1. ROLE OF HEALTHCARE PROVIDER IN GERIATRIC COUNSELING
Prepared by: Randa Samara
Sharjah PHC
Pharmacist

2. Introduction
In a report it was estimated that (75%) of elderly are taking medications.
Illness in older people are misdiagnosed, overlooked or dismissed as part of the normal aging process, simply because health professionals are not trained to recognize how diseases and drugs affect geriatrics.

3. Pharmacist by his professional knowledge and skill can provide a unique service towards geriatric care by:
Help prescribers choose the best clinical therapy for each individual patient.
Offer guidance on how to switch from one drug to another in the way most beneficial to the patient.
Reduce the variability of prescribing medication, so that every patient in a skilled nursing facility receives optimal care.

5. Methods to reduce prescribing errors in elderly patients
The causes of prescribing errors in this patient population are:
Prescribers’ lack of knowledge of aging physiology
Geriatric medicine,
Geriatric pharmacotherapy,
Overprescribing that frequently leads to major polypharmacy, inappropriate prescribing, and inappropriate drug omission.

6. Causes of prescribing errors
Classification of factors that predispose to prescribing errors

7. Prescribing Optimization Method (POM)
To assist physicians to optimize polypharmacy prescribing for the elderly population is based on six open questions. These questions should help physicians check whether their elderly patients are receiving the best pharmacotherapeutic treatment possible.
Is the Patient Undertreated and is Additional Medication Indicated?
Does the Patient Adhere to His/Her Medication Schedule?

8. Which Drug(s) can be Withdrawn or Which Drug(s) is (are) Inappropriate for this Patient?
Which Adverse Effects are Present?
Which Clinically Relevant Interactions are to be Expected?
Should the Dose, Dose Frequency and/or Form of the Drug be Adjusted?

10. Appropriate prescribing

11. Commonly undertreated conditions and medications advised by guidelines

12. Age-related changes in pharmacokinetics

13. Medication errors
Elders are highly susceptible to medication errors and drug-related problems due to their special needs with medications and uncoordinated care.
The side effects of medications in geriatrics often are more severe.
Hospital admissions among the elderly due to drug misadventures are six times that of the general population.
Use of drugs in the elderly is associated with increased risk of adverse side effects and morbidity.

14. Polypharmacy with elderly
Inappropriate medications put elders at risk for ADE’s that could lead to unnecessary morbidity and mortality based on polypharmacy, pharmacokinetics, pharmacodynamics and compliance factors.
Polypharmacy significantly increases the risk of drug-drug interactions.

15. Psychotropic medications have been consistently and significantly associated with an increased risk of falls in the elderly.
The tricyclic antidepressants, serotonin reuptake inhibitor, benzodiazepines and antipsychotic need to be monitored closely in the geriatric population with regard to falls.
Elderly patients are particularly susibtable to the sedative effects of psychotropic drugs resulting in an increased risk of falls and hip fracture.

16. Discomfort, pain or difficulty swallowing medication is a problem faced by many elderly patients.
Dysphagia is seen in patients with Parkinson’s disease, altered mental status or as a result of a cerebal vascular accident.

17. Adherance
Factors that have been shown to increase non- adherence include:
Female gender
Lower socioeconomic status
Living alone
Complicated drug regimens
Multiple diseases

18. Diseases affect adherence to drug therapy
Conditions that affect vision, e.g. macular degeneration or cataract formation, can make reading prescription labels and medication instruction difficult.

19. Hearing loss can prevent patients from understanding health care professional instructions and medication information.
Arthritis can add to the difficultly of opening medicine bottles.
In these cases providing patients with “pre filled pill boxes” for each day and bold written medication schedule may limit barriers to patient adherence.

20. Dosing of drugs in elderly
Drug dose should be reduced in elderly patients.
Although the rate of drug absorption is rarely affected. The lean body mass decreases and body fat increases by almost 100% in elderly persons as compared to adults

21. Volume of distribution of a water soluble drug may decrease and that of a lipid soluble drug like diazepam increases with age.
Drugs that are highly bound to albumin(e.g warfarin, phenytoin) may have a greater free concentration because albumin is decreased in the elderly.
Age related changes in hepatic and renal function greatly alters the clearance of drugs.
Serum creatinine may not be a good predictor of renal functions, as creatinine production declines with age

22. Decline in cardiac output with age results in decrease of renal perfusion by 40% to 50%.
Due to progressive decrease in renal function, the dosage regimen of drugs that are predominantly excreted unchanged in urine should be reduced in elderly patients.
A reduction in phase – 1 reactions (oxidation, reduction and hydrolysis) can occur results in prolonged elimination half lives of benzodiazepines and certain analgesics this may result in drug accumulation and possible adverse effects.

23. Age related physiologic changes affecting drug therapy

24. Factors create the need for flexibility in prescribing for the elderly
The prevalence of multiple chronic diseases or comorbidity is much higher in older individuals. For example, nearly 40% of the elderly suffer from arthritis plus another serious health condition, such as cardiovascular disease or diabetes.

25. An older body reacts to pharmaceuticals quite differently than a young one due to physiological changes that accompany aging; metabolism rates change, organ function declines and sensitivity to some drugs can be altered.
Compared with younger patients, there is generally a wider variation in pharmacological action of a drug across individuals.

26. Common disease pairs

27. Pharmacist role & responsibilities in geriatric
Pharmacist’s coordinating and optimizing drug therapy to improve outcomes by:
Targeting patients taking unnecessary multiple prescriptions
Reducing the number of serious at risk for side effects of drugs considered inappropriate for use in the elderly

28. Working with physicians to optimize drug therapies by increasing the use of medications considered to be best for individuals practices.
Providing therapeutic interchange for certain drugs to provide equal or better clinical outcomes .

29. Design, recommend, monitor and evaluate patient specific pharmacotherapy for geriatric patients.
Build the information base needed to design a medication therapy regimen for a geriatric patient
Design pharmacotherapeutic regimens for geriatric patients

30. Provide medication-use education to geriatric patients and their caregivers
Consider non-drug alternatives including physical exercise, physical therapy, counseling and relaxation techniques.
Written instruction, information leaflets, special containers, special packaging for appropriate use of medication.

31. Assure the adjustment of the dose is made carefully
Assure the adjustment of the dose is made carefully. Always follow “start low and titrate slow”.
Ensure continuity of pharmaceutical care for geriatric patients as they move among alternate care setting.
Provide inservice education to physicians, nurses and other practitioners serving geriatric patients.

32. Develop a proposal for a new geriatric pharmacy service.
Provide instruction to pharmacy technicians, pharmacy students and pharmacy aides.
Participate in the medication-use evaluation (MUE) program in the care of geriatric patients

33. Conclusion
Pharmacist are having responsibility for their patient’s medication-related needs, ensure that their medications are most appropriate, the most effective the safest possible and are used correctly; identify , resolve and prevent medication –related problems that may interfere with the goals of therapy.
Pharmacists can provide a variety of small but important services to make taking prescription medication easier for the elder patient.

34. Thank you