There is a clear opportunity for community pharmacists and their teams to lead best practice when it comes to supporting the ongoing health needs of older people

We all know that an expanding older population is putting a lot of pressure on community services, says Derek Taylor, chair of the UKCPA Care of the Elderly group. It is a situation he is all too familiar with in his role as assistant director of pharmacy – governance and risk with the Royal Liverpool and Broadgreen University Hospitals NHS Trust.

“We are seeing this on a day-to-day basis in hospital pharmacy, whether that is through admissions from care homes or people living at home with more complex care needs,” he points out.

Community pharmacies could prove to be the vital link in this chain, Taylor says, by bringing their knowledge of older patients and skills into play more often and in new ways. For instance, the UKCPA group he chairs has run a number of courses aimed at highlighting the crucial role of pharmacy in older people’s services.

“In most cases people will visit the same local pharmacy for years,” he says, “so the staff are ideally placed to help them manage their health more effectively, as well as liaise with other health professionals who may already be involved in their care by assisting with any transition to a new care environment, say, or working more closely with GPs to monitor patients.”

Things have already moved to this new footing in hospitals, says Tahir Masud, a consultant physician and professor of geriatric medicine at Nottingham University Hospitals NHS Trust, who recently became president of the British Geriatrics Society.

“Pharmacists have become a really important part of the team on hospital wards,” he says, “working closely with other medical staff as part of a multidisciplinary routine. Although it is already happening in the community to some extent, I can see a clear case for reinforcing this further.”

So what does this more integrated type of community pharmacy actually look like in terms of older people’s care?

Medicines optimisation

It is about taking an individualised approach to medicines optimisation, says Derek Taylor, with pharmacists assuming more of a lead role in reviews of the issues that typically affect older people, such as inappropriate prescribing, as well as supporting medication compliance and rationalising polypharmacy.

At present, polypharmacy (often defined as the use of four or more medicines) and compliance constitute the biggest medication problems in elderly patients that hospital services encounter, says Tahir Masud.

“As a simple by-product of longevity, people are experiencing a number of differing health issues as they age, which might see them visiting a cardiologist, gastroenterologist or endocrinologist and receiving multiple prescriptions. If these specialists happen to be unaware of each other, there is an increased risk of side-effects – which can easily lead to confusion, drowsiness or falls.”

As the common port of call, however, a community pharmacist can effectively bridge that gap, highlighting any inappropriate prescribing or warning patients to look out for any possible sideeffects. “This gives people a much better chance of offsetting any issues,” Masud continues, “and avoiding what can easily become a rapid cascade into full-time care.”

Enhanced ties between GPs and community pharmacy may also help initiate new conversations and highlight any issues with compliance – which can be a particular problem for those living on their own or suffering with dementia. “Offering some form of counselling can greatly help to reinforce the [compliance] message,” Masud says, “so it is an area I would be very pleased to see pharmacists taking a more active role in.”

Rationalising medication regimens and, depending on a patient’s views, actually deprescribing in some cases is becoming more widespread. “Statins are a good example of this,” Derek Taylor says, “as they may cause an outcome that is worse in older, more frail patients.” Medication for high blood pressure is another case in point.

“In middle age, it may be perfectly appropriate to prescribe such medication,” says Tahir Masud, “but it can also put an older patient at risk of problems at the opposite end of the spectrum, such as falls if their blood pressure then starts to drop. It is all about achieving a good balance for the individual.”

Medicines use reviews especially are an ideal opportunity for conversations of this kind, according to both Taylor and Masud, with the latter recommending the Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP) system for any rationalising conversation.

“We know that face-to-face medication reviews are particularly effective, especially when they are performed by a patient’s regular pharmacist,” Taylor says.

“Visiting a health centre, GP practice, person’s home or running a group session in the pharmacy are all good options for enhancing community ties. At my own hospital, we already operate a similar multidisciplinary approach, where a community pharmacist comes in and undertakes medication reviews during our falls clinic.”

Harnessing technology

Technology may hold the key to solving the challenge of keeping track of older patients as they move between care settings.

