Leslie A. Shimp

Recent Advances in Geriatrics: Drug-Related Problems in the Elderly

OBJECTIVE: To review recent articles examining drug-related problems in the elderly and comment on their potential impact on geriatric pharmacy practice. DATA SOURCES: Six articles published in 1997 and 1998. DATA SYNTHESIS: One study estimated that the cost of drug-related morbidity and mortality with the services of consultant pharmacists was

The Effectiveness of Four Education Strategies in the Elderly

4 billion, compared with

Chronic Hemodialysis Patients. Part I: Characterization and Drug-Related Problems

7.6 billion without the services of consultant pharmacists. A study of ambulatory elderly patients with polypharmacy documented that 35% reported experiencing at least one adverse drug event within the previous year. Another study of ambulatory elderly found that in those with discontinued medications, adverse drug withdrawal events were uncommon. Two studies, one from Canada and one from the US, describe the development, by consensus, of explicit criteria for defining and identifying inappropriate drug use in the elderly (i.e., drugs to avoid, drugs with dose limits, drug–drug and drug–disease interactions). Finally, a modified Delphi survey of an expert panel reached consensus on 18 potential risk factors for drug-related factors in long-term care facility residents. CONCLUSIONS: Drug-related problems are considerable for elderly patients. Data from published studies should provide some guidance for todays practitioners as well as direction regarding future research.

Potential Medication-Related Problems in Noninstitutionalized Elderly

A study was designed for practitioners wishing to provide comprehensive educational services to the elderly. The effectiveness of four methods (i.e., oral instructions alone or in combination with written information, a medication reminder calendar, or a medication reminder package) of changing patient attitudes, drug knowledge, and compliance behavior was measured in 158 ambulatory cardiovascular patients using a randomized, controlled, single-blind design. The results indicate that drug knowledge will most likely be improved by a strategy that provides small amounts of specific information, thereby reducing the possibility of overwhelming the patient. Noncompliance behavior caused by forgetfulness can be best improved by combining a reminder aid with oral reinforcement. The high levels of motivation present in these patients indicate that improving patient attitudes toward medication taking may be unnecessary.

A systematic approach to educating elderly patients about their medications

OBJECIVE: To describe medication use in hemodialysis patients and to characterize the potential drug-related problems that may occur in this population. DESIGN: All patients being dialyzed during the study period who were responsible for taking their own medications and who were able to provide an accurate medication history were included in this study. A pharmacist administered a structured medication history and drug therapy review protocol known as the Focused Drug Therapy Review Program to identify potential drug-related problems. This process was modified for a hemodialysis population. SETIING: Outpatient hemodialysis unit at a university-affiliated hospital. RESULTS: Thirty patients with endstage renal disease requiring hemodialysis were enrolled in the study. On average, 10 prescription and 2 prescribed nonprescription medications were used per patient. The incidence of potential adverse effects and medication allergies or intolerances averaged 5.5 and 2.2 per patient, respectively. Twenty patients (67 percent) reported missing an average of 3.4 (range I-II) doses of medication per month. A total of 216 potential drug-related problems (encompassing both prescribing choices and patient behaviors) were identifiedby the pharmacist; the categories of drug selection and medication compliance contained the greatest number of potential problems (24 and 23 percent, respectively). CONCLUSIONS: Hemodialysis patients use a large number of medications, which increases the risk for adverse reactions and other drug-related problems. The types of potential drug-related problems identified are amenable to pharmacist input. Thus, such patients should be targeted for clinical pharmacy intervention.

An assessment of different components of patient medication knowledge

The extent of potential medication-related problems was examined using a thorough review of drug therapy for 53 elderly patients who averaged five chronic illnesses and who used a mean of 11 drugs. An average of 11 specific potential medication-related problems was identified for each patient. These problems fell into three broad categories: Drug toxicity, physician prescribing, and patient medication behaviors. The strongest predictor of the total number of potential problems was the number of prescription medications. The type of drug therapy review used in this study can help health professionals identify and prevent the types of medication-related problems occurring in multiple medication users.

Integrating medication therapy management in the primary care medical home: A review of randomized controlled trials.

