1. The Pharmacists’ role leading medicines optimisation in older people
Lelly Oboh
Consultant pharmacist, care of older people
Guys & St Thomas NHS Trust and NHS Specialist Pharmacy Services
15th June 2017 and 5th July 2017

2. Older people: A growing population
UK over 65s to from 17% to 25% by 2051.
Increasing population of frail, over 85s
Not a homogeneous group
High users of NHS & Social care resources
Complex care
High users of medicines – polyharmacy
Increased sensitivity to ADEs and consequences
Paucity in evidence base for drug treatment
Optimising medicines use can have a high impact on patient experience, health outcomes and costs (Naylor S et al. Kings Fund 2013)

3. Frailty, Morbidity and Disability (Fried et al 2004)
26.6%
46.2%
5.7%
21.5% .
Fried LP et al. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care. J Gerontol A Biol Sci Med Sci (2004) 59 (3): M255-M263.doi: /gerona/59.3.M255

4. Co-morbidity: 2 or more LTC
NICE (NG56) Multimorbidity: clinical assessment and management. 2016
Treatment can be burdensome for individuals esp. polypharmacy
Interactions of treatments and conditions
Multiple individuals, providers and settings
Care is fragmented and uncoordinated
Requires tailored approach as conditions and treatments have high impact on their QoL and functioning

5. Frailty

6. Table 2. Baseline Association of Demographic and Health Characteristics With Frailty, in Percentages: the Cardiovascular Health Study
Fried LP et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M

7. What good services for frailty look like Fit for Frailty 2 2014
Interventions integrated across health and social care -> improves physical, mental and social functioning (outcome focused) vs. strictly disease orientated biomedical approach
Individualised treatment and interventions
Sustained support over a long time -> continues through intervening crises and adverse events.
Care plan that enables participation of the older person, their family and/ or carers
FO COMISSIONERS AND PROVIDERS- what best service should look likw

8. Principles of an approach to care that takes account of multimorbidity
Principles of an approach to care that takes account of multimorbidity. NICE CG
Once patient is identified, focus on
Interaction between health conditions treatments and and effect on QoL
Person's individual needs, preferences for treatments, health priorities, lifestyle and goals
Benefits and risks of following recommendations from guidance on single health conditions
Improving quality of life by reducing treatment burden, adverse events, and unplanned care
Improving coordination of care across services.

9. Older people and Medicines use (Lelly Oboh. 2016)
Drug handling, weight loss, reduced mobility
Mental health needs (Delirium, Dementia, Depression)
Multiple prescribers and Polypharmacy
Multi-morbidities and poor research evidence
Multiple practitioners and agencies involved
Frequent admissions and drug changes
Psychosocial needs/ crisis
Functional, sensory and cognitive impairments
The Older person’s medicines related needs1
Access to medicines
Adherence & practical support
Clinical/therapeutic
Frail older people- additional impact
So must take into consideration all these other factors in med review/prescribing- otherwise wont have full picture
1. Rosenbloom, E. K., and F. R. Goldstein. "The development of trigger questions to support the case finding of people with unmet medicines-management needs." IJPP 15 (2007): 21.

10. Medicines Related Problems (MRPs) in older people Everybody’s business: A multidisciplinary approach is needed
Patient
outcomes
Adverse drug events (ADEs)
Polypharmacy
Non Adherence
Supporting self-medication
Administering medicines
(De) Prescribing & Medication reviews (health only)
Requesting repeats
Collection/delivery
Monitoring medicine effects
Disposing of unwanted medicines
Monitoring adherence
Medication reviews
Medication reviews
How can we improve care?
Medication reviews

11. Reducing Polypharmacy (DTB 52:2014)
Many drugs are often continued beyond the point at which they are beneficial and may actually cause harm (DTB 52:2014)
Deprescribing
The complex process required for the safe and effective cessation (withdrawal) of inappropriate medication. Takes into account the patient’s physical functioning, co-morbidities, preferences and lifestyle
A significant element of the medicines optimisation process must include deprescribing.

12. Pharmacist primary motivation is to improve patient care by leading Medicines Optimisation
Why?
Improve patient outcomes
Quality of life
Health and emotional wellbeing
Personal Dignity
Control and choice
Improve other outcomes
 Unscheduled episodes of care
 Cost savings and  wastage
 Access to pharmacy expertise wherever patients present
Facilitate partnership working across continuum of care
How?
Evidence based practice
Aim to understand patients experience
Evidenced based choice of medicines
Safety (at patient and process level)
Routinely practiced
Proxy measures

13. What should we do different?
Patient centred medication reviews- Focus on patient and their outcomes vs. medicines
Lead medicines optimisation (over and above reviewing medicines lists)
Care co-ordinators (incl interdisciplinary referrals)
Provide advice on all aspects of medicines use
Work within integrated systems and facilitate partnership working
Enablers
Patient Advocate
Safety and Governance lead

14. Consultations and medication reviews
Product centred
Patient centred
Structuring and managing short consultations The Four E’s Barnett N 2011
EXPLORE
EDUCATE
EMPOWER
ENABLE

15. Pharmacist as MO care coordinator Adapted from NHSE 2014
Pharmacist as MO care coordinator Adapted from NHSE MDT Development - Working toward an effective multidisciplinary/multiagency team.
Praoactive working relationship with patient
Undertake holistic, person centred assessment in partnership with patient
Provide a central, continuous point of contact for the patient others involved with medicines
Key advocate for the patient as and when required-Facilitate communication between multiple agencies and practitioners
Assist patient to successfully navigate complex health and social care systems
Good knowledge of the range of local health and care services incl voluntary and community sector
Responsibility for care planning and ensuring that identified actions take place as agreed
Monitor and review care plans and agreed outcomes in partnership with the patient and evaluate outcomes.
To provide direct care where appropriate

16. A patient-centred approach to managing polypharmacy
Identify or receive referral for frail older person
© N Barnett L Oboh K Smith NHS Specialist Pharmacy Service 2015

17. Improve Pharmacy to pharmacy referrals
First point of contact for medicines issues in older people
Improve access to pharmacist wherever older people access care
Pharmacist expertise matched to the level of patient need
Robust communications and referral systems between pharmacists in different settings
Local Community clinical pharmacy teams, with appropriate clinical leadership
Peer support networks

18. Pharmacists leading medicines optimisation What action is within your control?
Move from product to patient centred care in your own practice
Get to know your local integrated team
Get to know local pharmacy colleagues involved in care of older people

19. Thank You for listening