly live in

Nursing Homes

All elderly people live in poverty

They are lonely and Unhappy

Old age starts at 65 years & Retirement ENDS your Life

Changes in Social Role

Changes in Capabilities

Africa, 50-65 years

UN agreed cutoff is 60+

years

Change in Work Patterns

Adult status of Children

Menopause

Invalid Status

Senility(Losing of Memory and

“Reason” due to Senescence)

Physical Changes

1. National Council on Aging in 2002 found that 45 % of 65+ years people consider themselves Middle-aged or younger [3]

2. Transition of livelihood for women is 45-55 years and for Men it is 55-75 years [4]

Developed Countries, 65 years

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Siblings

Introduction to carersA family member a friend or a paid helper who regularly looks after a child or a sick, elderly, or disabled

person [5]

Formal CarersInformal Carers

Partners

Children

Spouse

Friends Doctors

Home Carers

Counsellors

Social Workers

Chiropodist

Nurses

Pharmacists

Personal care, Social Support, Domestic Support

Medical Care

House issues, Social Issues, Financial Advice

Bereavement Support

Foot Care

General Health care, Bath, Dress, Incontinence Problems

Medication Management

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Continuing Care Retirement

CommunitiesFor those with Progressive Decline

Health, Provide all the services for a PEACE OF MIND

In Residential Homes

Supported Accommodation, e.g. Warden Controlled Flats

In Hospitals

In Homes of a Relative or Friend

In Nursing Homes

In Own Homes, With or Without a Spouse

Living Conditions of Elderly

Can Cope for themselves, with Occasional Support and Visit from Family members

and friends and formal carers

Death of Life Partner

Loss of Partner, No relative or Friend“Someone is there to look out for them”

All professional Services provided by licensed and skilled Nurses

All the Medical services within Hospital Premises

Independent LivingTransportation, Security,

Recreational activities, But NO HEALTH services

Assisted LivingBasic Health Services, Recreational and Social Activities BUT NO Skilled

Nursing,

Skilled Nursing Homes24/7 Care by licensed Professionals,

Housekeeping, Medical & Social Needs

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Vs Custodial CareSkilled Care

Types of Senior Care Terms used and Comparison [6]

Vs Hospice CarePalliative Care

Vs Home Health CareHome Care

Vs Adult Day Health Care

Adult Day Social Care

Virtual Companion Care

Vs Private Care Management

Public Care Management

services that can be given only by skilled or licensed medical

personnel

helps with activities of daily living (ADLs), such as bathing, dressing

and eatinge.g for Alzheimer’s diseased ones

Relieve Patients from Pain and Suffering

Unlike Medical care Which Cures the Underlying disorder

Treat terminally ill patients

Daily life services and Errands

Needs medical trainingChecking patient vitals,

respiration, braces and artificial limbs assistance etc

Provides seniors with supervision and care in a structured setting

during daytime hours

Services in Adult Day School with Medical Services

BENEFITS COUNSELLORSProvide Long term Care Management

Plans,They saves time and Money as they

provide just services which are needed at that time

CARE MANAGERSProvide Long term Care Management

PlansThey saves time and Money as they

provide JUST THOSE services which are needed at that time

Tablet computers are provided:1. Monitor Safety and MOOD2. Medication reminders are provided 3. Interaction with others from Home; Remove the feeling of Loneliness and Isolation 4. Reduce the cost

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Response to Medicaments

PolypharmacyAdherenceNeuronal & Mental ChangesPhysical Changes

Problems Associated With Elderly

Loss of DexterityContainer Closure

Problems

Loss of Visual AcuityProblems reading labels and med instsructions

Loss of HearingProblems with listening

and following instructions

Memory Loss and Cognitive

incapability

Gender

Socio-Economic Status

Living Alone

Multiple Diseases

Complicated Drug Regimens

Susceptibility to CNS Drugs

Impairment in Motor Neurons

Pharmacokinetics

Pharmacodynamics

Impaired Renal Function

Impaired Hepatic Function

Drug-Drug Interactions

Drug-Disease Interactions

Compliance related

Problems

Inappropriate Behaviour

Inappropriate Delivery

Inappropriate Prescribing

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Inappropriate Monitoring

Inappropriate Drug Selection

Main Reasons of Sub-Optimal Outcomes due to Incorrect use of medicines in Elderly [Kevin 2008]

