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Senior Care Pharmacy

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Senior Care Pharmacy. Part I-- Review and discuss the demographics of aging ... Discuss key issues in the evolution of senior care pharmacy ... – PowerPoint PPT presentation

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Title: Senior Care Pharmacy


1
Senior Care Pharmacy
2
Part I--
  • Review and discuss the demographics of aging
  • Understand the demographics as compared to the
    general population
  • Discuss where seniors live (independent vs.
    institutional dwelling)
  • Discuss cost of care to the health care system
    (nation)

3
Goals and Objectives
4
Aging in America
  • In 2004, there were 36 million individuals 65
    years and older
  • Approximately 12 of US population
  • More than 80 million by 2021

85-89
80-84
90-94
95-99
100
75-79
65 to 69
70-74
Source US Census Bureau
5
Age
Aging America
85
80
70
Male
Female
60
Baby Boomer Impact
50
40
30
20
10
1
1
2
3
2
3
Population in Millions
6
The Senior Market
Nursing homes 1.8 million residents
Other elderly 10.8 million residents
Assisted living 1.8 million residents
Home care 3.5 million beneficiaries
Community-based LTC 8.5 million individuals
NORCs 8.5 million residents
7
Rx Use and Seniors
  • Elderly account for 42 of total annual Rx
    spending in the US
  • 43 billion of 102 billion

US Population
Elderly Rx
Seniors
Non-elderly Rx
Source Families USA/Prime Institute July 2000
8
Rx Use and Seniors
  • 28.5 Rxs/year - 2000
  • 45 increase in utilization since 1992
  • Projected 2010 utilization - 38.5 Rxs/year
  • 2010 utilization 35 over 2000

SeniorUtilizationRxs/year
Source Families USA/Prime Institute July 2000
9
Rx Use and Seniors
  • Rx use increases with age
  • 65-69 year olds - 13.6 Rxs/year
  • 80-84 year olds - 18.2 Rxs/year
  • 2 or more ADL supports use 2X the Rxs as those
    without ADL supports
  • Seniors in poor health use 6X the Rxs as
    excellent health

Source AARP Issue Brief, 1991
10
Seniors Statistics
Source Kaiser/Commonwealth/Tufts-New England
Medical Center 2003 National Survey of seniors
and prescription drugs http//www.kff.org/medicare
/upload/Prescription-Drug-Coverage-and-Seniors-Fin
dings-from-a-2003-National-Survey-Chartpack.pdf
11
Safe Prescribing in the Elderly
  • Research - include elderly in drug trials
  • Diagnosis - is the medication really needed?
  • Choice of Medication
  • efficacy adverse effects
  • drug interactions disease interactions
  • cost ease of administration
  • quality of life
  • Dose - start low, go slow, but dont stop too
    soon
  • Therapeutic Endpoints

12
Risk Factors forAdverse Drug Reactions
  • Polypharmacy
  • Female gender
  • Small body size
  • Hepatic or Renal insufficiency
  • Previous ADRs

Source Royal College of Physicians, 1997
13
Prevalence of Selected Major Diseases of Aging
in the U.S.
Hypertension 50,000,000 Arthritis
40,000,000 Osteoporosis 10,000,000 Cancer
8,000,000 Stroke 4,000,000 Alzheimers
Disease 4,000,000
Source Compiled by PhRMA 2000
14
Chronic Illness and Seniors
  • Almost all seniors have at least one chronic
    condition many have multiple conditions
  • 35 arthritis
  • 50 hypertension
  • 32 heart disease
  • 16 orthopedic impairments
  • 16 diabetes


Source National Center for Health Statistics
2001-2002
15
Part II--
  • Review and understand the changing
    pharmacokinetics and pharmacodynamics in an
    elderly patient.
  • Define and discuss Medication Related Problems
    (MRPs) as they pertain to the elderly.

16
The Problem
  • A given dose of a given medication produces a
    different, and sometimes unexpected, response in
    an elderly patient compared to a younger patient
    of the same gender and similar body weight.

