Global Public-Private Partnerships for Pharmaceuticals: Operational and Normative Features, Challenges, and Prospects1,2 Sherri A. Brown3 Abstract Global public-private partnerships (GPPPs) in health have been created, purportedly, as a response to both market and government failure to provide health care goods and services, particularly in developing countries. They have been created to
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Novoce_ppr_geriatricC E C O M P L I A N C E C E N T R E N AT I O N A L C O N T I N U I N G E D U CAT I O N P RO G R A M • O C TO B E R 2 0 0 4
After reading this lesson you will be
1. Identify the need for special counselling
attention in geriatrics
2. List factors contributing to drug-use
problems in the elderly
3. Describe specific factors affecting
medication adherence by the elderly
4. Describe the issues in dealing with
5. List different techniques and tools to
assist counselling geriatric patients
by Melanie Rantucci, M.Sc.Phm., Ph.D 1. INTRODUCTION
CK is a 76-year-old woman who receives nine different medications every three ters of seniors have taken a medication in months from pharmacist BB. She suffers 1. After carefully reading this lesson, study
from diabetes, CHF, arthritis, COPD, con- stipation and cataracts, and is a little hard extensive use of medications by seniors is you believe to be correct. Circle the appro- of hearing. She seems frail and unsteady on partly a result of the increasing morbidi- priate letter on the attached reply card.
her feet and most often receives her pre- 2. Complete the card and mail, or fax to
scriptions by delivery. She calls the pharma- cy to ask about a refill for one of her 3. Your reply card will be marked and you
inhalers but seems unclear about which one will be advised of your results in a letter she needs (she uses both salbutamol and orciprenaline). BB asks her to describe the the inappropriate use of these medications 4. To pass this lesson, a grade of 70%
colour and is able to identify it as the salbu- (14 out of 20) is required. If you pass, your tamol, but notices in her record that she including drug interactions, adverse drug CEU(s) will be recorded with the relevant received it the previous week. CK sounds reactions (ADRs), lack of effect or excess annoyed when the pharmacist tells her this effects and unnecessary use of medications, and insists she did not get it. BB becomes annoyed also and says he will send another iors.9 This results in six to 28% of hospital out but that CK should keep better track of admissions, as well as physician visits, drug therapy, ER visits, long-term care admis-sions and ultimately deaths, at an estimat- by seniors have been shown to be inappro- inappropriate prescribing.6 Studies in the to reach 6.7 million in 2021 and 9.2 mil- elderly indicate that age does not appear to Approved for 1 CE unit by the
Canadian Council on Continuing
Education in Pharmacy.
years of age is growing even faster, with File # 137-0604
more recently investigated as a factor in COUNSELLING GERIATRIC PATIENTS
varying degrees, aging results in physiolog- of people over age 65 in Canada live alone ic changes to the gastrointestinal system fifth (16.3%) receive at least one potential- at least one activity of daily living such as ly inappropriate medication. Other studies olizing enzyme activity and glomerular care.2,4 Paying deductibles or coverage for filtration rate which may alter absorption, issue since 19% of seniors (53% of elderly of drugs, and result in increased sensitivity to drugs and adverse effects.6 Other than decreased renal function (creatinine clear- food, taking or paying for medication, and (BMI <22), these effects of aging are not easily identifiable. It is considered wise to indicator of a greater risk of adverse drug events, so the very elderly should be iden- discussed in future lessons) and improved Co-morbidities: Thirty-two percent of
varying rates with age. A decline in short- advice.8 To fulfill this role, pharmacists aging, Alzheimer’s disease, or other demen- tias, but more often occurs due to sleeping FACTORS AFFECTING DRUG-USE
cataracts and diabetes.4 Having more than PROBLEMS IN THE ELDERLY
MANY FACTORS CREATE AN INCREASED RISK
identified as a risk factor for DRPs in the dysfunction such as memory deficits, hal- lucinations, lethargy, headaches, central nervous system depression, catatonic states, was “patient not receiving a required drug ness”of geriatric patients have been recog- for a symptom.”3,8 Having multiple con- ditions makes DRP identification difficult agents, antiepileptics, antipsychotics, ben- Physicians’ issues such as their lack of zodiazepines, cardiovascular drugs, corti- natural result of aging or a drug effect.
