The Role of the Pharmacist in Optimizing Pharmacotherapy in Older People
ABSTRACT Prescription of medicines is a fundamental component of the care of older people, but evidence suggests that pharmacotherapy in this population is often inappropriate. Pharmacists have been involved in different approaches for the optimization of prescribing and rational medication use in older people. This article describes the different models of care in which pharmacists are involved in the optimization of pharmacotherapy in older people, and reviews the impact of these approaches on both process and outcome measures. The provision of pharmaceutical care, medication reviews and educational interventions by pharmacists in the nursing home, ambulatory and acute care settings are discussed. We selected systematic reviews, reviews and original studies, and for the latter, we focused more specifically on European publications published between 2001 and 2011.
From the literature reviewed, it is clear that when pharmacists play a proactive role in performing medication reviews and in the active education of other healthcare professionals, pharmacotherapy for older patients is improved. However, the evidence of the impact of pharmacists’ interventions on health outcomes, quality of life or cost effectiveness of care is mixed. Better results have been reported when pharmacists are skilled and work in the context of a multidisciplinary team. Opportunities remain for multicentre, European-based, pharmacist-intervention trials in all settings, to determine the effectiveness and economic benefit of pharmacist involvement in the optimization of pharmacotherapy in older people.
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ABSTRACT: Inappropriate prescribing is highly prevalent in older people and is a major healthcare concern because of its association with negative healthcare outcomes including adverse drug events, related morbidity and hospitalization. With changing population demographics resulting in increasing proportions of older people worldwide, improving the quality and safety of prescribing in older people poses a global challenge. To date a number of different strategies have been used to identify potentially inappropriate prescribing in older people. Over the last two decades, a number of criteria have been published to assist prescribers in detecting inappropriate prescribing, the majority of which have been explicit sets of criteria, though some are implicit. The majority of these prescribing indicators pertain to overprescribing and misprescribing, with only a minority focussing on the underprescribing of indicated medicines. Additional interventions to optimize prescribing in older people include comprehensive geriatric assessment, clinical pharmacist review, and education of prescribers as well as computerized prescribing with clinical decision support systems. In this review, we describe the inappropriate prescribing detection tools or criteria most frequently cited in the literature and examine their role in preventing inappropriate prescribing and other related healthcare outcomes. We also discuss other measures commonly used in the detection and prevention of inappropriate prescribing in older people and the evidence supporting their use and their application in everyday clinical practice.Drugs & Aging 06/2012; 29(6):437-52. DOI:10.2165/11632610-000000000-00000 · 2.50 Impact Factor
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ABSTRACT: Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention’s success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape ‘age-attuned’ health and drug policy.Drugs & Aging 06/2012; 29(6):477-94. DOI:10.2165/11632400-000000000-00000 · 2.50 Impact Factor
- Drugs & Aging 06/2012; 29(6):423-5. DOI:10.2165/11630990-000000000-00000 · 2.50 Impact Factor