Medicine optimization strategy in an acute geriatric unit: The pharmacist in the geriatric team

Abstract

Aim: Older patients admitted to acute geriatric units (AGU) frequently use many medications and are particularly vulnerable to adverse drug events, so specific interventions in this setting are required. In the present study, we describe a new medicine optimization strategy in an AGU, and explore its potential in reducing polypharmacy and improving medication appropriateness.Methods: The present prospective study included patients aged ≥75 years who were admitted to an AGU in a tertiary hospital. An intervention based on a pharmacist clinical interview, medication history and a structured medication review within a comprehensive geriatric assessment was proposed. The differences regarding polypharmacy as the primary outcome (≥5 chronic drugs), hyperpolypharmacy (≥10), number of drugs, drug-related problems and Screening Tool of Older Person's Prescription/Screening Tool to Alert Doctors to Right Treatment criteria between admission and discharge were evaluated.Results: From October 2016 to April 2017, 234 patients were enrolled, aged 87.6 years (SD 4.6 years); 143 (61.1%) were women. The intervention resulted in a statistically significant improvement in polypharmacy (−10.2%, 95% CI −15.3, −5.2), hyperpolypharmacy (−16.6%, 95% CI −22.3 −11.0), number of medications (−1.4, 95% CI −1.8, −1.0), Screening Tool of Older Person's Prescription criteria (−19.2%, 95% CI −24.9, −13.6), Screening Tool to Alert Doctors to Right Treatment criteria (−6.8%, 95% CI −10.1, −3.5) and drug-related problems (−2.7, 95% CI −2.9, −2.4; P ≤ 0.001 for all). Conclusions:A systematic pharmacist-led intervention at hospital admission to an AGU within a comprehensive geriatric assessment was associated to a decrease in polypharmacy, drug-related problems and potentially inappropriate prescribing.

Effectiveness of Interventions to Reduce Potentially Inappropriate Medication in Older Patients: A Systematic Review

“…Forty-seven articles ( Allard et al, 2001 ; Brown and Earnhart, 2004 ; Fick et al, 2004 ; Spinewine et al, 2007 ; Wessell et al, 2008 ; Castelino et al, 2010 ; Lampela et al, 2010 ; Gallagher et al, 2011 ; Keith et al, 2013 ; Rognstad et al, 2013 ; Dalleur et al, 2014 ; Franchi et al, 2014 , 2016 ; Frankenthal et al, 2014 ; Lopatto et al, 2014 ; Clyne et al, 2015 , 2016 ; Ilić et al, 2015 ; Tallon et al, 2015 ; Campins et al, 2016 ; Moss et al, 2016 ; Urfer et al, 2016 ; Frankenthal et al, 2017 ; Price et al, 2017 ; Stevens et al, 2017 ; Van der Linden et al, 2017 ; Vanderman et al, 2017 ; Chan et al, 2018 ; Etxeberria et al, 2018 ; Fajreldines et al, 2018 ; Gibert et al, 2018 ; Hurmuz et al, 2018 ; Najjar et al, 2018 ; Sennesael et al, 2018 ; Stuckey et al, 2018 ; Van Der Linden et al, 2018 ; Vandenberg et al, 2018 ; Boersma et al, 2019 ; Gutiérrez-Valencia et al, 2019 ; Khera et al, 2019 ; Liu et al, 2019 ; McDonald et al, 2019 ; Moss et al, 2019 ; Regueiro et al, 2019 ; Vu and Huong, 2019 ; Akkawi et al, 2020 ; Winata et al, 2020 ) fulfilled the inclusion criteria and were included in this systematic review ( Figure 1 ).…”