analgesics.12 When any of these drugs are nized (e.g. depression), or are attributed to Patient Issues: The elderly are a het-
should take particular note of the patient’s normal aging (e.g. forgetfulness). Lack of tive changes that come with aging occur to different degrees and at different rates. To patients’ susceptibility to DRPs. One-third FACULTY COUNSELLING GERIATRIC PATIENTS
ABOUT THE AUTHOR
Melanie Rantucci has a doctorate in pharma- All lessons are reviewed by pharmacists for accuracy, currency and relevance to current [email protected] rogers. com.
patient counselling for nonprescription drugs and factors affecting drug misuse in the eld- This CE lesson is published by Rogers Media erly. She has published numerous articles on CE COORDINATOR
Healthcare/Sante, One Mount Pleasant Rd., counselling, as well as books which have been Toronto, Ont. M4Y 2Y5. Tel.: (416) 764-3916 schools around the world. In addition, Melanie For information about CE marking, please lesson may be reproduced, in whole or in part, without the written permission of the publisher.
selling for practising pharmacists across rci.rogers.com. All other inquiries about CE COUNSELLING GERIATRIC PATIENTS
of side effects, perceived lack of efficacy, approach to learning, the elderly also may and cost.6,7 While personal characteristics (age, sex, education, marital status, social Polypharmacy: Taking six or more
in elderly patients, patient understanding drugs has been indicated as a risk factor for DRPs in geriatric patients.6 Fifty-six percent of the elderly reported using two require grade eight-level or a higher read- ing ability, yet seniors have, on average, Communication: Elderly patients are
appropriately prescribed, it has been esti- simple reading tasks.4,18 Literacy and edu- cation levels will likely improve with the visits.8 Examples of drugs inappropriately prescribed include long-acting and short- pharmacist’s and the patient’s perspective.
enough to read, even with glasses.6 Sixty selective NSAIDs without cytoprotection.6 sound distortion, with 8% unable to adhere to beliefs, values and perceptions follow a conversation even with a hearing learned in their younger years, such as the silence, prudishness about their body func- tions, and keeping health matters private.19 unable to hear or see information provid- Their view of health professionals may be more respectful due to their knowledge and frequent requests for repetition, turning status, and they may expect an authoritari- head so that ear is closer, squinting, cup- Multiple drug use results in drug interac- them to higher standards and have a stereo- tions and adverse effects. The greater the typical view of how a professional should of such problems.14 Attention to the envi- look (e.g. male, well-groomed, profession- cy of ADRs, the less likely it is that the aids and approaches (e.g. voice amplifica- appear demanding because of their need to the greater the possibility of being admit- assert their independence, because they are ted to hospital for problems arising from sad, grieving the loss of a spouse, or lack mental characteristics including intelli- Elderly patients’ prescription and non- solving, and approach to learning tend to patients in a stereotypical way, expecting larly reviewed and assessed for indication decrease with age. Fluid intelligence (per- them to be frail, confused, slow, hard of hearing, visually impaired and needy.
People fear aging — dealing with the eld- intelligence (number facility, verbal stress in the relationship.14 Cultural Issues: Elderly patients reflect
Canada’s diverse cultural mix, with one in Information processing is affected so that there is increasing difficulty with register- ferent for the elderly. Reasons in elderly ing new information and retrieving infor- acclimatized to Canadian culture. However, purpose, forgetfulness, intolerable adverse ability may be associated with age due to a seniors, with Asians being the fastest grow- instructions, inability to take medication organizing complex material, interference ing cultural minority.4,20 While the majori- (difficult opening vial, trouble swallow- from previous learning, and difficulty dis- ty of seniors speak one or both of Canada’s ing), belief that drug is not needed, fear COUNSELLING GERIATRIC PATIENTS
Accommodations to Counselling and Compliance for Disabilities14
may have genetically inherited traits (e.g.
Mediterranean area, lactose intolerance in Address patient directly (not care-giver) Solicit feed-back to ensure understanding However, they still have double and triple heart disease, hypertension, diabetes and Use simple sentences to allow for lip-reading Supplement verbal information with print materials, charts,diagrams also have different views about what causes illness and how to prevent or treat illness, Use large print and colour coding or Braille labels as needed professionals resulting in health behaviours Vary sizes of medication container to help identify differentmedications Use audio-taped information where available may not report symptoms (due to sideeffects or illness). They may be noncompli- Physical disabilities Provide simple-to-open containers Remove physical barriers to access – wide doorways andaisles, remove clutter medicine is too strong and fear side effects.