“When a person has been admitted to hospital and then goes to an intermediate care unit as part of the reablement process, they can very easily slip through the net,” Derek Taylor explains. “That is a real problem because a community pharmacy needs to be aware of their changing care needs and working to ensure maximum levels of medicines optimisation at all times.”

His own hospital is working to combat this by trialing an electronic discharge package through PharmOutcomes. The package contains essential notes on discharge as well as any changes to medications or possible side-effects that can go straight to a patient’s GP and local pharmacist.

“Traditionally, this has always been a weak point in the relationship between hospital and community pharmacy,” he says, “but technology is negating the usual problem of time and workload, and giving care providers the opportunity to receive essential patient updates. Through extending the role of PharmOutcomes, we are hoping to increase the level of patient tracking to include admissions as well.”

Technology now gives community pharmacy the opportunity to considerably enhance the level of medicines advice depending on the care setting of the patient, says Taylor.

There is already good evidence to show that this type of improved communication does have an effect on reducing hospital readmissions, he says. “Making community pharmacists part of this conversation would only enhance this. In the scheme of things, this doesn’t just benefit a patient but the system as well, generating some much-needed cost savings. That must be good news for everyone.”

Better mental wellbeing

Depression affects one in five people⁵ and is especially common in older age groups. Symptoms include:

• Lack of interest and an inability to enjoy things normally enjoyed
• Being reluctant to engage in usual activities or leave the house
• Feeling tired and/or sleeping too much or too little
• Loss of appetite or eating more than usual
• Losing or gaining weight over a relatively short time
• Losing confidence and feeling life is pointless
• Being self-critical and feeling guilty
• Having suicidal thoughts.

In cases where depression is suspected, customers who have experienced some of the symptoms of depression on most days for two to four weeks should be advised to visit their GP.

Improving community ties has been shown to boost mental wellbeing in older age groups and pharmacy can help promote such services by displaying posters and offering leaflets. Key initiatives include Call in Time, No One Should Have No One at Christmas from Age UK, the University of the Third Age and the Men’s Sheds Association – as well as numerous, more targeted, local and national health groups.

Supporting people with dementia

Two-thirds of patients living with dementia in the UK live in the community, making the pharmacy sector integral in both helping to identify the early signs of dementia in older people and providing ongoing support. The Alzheimer’s Society’s Dementia Friends programme offers targeted advice for pharmacy teams. To date, more than 2,345 pharmacies have signed up, creating around 65,200 Dementia Friends across the UK.

Dementia remains incurable, of course, but with cognitive decline believed to begin up to 10 years before any diagnosis, most research is centred on early detection. This includes a new study by University College London, which found a straightforward neck scan could well hold the key to highlighting risk by measuring pulse strength.⁶

Technology is also integral to the Alzheimer’s Society current thinking, with the organisation reporting that artificial intelligence is showing promising results by interpreting brain scans and speech patterns. Working in partnership with the University of Oxford’s Big Data Institute, it is calling on people to download and use GameChanger – a new brain games app – for just five minutes a day over one month in order to help with this research. 

Mobility aids

Better independent living is widely linked to improved health and wellbeing, with older people able to benefit from straightforward walking sticks or scooters to smarter gadgets that can help them monitor their own health as well as assist with daily tasks.

These include sensors to monitor water intake, bathroom aids and rails, as well as shaped cutlery and kitchen tools. Pharmacy teams can prove invaluable to achieving better quality of life by highlighting their availability to relevant older customers and their carers.

References

1. Age UK article: 1.4 million older people aren’t getting the care and support they need
2. The Institute for Fiscal Studies and the Health Foundation (2018). Securing the future: funding health and social care to the 2030s
3. Charlesworth A, Thorlby R, Gershlick B (2017). Election briefing: NHS and social care funding – three unavoidable challenges. The Health Foundation
4. ‘What’s the problem with social care, and why do we need to do better?’ – Institute for Fiscal Studies, The King’s Fund, Nuffield Trust and The Health Foundation
   
5. Age UK article on depression and anxiety
   
6. Neck scan could predict dementia. University College London: ucl.ac.uk/news/ headlines2/November-2018/121118-neck-scan-Alzheimers.