Malaysian Pharmaceutical Society 5 th Pharmacy Scientific Conference

1. Malaysian Pharmaceutical Society 5th Pharmacy Scientific Conference “Responding to new roles & challenges” Geriatrics: The pharmacists’ role in improving health outcomes for older people through quality use of medicines Andrew Gilbert University of South Australia

2. Overview • In this presentation I will discuss: • Special needs of older people in terms of medications and medication use • Relevance of considerations of an ageing population to pharmacists in Malaysia • Practical ways in which pharmacists in hospital and community will be able to better serve their older patients • Some of the work my Centre is conducting with the Australian Government’s Department of Veterans’ Affairs to improve medication management in the veteran population

3. What is the issue? My story: The elderly ought to be the main beneficiaries of modern medicines However: “illness caused by medication may be the most significant health problem among the elderly which is amenable to treatment” (Beers & Ouslander, 1989)

4. For example • In 1000 Community dwelling patients in the state of South Australia judged to be at risk of medication-misadventure • - Mean age 71 years (SD 13 years) • - Mean number of medicines 10 (SD 4) • 2,222 medication-related problems identified • 81% resolved, well managed or improving after a collaborative doctor/pharmacist medication review

5. What were the medication-related problems we found? • Need for additional test • Need for additional therapy or medicine • Wrong or inappropriate medicine • Adverse drug reaction/interaction • Unnecessary medication • Wrong dose or regimen • Poor compliance • Poor technique • Out-of-date medication

6. Extent of the problem • 2.4% of all Australian public hospital admissions are medication-related • 140,000 medication-related admissions 2000/2001 • approximately 50% are avoidable • Australian Safety and Quality Report2002

7. Medication-related hospital admissions(Roughead et al, 2002)

8. Factors making elderly susceptible to medication-related problems • Poly-morbidity and consequent polypharmacy • age-related changes in the way the body deals with medications • the sensitivity of the body to medications • altered homeostasis • types of medicines used

9. Poly-morbidity and consequent polypharmacy • Many older people have multiple chronic medical conditions. - 60% of 65yo have 2 chronic conditions - 80% of 85yo have 4 chronic conditions • Treatment of chronic conditions usually involves a number of different medications • The likelihood of an adverse drug event rises exponentially with the number of medicines used. • Diseases themselves can modify drug disposition and clinical response

10. Poly-morbidity and consequent polypharmacy • Adversely affects the patient’s; - Ability to safely use the medicines - Knowledge about medications and conditions but polypharmacy can often be useful to reduce the dose of each drug if effects are additive

11. Poly-morbidity and consequent polypharmacy In Australia the management of chronic conditions is being driven by evidence-based guidelines. These guidelines are; • Nearly always single disease focused • Often miss those at most need who have multiple chronic conditions and • Following clinical guidelines inevitably leads to polypharmacy Dr JoAnne Epping-Jordan; WHO; 2004 National Disease Management Conference

12. Best practice management Diabetes • Oral hypoglycemic or insulin 1 • ACE inhibitor 2 • Low Dose Aspirin 3 • Lipid Lowering agent 4 CHF • ACE inhibitor • Diuretic 5 • B-Blocker 6 • Spironolactone +/- digoxin 7

13. What are the consequences of moving toward disease management and guideline driven approaches to medicine in a population demographic where many people moving into their sixties and seventies have multiple chronic medical conditions? • There are few data which demonstrate positive outcomes for older people in this scenario. • Guidelines and disease management program treatment strategies are not usually derived from data on an elderly cohort of patients, rarely considered in the context of multiple chronic conditions and usually require 10-15 year adherence to demonstrate their positive benefits. Tinetti M et al,Potential Pitfalls of Disease-Specific Guidelines for Patients with Multiple Conditions. NEJM 2004: 351;2870-2874.

14. Age-related changes in the way the body deals with medications • Changes in pharmacokinetics • Absorption • Distribution • Hepatic metabolism • Renal clearance

15. Age-related changes in the way the body deals with medications • Changes in pharmacodynamics/receptor sensitivity • Unpredictable • Need to individualise therapy and dose regimen • Changes in homeostatic mechanisms • blood pressure • Posture and body sway

16. The sensitivity of the body to medications

17. Types of medicines used • Low therapeutic index drugs - Digoxin, lithium carbonate, methotrexate • Drugs to which older people are known to be more sensitive; - Trimethaprim+sulphamethazole, antihypertensives, antidepressants, vasodilators, NSAIDs, H2 receptor antagonists,anticholinergics.

18. What medications cause most problems?

19. In the community setting • Main medication groups involved • Cardiac medications (39% of ADRs) • CNS medications (27%) • Musculoskeletal (12%) • At the level of medication class • ACE inhibitors accounted for 14% of all ADRs • antidepressants 11% • NSAIDs 10%

20. The older populationThe world health report 2005

21. The older populationThe world health report 2005 Life expectancy at age 60 • Malaysia • Males 10.9 years      Females 12.0 years • Australia • Males 16.9  years     Females 19.5 years

22. The dominant causes of hospital admissions and of death in Malaysia Pre-1970's : infectious diseases; malaria, cholera, typhoid and tuberculosis Post-1980 : cardiovascular diseases, cancer, stroke, accidents, chronic pulmonary diseases and other chronic diseases Source: Ministry of Health, Malaysia 1996.

