Tejal Patel

An Interdisciplinary Memory Clinic A Novel Practice Setting for Pharmacists in Primary Care

Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care–based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care–based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists’ activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.

The "Rising Tide" of dementia in Canada: What does it mean for pharmacists and the people they care for?

Dementia is an umbrella term for a large class of brain disorders. The prevalence of dementia was estimated at 44.4 million people worldwide in 2013, and in the absence of any significant new scientific discovery, prevalence rates are estimated to increase to 75.6 million in 2030 and 135.5 million in 2050.1 Alzheimer’s disease is the most common irreversible form of dementia. It is a fatal, progressive and degenerative disease that destroys brain cells.2 The syndrome consists of a number of symptoms that include changes in memory, judgment, reasoning, mood, behaviour, communication abilities and the ability to function on a day-to-day basis. Rising Tide: The Impact of Dementia on Canadian Society3 is a report released by the Alzheimer Society in 2010 following 2 years of intensive study. It is the first study to estimate the health and economic burden of dementia in Canada over the next 30 years. It also reviews and makes recommendations on policy options to address this issue. The 5 main pillars are as follows: Provide support for family caregivers (family includes anyone in the supportive network of the individual). Emphasize risk reduction and early intervention. Build an integrated system of care. Strengthen and supplement Canada’s dementia workforce. Increase investment in dementia research. Approximately 747,000 Canadians are living with cognitive impairment including dementia.4 Additional statistics from Rising Tide are similarly compelling. Despite advancing age being the biggest risk factor for Alzheimer’s disease, more than 70,000 of those living with dementia are under the age of 65. Women make up 72% of those living with Alzheimer’s disease. Within a generation, incidences of new cases will increase from 1 every 5 minutes to 1 every 2 minutes. The total cost of care for persons with dementia was about

Parkinson's disease guidelines for pharmacists.

15 billion in 2008 in Canada; this is expected to rise to

Medication-related problems in individuals with spinal cord injury in a primary care-based clinic

153 billion in 2038.3 Moreover, long-term care beds are projected to have a shortfall of 157,000 in Canada by the year 2038. The number of older persons with dementia living at home is expected to steadily rise from 55% to 62%.3 All of these trends will require community or home-based care to become more responsive to the needs of those living with dementia. Pharmacists play a vital role in the health and overall well-being of all Canadians. Pharmacists are highly visible and regularly accessed by members of the community, forming long-standing relationships with their patients. They are trained to understand pharmacotherapy that can benefit or impair cognitive function, and they can monitor for progression and related issues such as medication adherence. However, like many health care professionals, pharmacists may feel ill-equipped to support the unique needs of people living with dementia and their families or caregivers. Simply put, many pharmacists are uncomfortable dealing with patients with dementia. This article is the first in a series that aims to identify roles, strategies and resources pharmacists can apply in daily practice in service of people with dementia.

Use of potentially inappropriate medications among ambulatory home-dwelling elderly patients with dementia: A review of the literature:

Parkinson’s disease (PD) is a chronic, progressive, neurodegenerative disorder, characterized by the loss of dopaminergic neurons from the substantia nigra that subsequently results in the loss of control of voluntary movement over time.1-3 An estimated 100,000 Canadians have PD, and the incidence rate is between 10 to 20 per 100,000.4 Although younger people are diagnosed with PD, it is often thought of as a disease of the elderly, and indeed, the mean age of onset is 60 years, with 85% of individuals diagnosed with PD being older than 65 years.1,2,4 Over the course of 6 years, between 1993 and 1999, the prevalence of PD increased by 26% in Ontario, related in part to the increase in the population of those aged 65 years and over.5 A review by Health Canada in 1998 indicated that PD is associated with substantial direct (

Knowledge, Perceptions and Attitudes toward Chronic Pain and Its Management: A Cross-Sectional Survey of Frontline Pharmacists in Ontario, Canada

87.8 million) and indirect (

Office-Based Case Finding for Chronic Obstructive Pulmonary Disease in Older Adults in Primary Care

470.3 million) costs.4 Although 70% of the cost is associated with long-term disability, life expectancy is also significantly shorter, with premature mortality accounting for 14.1% of the cost of the disease.2,4 Although the clinical presentation can vary from one individual to another, patients will typically present with complaints of asymmetrical (i.e., more on one side of the body than the other) tremors at rest in one extremity, whether it be the arm or the leg, and stiffness or rigidity and/or slowness in movement (bradykinesia). Over time, individuals will develop a shuffling gait and postural instability (see Table 1 for a complete list of the motor features of PD).1,2 Motor symptoms are thought to result when 60% to 70% of dopaminergic neurons have been lost.2 The loss of dopaminergic neurons results in a deficiency of dopamine, the primary neurotransmitter involved in the coordination of movement. Currently, the pharmacotherapy of PD is primarily related to replacing dopamine or mimicking the activity of dopamine. As the disease progresses, patients struggle to maintain the balance between the positive and negative effects of pharmacotherapy, often requiring multiple adjustments of drug doses and dosing regimens as well as the addition and removal of adjuvant drugs.1,3 Table 1 Clinical presentation of motor features of PD