17
The Explanation
  • Pharmacokinetic and/or
  • Pharmacodynamic alterations with age

18
Pharmacokinetics
  • Absorption
  • Gastrointestinal (GI)
  • Intramuscular (IM)
  • Transdermal
  • Distribution
  • Protein binding
  • Metabolism
  • Elimination

19
PharmacokineticsGI Absorption
  • Decreased gastric emptying rate
  • Decreased intestinal motility
  • Decreased intestinal blood flow
  • Decreased intestinal surface area
  • Decreased gastric acid output
  • Increased gastric pH
  • Outcome
  • No significant change in quantity absorbed
  • Time to onset or peak may be delayed

20
PharmacokineticsIM Absorption
  • Decreased muscle mass
  • Decreased peripheral circulation
  • Increased connective tissue
  • Outcome
  • Possible decreased IM absorption

21
PharmacokineticsTransdermal Absorption
  • Decreased skin hydration
  • Decreased surface lipids
  • Decreased peripheral circulation
  • Increased keratinization
  • Outcome
  • Possible decreased absorption from
    transdermal patches

22
PharmacokineticsDistribution
  • Decreased muscle mass
  • Decreased body water
  • Decreased cardiac output
  • Increased body fat
  • Altered regional blood flow
  • Altered tissue barriers
  • Outcome ? Vd of lipid soluble medications
  • ? Vd of water soluble medications

23
PharmacokineticsProtein Binding
  • Decreased serum albumin
  • Decreased protein affinity
  • Increased alpha1-acid glycoprotein
  • Outcome
  • Increased free fraction of highly protein-
  • bound medications (ex. Phenytoin)

24
PharmacokineticsMetabolism
  • Decreased hepatic mass
  • Decreased hepatic blood flow
  • Outcome
  • Phase 1 (oxidation, reduction) decreased
  • Phase 2 (conjugation) unchanged
  • CYP 450 activity unchanged
  • Enzyme induction/inhibition
    controversial

25
PharmacokineticsRenal Elimination
  • Decreased renal blood flow
  • Decreased renal tubular secretion
  • Glomerular filtration rate - creatinine clearance
  • Stable serum creatinine due to ? muscle mass
  • Outcome
  • Average renal function of an 80 yr old
  • is 50 of a 20 yr old

26
Estimating Creatinine Clearance
  • Cockcroft-Gault Equation
  • CrClmen (140 - Age) x IBW
  • Scr x 72
  • CrClwomen CrClmen x 0.85
  • IBW men 50 kg (2.3 x inches 5 ft)
  • IBWwomen 45.5 kg (2.3 x inches 5 ft)

27
Pharmacodynamics
  • Pharmacodynamic changes are assumed when
  • pharmacokinetic changes do not explain
    alterations
  • Not as well understood as pharmacokinetics
  • More variable than pharmacokinetics
  • Changes are seen in
  • Numbers of receptors
  • Sensitivity of receptors
  • Counter-regulatory mechanisms

28
Pharmacodynamics - Examples
  • Increased receptor sensitivity
  • Benzodiazepines, CNS depressants
  • Decreased receptor sensitivity
  • Beta-adrenergic receptors
  • Decreased baroreceptor sensitivity
  • Orthostatic hypotension with vasodilators, TCAs,
    antihypertensives

29
Pharmacodynamics (cont.)
  • Increased risk of tardive dyskinesia and
    parkinsonism with antipsychotics
  • Increased sensitivity to anticholinergic effects
  • Increased sensitivity to warfarin

30
Pharmacodynamics (cont.)
  • Increased sensitivity of Na, K-ATPase
  • Increased toxicity to digoxin, especially with
    hypokalemia
  • Decreased renin and aldosterone levels
  • Decreased response to ACE inhibitors and
  • beta-blockers
  • Increased risk of hyperkalemia with NSAIDs,
  • ACE-Inhibitors, and K-sparing diuretics

31
Medication Problems of the Elderly
  • Pharmacokinetic/Pharmacodynamic issues
  • Polypharmacy issues
  • Comorbid conditions
  • Socioeconomics
  • Financial ability to pay for medications
  • Sensory/physical impairment
  • Cognitive impairment

32
"Any symptom in an elderly patient should be
considered a drug side effect until proved
otherwise." J Gurwitz, M Monane, S Monane, J
Avorn Brown University Long-term Care Quality
Letter 1995
33
Health Care - Evolving to a Focus on Chronic
Rather than Acute Illness
  • "It is now chronic disease that poses a threat
    to our nation's health and economic well-being.