Choice of Unsuitable Drug

Overdosing/ Duplicity of Meds

Failure to document Indication of New

drugs

Failure to keep List of New drugs in PMP

Failure to record response to new drug

Failure to monitor Lab test results

No periodical review of continuous meds

used

Under Dosing

Non Availability

Failure to Administer

Cholinesterase inhibs for Dementia;

Cause DiarrhoeaSo Anticholinergics

COX2 Inhibs in HF, Increase fluid retention

so exacerbate HF

Anti-Coagulants

Opioids

Reduce risk of Strokes in Atrial Fibrillation but there is Risk of

Bleeding So Elderly Don’t take it

Clinicians are hesitant for Cancer patients for fear of dependence.They suffer unnecessary Pain

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To Confirm the info they have received from others, such as neighbours, nurses and doctors

To discuss their concerns about health, finance, family matters and Social issues

To Discuss Therapy and Meds advertised on Social and Broadcasting Media

To gain Health Promotion advice(Diet Control, Smoking cessation)

To Seek advice about Prescribed or Purchased Medications

To Obtain Meds, Ordered on a Prescription

To Purchase Over The Counter (OTC) MedicinesPharmacist

Approached by Patients for

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Approach of Pharmacist

towards Elderly Care

Non-Pharmaceutical

ApproachPharmaceutical

Approach

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Pharmaceutical Approach

General Considerations

Drug Dose Considerations

Affect the Rate of Abs

Affect the Rate of Abs

Reduced Elimination ofrenally excreted meds

Decreased Protein binding

Decreased Vd of Hydrophilic Drugs

Increased Vd of Lipophilic drugs

Prevalence of Multiple Chronic Diseases is MUCH higher in

Elders

Elder Body reacts to Pharmaceuticals Quite

Differently than Young one

Wide Variation in Pharmacological action of

Drugs than in General Population

GI Motility

Gastric PH

Renal Function

Serum Albumin

Total Body Water

Body fat/lean body mass Ratio

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Drug-Drug and Drug-Disease Considerations

Pharmaceutical Approach

Adverse EffectsPotential Drug-Drug InteractionComorbid Disease Pair

NSAIDS↑ Level result in potential Digoxin toxicityNSAIDS + DigoxinArthritis + High Blood

PressureSome NSAIDS may blunt the ACE-Inhibitors antihypertensivenessNSAIDS + ACE InhibitorsArthritis + High Blood

Pressure

Thiazides ↓ Insulin EffectivenessThiazides + InsulinDiabetes + High Blood Pressure

Harmful ↑ in Blood sugar levelCortisone + InsulinArthritis + Diabetes

NSAIDS ↑ anticoagulant effect and may cause GI BleedingNSAIDS + WarfarinArthritis + Heart Disease

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Extended Pharmaceutical Services

[7, 8]

Pharmaceutical Approach

Domiciliary Visits

Repeat Prescribing services

Pharmacy clinics in Non-Pharmacy premises

Pharmacy telephone Helplines

Services to Residential Homes

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Pharmacist Responsibilities in Medical Care of geriatric patients

Design, recommend, monitor and evaluate patient specific pharmacotherapy

Build INFORMATION BASE needed for medication therapy regimen

Design pharmacotherapy regimen

Provide Medication-use advice to geriatrics and their care givers

Consider Non-drug alternatives like exercise, physical therapy and relaxation techniques

Document Pharmaceutical care activities for geriatrics appropriately

Provide concise, applicable and timely responses to requests for Drug Information to geriatric patients