“…Among the included studies, 24 were conducted in Europe ( Spinewine et al, 2007 ; Lampela et al, 2010 ; Gallagher et al, 2011 ; Keith et al, 2013 ; Rognstad et al, 2013 ; Dalleur et al, 2014 ; Franchi et al, 2014 ; Lopatto et al, 2014 ; Clyne et al, 2015 ; Ilić et al, 2015 ; Tallon et al, 2015 ; Campins et al, 2016 ; Clyne et al, 2016 ; Franchi et al, 2016 ; Urfer et al, 2016 ; Van der Linden et al, 2017 ; Etxeberria et al, 2018 ; Gibert et al, 2018 ; Hurmuz et al, 2018 ; Sennesael et al, 2018 ; Van Der Linden et al, 2018 ; Boersma et al, 2019 ; Gutiérrez-Valencia et al, 2019 ; Regueiro et al, 2019 ), 14 in North America ( Allard et al, 2001 ; Brown and Earnhart, 2004 ; Fick et al, 2004 ; Wessell et al, 2008 ; Moss et al, 2016 ; Price et al, 2017 ; Stevens et al, 2017 ; Vanderman et al, 2017 ; Chan et al, 2018 ; Stuckey et al, 2018 ; Vandenberg et al, 2018 ; Khera et al, 2019 ; McDonald et al, 2019 ; Moss et al, 2019 ), six in Asia ( Frankenthal et al, 2014 , 2017 ; Najjar et al, 2018 ; Liu et al, 2019 ; Vu and Huong, 2019 ; Akkawi et al, 2020 ), two in Oceania ( Castelino et al, 2010 ; Winata et al, 2020 ), and one in South America ( Fajreldines et al, 2018 ). The most frequented settings of the included studies were hospital ( n = 26) ( Brown and Earnhart, 2004 ; Spinewine et al, 2007 ; Gallagher et al, 2011 ; Dalleur et al, 2014 ; Franchi et al, 2014 ; Tallon et al...…”

“…Twenty-five articles fulfilled more than 80% of the exploratory questions ( Castelino et al, 2010 ; Gallagher et al, 2011 ; Rognstad et al, 2013 ; Frankenthal et al, 2014 ; Lopatto et al, 2014 ; Clyne et al, 2015 , 2016 ; Campins et al, 2016 ; Price et al, 2017 ; Stevens et al, 2017 ; Vanderman et al, 2017 ; Chan et al, 2018 ; Etxeberria et al, 2018 ; Fajreldines et al, 2018 ; Gibert et al, 2018 ; Hurmuz et al, 2018 ; Sennesael et al, 2018 ; Gutiérrez-Valencia et al, 2019 ; Khera et al, 2019 ; Liu et al, 2019 ; Moss et al, 2019 ; Regueiro et al, 2019 ; Vu and Huong, 2019 ; Akkawi et al, 2020 ; Winata et al, 2020 ). Eighteen studies pointed out clearly potential sources of bias ( Brown and Earnhart, 2004 ; Fick et al, 2004 ; Spinewine et al, 2007 ; Wessell et al, 2008 ; Lampela et al, 2010 ; Rognstad et al, 2013 ; Campins et al, 2016 ; Franchi et al, 2016 ; Urfer et al, 2016 ; Frankenthal et al, 2017 ; Price et al, 2017 ; Van der Linden et al, 2017 ; Etxeberria et al, 2018 ; Gibert et al, 2018 ; Boersma et al, 2019 ; Gutiérrez-Valencia et al, 2019 ; Khera et al, 2019 ; Moss et al, 2019 ). Through analysis of Table 2 , the main limitations were related to the low sample size and the lack of blinded intervention.…”

Key concepts in medication management in older persons for pharmacists practicing in non‐geriatric specialties

“…It differs from usual medical care through an in-depth evaluation of multiple systems, usually within a geriatrician-led multidisciplinary team that may include nursing, social work, occupational therapists, dieticians, physiotherapists, speech pathologists and pharmacists. 28,29 Pharmacists caring for older persons who are not under the care of a geriatrician can review medications in the context of the components and elements of a CGA (Table 3), and should provide medication management recommendations that align with the patient's treatment goals and, where relevant, their advance care plan.…”

“…Evidence across multiple settings including oncology, acute geriatrics and day hospitals have shown positive medication-related outcomes when pharmacists are integrated into the multidisciplinary geriatric medicine team performing CGA, including increased identification of prescribing issues, reduction in polypharmacy, and a reduction in use of potentially inappropriate medicines (PIMs) and medication-related problems. 29,30,35…”