Daniel Perry, Alliance for Aging Research, 1999
34
Medication-Related Problems
  • Undesirable event experienced by a patient
  • Involves or is suspected to involve drug therapy
  • Actually or potentially interferes with a desired
    patient outcome

35
Symptoms ofMedication-Related Problems
  • Confusion
  • Depression
  • Delirium
  • Insomnia
  • Parkinsons-like symptoms
  • Incontinence
  • Weakness or lethargy
  • Loss of appetite
  • Falls
  • Changes in speech

36
Seven Categories of Medication-Related Problems
  • Medical condition that requires new or additional
    drug therapy
  • Patient taking unnecessary drug given present
    condition
  • Wrong drug for patients medical condition
  • Correct drug, dose too low
  • Correct drug, dose too high
  • Adverse drug reaction
  • Patient not taking drug correctly

37
Reasons Seniors are at Greater Risk for
Medication-Related Problems
  • Multiple chronic diseases
  • Multiple prescribers
  • Multiple medications
  • Types of medications prescribed
  • Under-representation in clinical trials,
    particularly those over age 75
  • Shortage of trained professionals in geriatric
    pharmacotherapy

38
28 of hospitalizations of the elderly are due to
Adverse Drug Reactions (17) and Non-Compliance
(11)
Source Arch Intern Med, April 1990
39
Adverse Drug Events and Seniors
  • Incidence in high risk seniors (5 Rxs)
  • 35 experienced ADE
  • 95 of ADEs were predictable
  • 63 required physician intervention
  • 10 required ER visit
  • 11 required hospitalization

Source Hanlon, JAGS, 1997
40
Common geriatric issuesImpact of medications
ADLs/IADLs Behavior Cognition Dehydration Delirium
Falls Incontinence
Involvement in activities Nutrition Mood Psychosoc
ial well-being Pressure sores Psychotropic
medication use
These are the areas of greatest concern to the
patient!
41
High-Risk Potential Drug Interactions
  • Highly protein-bound drugs
  • Drugs metabolized by CYP 450 system
  • Enzyme inducers or inhibitors

42
Barriers to medication adherence
  • Lack of understanding or misinterpretation of
    directions
  • Sensory impairments
  • Drug regimen interferes with daily activities
  • Drug regimen is too complex
  • Lack of understanding why the medication is
    important or the goals of therapy
  • Doesnt believe the medication will work or is
    even necessary

43
Economic Impact of Disease
128 billion
Heart Disease
104 billion
65 billion
100 billion
92 billion
30 billion
100 billion
Source PhRMA 1997
44
Part III--
  • Discuss what consultant pharmacists have done to
    reduce medication-related problems in long-term
    care (ie. Fleetwood Project results)
  • Prospective vs. Retrospective review
  • Understand the pharmacists work up of drug
    therapy
  • Discuss key issues in the evolution of senior
    care pharmacy

45
Medication-Related Problem (MRP) Costs in Nursing
Facilities
  • Without Consultant Pharmacists
  • 7.6 billion
  • With Consultant Pharmacists
  • 4.0 billion
  • Estimated total savings from Pharmacists 30-day
    retrospective review
  • 3.6 billion

Source BootmanL, et al, Analysis of
Drug-related Morbidity and Mortality in Nursing
Facilities Arch Internal Medicine Oct 1997
46
The Senior Care Pharmacy Imperative
  • MRPs impact on quality of life
  • MRPs increase cost
  • MRPs in seniors - 50 preventable
  • MRPs 100 Billion in Direct Medical Costs
  • Purchasers want to reduce the cost of MRPs

47
Pharmacist Workup of Drug Therapy
  • Patient needs
  • Demographics and Background
  • Medical conditions/Problem list
  • Allergies and Alerts
  • Medication record
  • Indication, goals of therapy, progress
  • Review of systems
  • MRPs to be resolved or prevented
  • Care Plan
  • Follow-up evaluation

48
Key Issues in Senior Care Pharmacy Practice
  • The evolution continues
  • Retrospective drug regimen review had an impact
  • Pharmacists proved themselves
  • Prospective drug regimen review
  • Certification in Geriatric Pharmacy

49
Fleetwood Project Research Initiative
  • Estimate the cost of medication-related morbidity
    and mortality in U.S. nursing facilities
  • Assess the impact of Consultant Pharmacist
    services on health care costs and outcomes
  • Develop and demonstrate a model of prospective
    drug regimen review

50
Fleetwood Project Phase I
  • First Pharmacoeconomic study to quantify the cost
    of medication-related problems in nursing
    facilities
  • Quantify the value of Consultant Pharmacists
    services