Provide in-service education to physicians, nurses and other participants of G-care

Provide written instructions, information leaflets, special containers and packaging

Assure DOSE ADJUSTMENT is made carefully, Follow “Start Low titrate Slow”

Ensure Continuity of Pharmaceutical care as they move among Alternate care settings

Participate in medical-use evaluation program n the care of geriatric patients

Develop a proposal for a new geriatric pharmacy service

Provide instructions to pharmacy technicians, student and aides

Perform prospective and retrospective financial and clinical outcome analysis

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Non- Pharmaceutical ApproachGuidance to Geriatrics and Geriatric Carers

Respiratory care

Digestive Care

Urinary Care

Endocrine care Reproductive care

Nervous System changes & Care

Renal care

Psycho-Social Care

Circulatory System care

Integumentary Care

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Psycho-Social Care

Fears of Sick Person

Loss of Function

Dementia

Some Individuals Cope with Psychosocial changes, others don’t and experience extreme frustration and mental distress

Pain

Chronic illness

Death

Dealing With Fear by illness

Listening

Patience

Understanding

Provide Support

Loss of Mental Stability

Memory loss

Impaired Judgement

Personality Changes

Disorientation

Dealing with Dementia

Provide Safe & Secure Environment

Follow same routine

Keep activities Simple

Keep the activity for short period of time

Avoid Crowded Rooms

Excessive Commotion

Promote Reality Orientation

Avoid Loud Noises

REALITY ORIENTATION

Avoid: Sweetie, Honey, Baby

State your name correctly if addressed by wrong name

Make reference to day, time, place

Address person by name Preferred

Use Clocks, Calendars, bulletin boards

Keep Individual Orientation to day night Cycles

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Open curtains during the day

Close curtains at night

Pajamas at Night

Regular clothes during the day

Reality Orientation Continued…

Ask clear simple Questions

Never Rush or Hurry the Individual

Repeat instructions patiently, wait for response

Speak Slowly & Clearly

Encourage conversations about familiar things or current events

Encourage use of tv, radio without over- stimulating them

Keep familiar objects in view

Avoid moving belongings & furniture

Do not agree with incorrect statements

Be sure individual uses sensory aids

Avoid Arguments

Encourage independence & self help whenever possible

Do not hesitate to touch or communicate with person

Respect his/her cultural necessities

Respect his/her religious articles

Respect the religious beliefs without bias

Provide privacy during clergy visits

Honour request for special food

Allow him/her to practice religion

Report any abuse observed to proper authority

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Circulatory System care

With Circulatory Changes

Avoid over exertion & strenuous exercise

Periods of Rest

Moderate tolerable exercise

Prevention of Blood clot

Support Stocking, Anti-embolism hose

Avoid Garters or Tight bands around Legs

High Blood Pressure

Diet low in Salt

Decrease Fat intake

Recommendation of appropriate exercise

Respiratory care

Digestive Care

Urinary Care

Endocrine care

Reproductive care

Nervous System changes & Care

Renal care

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SHAH

AN

THAN

KS…

!

HAVE

A N

ICE

DAY…

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References:1. Glascock AP, Feinman SL. A Holocultural analysis of old age. Comparative Social Research.

1980;3:311-322. Roebuck J. When does old age begin?: the evolution of the English definition. Journal of Social

History. 1979;12(3):416-283. National Council on Aging. Survey. 2002: 6. Available at: http://www.ncoa.org4. Thane P. The muddled history of retiring at 60 and 65. New Society. 1978;45(826):234-2365. http://www.oxforddictionaries.com/definition/english/carer6. file:///E:/httpswww.payingforseniorcare.comlongtermcaretypes.html.html7. Schneider, J. and Barber, N. (1996) Provision of a domiciliary service by community

pharmacists. International Journal of Pharmacy Practice, 4, 19–248. Harris, C.M. and Dajda, R. (1996) The scale of repeat prescribing. British Journal of

General Practice, 46, 640–641.

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