23. DiabetesThe world health report 2005 2000 2030 Australia 941000 1673000 Malaysia 942000 2479000 How will pharmacy respond to help both our countries and individuals deal with this increase in prevalence of chronic diseases?

24. Ageing in Australia • Those over 60 make up about 16.5% of the Australian population. (Malaysia 6.7%) • Less than 10% reside in residential aged-care accommodation • Most older people lead active lives

25. Ageing in Australia • Factors influencing well-being of elderly • Loss of independence (financial, social) • Diminished social support (loss of spouse) • Discounted role • Complex poly-morbidity

26. Health concerns for elderly • Loss of cognitive abilities/mental health • Loss of independence • Chronic pain • Negative perceptions and stereotyping • Loneliness/isolation • Reduced physical capabilities • Injury/safety

27. Ageing and Medications The over 65’s account for 12% of the population but account for 36% of total medication expenditure (over $M700/year)

28. Ageing in Australia • Surveys among elderly people indicate: • 26% taking 5 or more medications concurrently • 89% taking one or more medication • 33% taking one or more non-prescription medications

29. Ageing in Australia Medicines for; • blood pressure • other cardiovascular problems • infections • arthritis • asthma • sleep problems/anxiety • general poor health

30. What does the veteran population look like? Veteran Treatment population by age

31. Veteran Self-reported Health Problems 1997 2003 • Visual problems 86% 92% • Arthritis - 53% • Depression 19% 22% • Hearing difficulties 49% 55% • Dementia memory loss 16% 38% • Insomnia/sleep disturbance 28% 33% • Anxiety 18% 18% • Foot/leg problems that affect mobility 19% 43% • Incontinence 8% 15% • High blood pressure 38% 44% • Post Traumatic Stress Disorder 9% 13% Department of Veterans’ Affairs 2003 Survey of Veterans, War Widows and their Carers

32. Unique Prescription Medicines 2004 64% DVA Departmental Management Information System – March 2005

33. What should we, as pharmacists, do? • Work within a Quality Use of medicines framework • Judicious use • is medication necessary? • Appropriate • If medication best option what is the best medicine considering other medications and other conditions? • Safe and effective • Is the pharmaco-therapy individualised and does the patient have the knowledge and skill to use their medicines safely and effectively?

34. How would this work in practice? • In hospitals: • Pharmacists as members of Drug and Therapeutics Committees • Pharmacists in the wards to participate in pharmaco-therapy decisions and to individualise pharmaco-therapy, monitor outcomes of pharmaco-therapy • Pharmacists involved in patient medication review on admission and discharge • Pharmacists involved in patient medicines education and training • Pharmacists involved in liaison services between the hospital and the community or aged care setting to which their patient is returning to ensure continuity of care

35. How would this work in practice? • In hospitals • Plus • ADR reporting • Safety and Quality activities • Educational activities for doctors, nurses etc • Specialised practice TDM, cytotoxic preparation • etc

36. How would this work in practice? • In aged-care • As for the hospital setting • In Australia community pharmacists provide these services to aged-care facilities • Aged-care facilities are required by legislation to have a contract with a pharmacy for these services • Major difference is the residents will be in your care for a long time, not sort episodes as in the hospital. • Preventing and resolving medication-related problems is a major focus

37. How would this work in practice? • In the community setting • As per hospital and aged care • Additional considerations because your patients will be; • self administering medicines, • making choices about when and whether to take them • Mixing them with non-prescription and traditional medicines • Seeing other doctors and pharmacists • This requires greater attention to checking and reviewing at risk patients at each visit. Providing medilists and keeping good patient records in your practice is the key to the success of this style of practice

38. Key pointers for practice: • Is preventing or resolving medication-related problems a possible role for pharmacists in Malaysia? • Pharmacists role in aged-care • Pharmacists role in medication review • Understand, interpret and relay to doctors and patients the basis of evidence-based treatment guidelines and their applicability in the poly-morbid older person • Individualising medication therapy for the elderly; medication choice, dose, monitoring • Documentation of ADRs in both the community and hospital setting • Pharmacy care for older people in any setting (aged-care, community, hospital) is an important aspect of pharmacy practice and requires attention to a range of clinical (eg individualisation of therapy) and systems (eg recording and reporting ADRs) roles. • A key role for pharmacists will be to work with doctors and nurses to provide pharmaceutical care as part of the overall chronic disease care plan developed with the doctor

39. Case study • Mrs Tan (75year old, regular customer in your pharmacy). Asks to see the pharmacists because of frequent dizzy spells. • What would you do? • Sell her a product? • Provide advice and send her home? • Send her to the doctor? • Do a medication review?

40. Mrs Tan • Current medications • Ramipril 5mg m started 18/10/05 • Frusemide 40mg m started 20/02/02 • Metformin 500mg bd started many years ago • What is a likely cause of the dizziness • Now what would you do? • Sell her a product? • Provide advice and send her home? • Send her to the doctor?

41. Mrs Tan Actions • Document the review on a patient file • Provide advice and send home • If no better in two to three days go back to your doctor • Write your comments on a referral note for her to take to the doctor with her • Ask her to report back to you in two to three days and add outcome to your patient file • Make a note on her file to offer assistance with any other issues at each visit

42. Key points • The increasing prevalence of older patients with multiple chronic diseases adds to the complexity of medication management. • Medication management is a key component of chronic disease management. • Collaborative medication reviews are a key medication management strategy. • Patient records and good documentation is critical to pharmaceutical care for your older patients