51
Fleetwood Phase I ResultsConsultant Pharmacist
DRR . . .
  • Improves optimal therapeutic outcomes by 43
  • Saves 3.6 billion annually in costs from avoided
    Medication-Related Problems
  • 7.6 billion without consultant pharmacists
  • 4 billion with consultant pharmacists

52
Fleetwood Project Phase II
  • Feasibility study to compare outcomes associated
    with the federally-mandated retrospective DRR to
    prospective DRR
  • Formalize pharmaceutical care planning in
    high-risk elderly patients
  • Prospective screening to identify patients at
    high risk for Medication-Related Problems

53
Fleetwood Project Phase IIResults
  • Allowed pharmacists greater input into clinical
    decision-making and interventions
  • Enhanced interaction with patients and families
  • Improved communication with the interdisciplinary
    team
  • Greater job satisfaction
  • Improvement in pharmacy workflow efficiency

54
Fleetwood Project Phase III
  • Pharmacist-sensitive outcomes
  • National implementation of the Fleetwood Model to
    identify, prevent, and resolve MRPs
  • ASCP Foundation will train pharmacists in the
    Fleetwood Model
  • Evaluation of pharmacists impact on health
    outcomes and health care costs

55
Part IV--
  • How senior care pharmacists can extend what
    they've done in LTC to the much larger and
    rapidly growing community dwelling/healthy
    seniors.
  • Adult care facilities
  • Community dwelling seniors
  • Adult day care programs
  • P.A.C.E programs

56
Why Senior Care Pharmacy?
  • Modern medicines may be the most important health
    care technology in preventing illness,
    disability, and death in the geriatric population
    (Avorn 1995)
  • Persons aged 65 represent about 13 of
    population yet consume 30-40 of all Rx and OTC
    medications.
  • Older persons at greater risk for and experience
    a disproportionate share of MRPs
  • 50 or more of MRPs are preventable

57
Senior Care Pharmacy Thru Pharmaceutical Care for
Seniors
  • A practice in which the pharmacist takes
    responsibility for a patients medication-related
    needs and is held accountable for this commitment
  • Ensures that patients medication therapy is
    appropriate, most effective available, safest
    possible, and is used as indicated
  • Accomplished by identifying, resolving, and
    preventing MRPs that interfere with achieving
    therapeutic goals and producing positive outcomes

58
Senior Care PharmacyA Golden Opportunity
  • Unmet need
  • Someone will do it
  • Not driven by regulation
  • You have to go out and get it it wont come to
    you

59
Senior Care Pharmacist Description
  • Senior care pharmacists have specialized
    knowledge in geriatrics, geriatric
    pharmacotherapy, and the unique
    medication-related needs of the senior
    population, which they apply in the provision of
    pharmaceutical care.
  • Senior care pharmacy practice is unique in
    that it is population rather than site specific.

60
Senior Care PharmacyHow will you get there?
  • Knowledge and skills
  • Tools
  • Environment

61
Knowledge and Skills
  • Geriatrics
  • Geriatric pharmacotherapy
  • Special medication-related needs of seniors
  • Gerontology

62
Useful Tools
  • www.ascp.com
  • Geriatric Curricular Resources
  • www.ascpfoundation.org
  • MDS MedGuide
  • Screening/Assessment Forms
  • Geriatric Depression Scale
  • AIMS, DISCUS
  • MMSE
  • Geriatric texts
  • Geriatric Dosage Handbook
  • Pharmaceutical Care Handbook

63
Where are Senior Care Pharmacists?
  • Area Agencies on Aging
  • Home Care
  • Senior centers
  • Adult day care
  • Home health
  • Support groups (patients/caregivers)
  • Social Workers
  • Case/Care Managers
  • Long-distance care-giving services

64
Todays OpportunityTomorrows Imperative
  • 200 billion problem to impact
  • Roughly 35 million person market

65
Senior Care PharmacyPractice Characteristics
  • Service (people) business
  • Decisions focus on patient
  • Patient care generates revenue
  • Success measured as patient outcomes
  • Documentation supports patient care
  • Follow-up determined by risk and benefit of
    medication therapy and needs of patient

66
ASCPs Vision
  • The senior population realizes improved quality
    of care and quality of life through the provision
    of pharmaceutical care
  • Senior care pharmacists are recognized and valued
    for their care of patients
  • Senior care pharmacists are professionals,
    essential in healthcare systems
  • ASCP is the acknowledged leader in senior care
    pharmacy practice
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