The purpose of this study was to evaluate a pharmacist-initiated, total package, patient education program based on the concepts described in the PRECEDE model. This program was directed towards 94 therapeutically complex elderly patients and consisted of a medication history, therapeutic evaluation, patient education needs assessment, patient education session, and a patient feedback/satisfaction telephone interview. Pharmacists identified on average 5.6 medication-related problems and provided an average of 6.2 recommendations. Problems commonly identified involved inadequate drug knowledge (25.5%), noncompliance (22.7%), and inappropriate drug use (17.4%). Typical recommendations included altering drug use (35.9%), improving compliance behavior (18.1%), and improving communication with health professionals (18.1%). Patient satisfaction with the education session was overwhelmingly positive. Based on the findings of this study, it is apparent that a patient education program based on the PRECEDE model can be used successfully by pharmacists to prepare education plans that would benefit the therapeutically complex elderly patient.

Chronic Hemodialysis Patients. Part II: Reducing Drug-Related Problems through Application of the Focused Drug Therapy Review Program

Different components of drug knowledge (i.e., knowledge of the drug purpose, regimen, action if a dose is missed, and common side effects) were examined in 187 ambulatory cardiovascular patients in order to determine whether the components were similar enough to be considered interchangeable in representing drug knowledge. Patients and physicians were interviewed in a family practice setting and their responses compared for each cardiovascular drug the patient was taking. Scores were highest for knowledge of the drug regimen and purpose, fewer patients were correct about the appropriate action if a dose were missed, and only a small number could accurately identify common side effects associated with their drug therapy. The comparison of patient responses to each of the knowledge measures indicated that there was little consistency in response across the various types of knowledge. The differences in the measures were supported further by regression equations that showed different relationships between a set of independent variables and knowledge of drug purpose and regimen, respectively. The study findings suggest that a partial explanation for inconsistencies of research about drug knowledge may be the way this concept is measured.

Patient-centered medical home: developing, expanding, and sustaining a role for pharmacists.

PURPOSE Randomized controlled trials (RCTs) that evaluated the effect of medication therapy management (MTM) on patient outcomes in the primary care medical home were reviewed to determine how these services may be integrated into the primary care medical home. METHODS A literature search was conducted to identify RCTS published between 1989 and 2009 that evaluated the impact of MTM services on patient outcomes. To qualify as MTM services, the interventions had to include both a review of medication therapy and patient interactions, including educating patients about drug therapy, identifying potential barriers to medication adherence, and helping patients manage their diseases. The internal validity of the studies was evaluated using previously published criteria. The description, specification, and appropriateness of study objectives, study population, intervention, randomization, blinding, outcome measures, statistical analysis, and conclusions were evaluated. RESULTS A total of 1795 publications were identified, but only 8 met the inclusion criteria. These studies targeted patients with specific medical conditions or patients with multiple medications without specifying a medical condition. The interventions varied in intensity (i.e., frequency and length of patient contact), ranging from a single patient contact in a community pharmacy setting to multiple visits with an ambulatory care pharmacist practicing in a collaborative care model. Two of the 8 studies obtained expected results. These studies targeted patients with unrealized therapeutic goals, and the interventions involved collaboration between pharmacists and physicians and extensive patient follow-up. CONCLUSION Of 1795 publications identified, 8 were RCTs meeting selection criteria for evaluation of the effect of MTM services on patient outcomes. Two service elements that benefit patient care were identified: (1) selecting patients with specific therapeutic problems and (2) implementing MTM services that involve timely communication with primary care providers to discuss therapeutic problems, along with routine patient follow-up to support medication adherence to changes in therapy.

Safety issues in the pharmacologic management of chronic pain in the elderly

OBJECTIVE: To test the value and measure the impact of a model of pharmacy practice called the Focused Drug Therapy Review Program (FDTRP)in patients with endstage renal disease on hemodialysis. DESIGN: A modified version of FDTRP, adapted for a hemodialysis population, was assessed for its impact on prescriber behavior. The impact was measured by examining the percentage of pharmacist therapeutic recommendations accepted and implemented by the prescriber. SETTING: Thirty patients at a university hospital-based outpatient hemodialysis unit participated in the study. Twenty-four patients completed the study through the implementation evaluation. RESULTS: The pharmacist generated 114 therapeutic recommendations and 85 informative comments regarding drug therapy. The prescriber accepted 76 percent and implemented 70 percent of the therapeutic recommendations. The prescriber considered the informative comments to be helpful, even if the information was known previously. CONCLUSIONS: The FDTRP has been shown to be useful in the care of chronic hemodialysis patients. In addition, the pharmacist was able to provide clinically important recommendations in a closely monitored patient population.