Vitamin D supplementation for bone health in adults with epilepsy: A systematic review

Objective: To determine the frequency of medical problems, reason for referral/primary complaint, products used, medication-related problems, and polypharmacy in patients with spinal cord injury (SCI) seen at an interprofessional primary care mobility clinic. Design: Retrospective review of medical records of patients with SCI for patient visits between August 2012 and March 2013. Methods: Data were abstracted from medical records of patients with SCI. Results: Of 74 patients who presented to the clinic, 19 had an SCI. Mean age was 46.7 years and 74% were male. Most frequent medical problems were depression/anxiety (37%), osteoporosis/osteopenia (26%), hypertension (21%), dyslipidemia (21%), and osteoarthritis (21%). Most common presenting complaints were pain (23%) and bowel/bladder issues (13%). Most common medication-related problems were untreated conditions (41%), ineffective medications (21%), adverse drug reactions (18%), and under- and over-dosage (each 9%). Patients with SCI most frequently used products to treat pain (68%), constipation (42%), muscle spasm (42%), hypertension (42%), and depression (37%). When including natural health products, vitamins and minerals, polypharmacy was seen in 74% of patients with SCI (63% when limited to prescription and over-the-counter medications). For patients with SCI in whose care a pharmacist collaborated, a mean of 3.2 medication-related problems per patient were identified compared with 1 per patient when the pharmacist was not involved. Conclusion: This study is the first to describe medication use, polypharmacy and medication-related problems in patients with SCI seen at an interprofessional primary care clinic. Use of high-risk medications, polypharmacy, and medication-related problems in patients with SCI suggest the need for collaborative interprofessional care that includes a pharmacist.

Identifying frailty in primary care: A systematic review

Background: Older adults with dementia are at high risk for drug-related adverse outcomes. While much is known about potentially inappropriate medication use in older adults, its prevalence and characteristics among those with dementia are not as well elucidated. We conducted a literature review to examine the prevalence of potentially inappropriate medication use among home-dwelling older adults with dementia. Our secondary aim was to determine the most frequently implicated medications and factors associated with potentially inappropriate medication use. Methods: MEDLINE, EMBASE, CINAHL, and International Pharmaceutical Abstracts were searched between 1946 and 2014 for articles that referenced potentially inappropriate medication use and types of dementia. One reviewer screened all titles and abstracts from the initial search and full-text articles after the initial screen for eligibility, then 2 reviewers independently abstracted data from included studies. Results: Searches yielded 81 articles, of which 7 met inclusion criteria. Prevalence of potentially inappropriate medication use varied from 15% to 46.8%. No single drug or drug class was reported consistently across all studies as the most frequent potentially inappropriate medication, but anticholinergics and benzodiazepines, drugs that affect cognition, were among the most common medications or pharmacological classes listed. Discussion: Older adults with dementia may be particularly vulnerable to potentially inappropriate medications because of cognitive impairment from their condition and the greater likelihood of experiencing adverse events from medications. Given this population’s greater susceptibility to adverse events, more intense medication and patient monitoring may be warranted, especially among those taking anticholinergics and benzodiazepines, as these drugs can contribute to cognitive impairment.

Practice recommendations for Parkinson's disease: Assessment and management by community pharmacists.

The treatment of chronic pain consumes a significant share of primary care. Community and family health team pharmacists frequently see patients with chronic pain, thus have the opportunity to improve their care. To assess the knowledge, perceptions, and attitudes of Ontario pharmacists, we invited 5,324 Ontario pharmacists, to participate in an online survey we developed using Qualtrics. The 31-question survey gathered demographic information, assessed pharmacists’ knowledge of three chronic pain conditions; chronic lower back pain (CLBP, eight true/false statements); chronic headache disorder (CHD, eight true/false statements) and painful diabetic neuropathy (PDN, seven true/false statements), and their attitudes toward and perceptions of patients with these conditions, and knowledge, attitudes, and perceptions of opioids in pain management. We received 688 responses (12.9%) and 392 pharmacists completed the survey. The mean age of respondents was 48.5 years and 48.5% were male. More than 50% of respondents were in practice for more than 20 years and 58.7% worked 25–40 hours per week. The mean knowledge scores were 4.5/8, 5.5/8, and 5.3/8 for CBLP, CHD, and PDN respectively. While 95% of respondents were aware of the increasing death rates due to opioid use, only half were familiar with the Canadian guideline for safe opioid prescribing for non-cancer use. Responses were compared based on gender, time in practice and location of practice. Pharmacists with more than ten years of experience scored significantly higher than those with less experience. Fewer differences were found in comparisons of gender and location of practice. Safe and effective care of chronic pain patients, particularly with opioids, will require additional pharmacist education.