They often self-medicate with traditionalmedicines that may interfere with prescrip-tion medication or be used to replace it.20 tration, but also irritation with others’ ISSUES IN COUNSELLING GERIATRIC
care workers and the elderly, both parties PATIENTS
WHEN PHARMACISTS COUNSEL ELDERLY
consider. Issues such as wheel-chair acces- patients, they need to recognize a variety sibility, available seating, need for quiet affect our attitudes and communication.
dures should be adapted to assist patients Ageism: Our attitudes to the elderly
to see, hear and understand information.
Disabilities: Elderly patients may
It is important to allow adequate time for own experiences. To a degree, the elderly are generally ill, rigid in thinking, and fail- ing mentally. However, they are actually a diverse group, still largely active members the pharmacy or physician’s office or by asking for feedback in a way that may be tainted by these stereotypes,21 due the patient. For example, ask, “So that I in part, because we deal largely with the also be made.14 The pharmacist may take this medication.” palliative therapy to elderly patients and feel tension, frustration, embarrassment, aversion or pity when dealing with a dis- abled patients by making home visits. This abled patient. The patient may feel frus- COUNSELLING GERIATRIC PATIENTS
arise. These are summarized in Table 2.
TABLE 2 Counselling Techniques and Tools for Geriatric Counselling
Counselling Content: It is critical to
gather elderly patients’ complete healthand medication history, including non- prescription medications, herbal and folk History of conditions particularly GI, liver and kidneyComplete drug use Assess drug-taking ability and factors that may contribute Part of an elderly patient’s assessment situation, social supports, need for assis- tance with daily living activities, and abil- ity to take medications, and referrals for assessment by home-care, dietitian, social worker, or other health-care professionals At first patient meeting and when new drugs added In pharmacy, clinic, doctor’s office or home conducted with elderly patients as condi- tions, medications and dosage may change.
Use pre-planned format, e.g. “Just Checking” Focus on issues of importance to drug use in the elderly andvarious recommendations their families, care-givers and other health-care professionals involved should be Use strategies to maximize learning ability Actions to reduce each factor that contributes to nonadherence Educate and involve care-givers about drugs and DRPs Assist patients to find support if needed Offer services to elderly and care-givers about a new drug, it is important to con- sider any assistance the patient may needin taking the medication, including issuessuch as scheduling in relation to other medication assessment, to administer such medications, diet and cognitive abilities. Memory and Mental Deterioration:
fessional to identify a senior patient expe- blister packaging, and refer patients for important that they be presented in a way home-care visits to assist in taking medi- that is not frightening and easily under- Learning Style and Time: Difficulty
registering new information and retrieving may not be attributed to medication use.
simple format (i.e. short lists) and uncom- information, it should be provided as sim- plicated content.16 More reinforcement is ply as possible. To avoid overwhelming the needed to learn new material, so material should be reviewed regularly. Motor tasks may make excuses or deny any problems.
tend to be done more slowly in order to be many medications. A variety of counselling patient’s physician should be notified of performing and learning tasks like inhaler relieve the volume of material. Providing use.15 Problem-solving ability can be assist- the patient with a series of questions may There are tests a health professional can material, relating it where possible to pre- Conducting Medication Reviews:
administer to assess mental status such as the Short Mental Status questionnaire.23 A series of simple questions are asked (e.g.
COUNSELLING TECHNIQUES AND
Following a pre-planned format is helpful TOOLS FOR GERIATRIC COUNSELLING
and the patient is asked to do some simple PHARMACISTS SHOULD BE PREPARED TO
“Just Checking” program is an ideal tool Canadian Pharmacists Association, in col- Pharmacists may be in a position, during a COUNSELLING GERIATRIC PATIENTS
affect everyday life such as excessive uri- and tested for efficacy by pharmacists.24,25 ground noise, to allow patient to focus on pharmacist assessment tool, and forms for • Utilize patient’s experiences or knowl- • Difficulty hearing or seeing instructions tified problems and follow-up plan. There • Inquire and be alert to signs of difficul- are tips on enhancing relations with older ties. Provide written materials in larger print, and speak clearly in a quiet, well-lit tion issues, and dealing with specific prob- patient to learn in his or her own time.
Pause frequently. Allow time to respond.
• Inability to take medication (difficulty • Present material over several sessions.
available in print or computer-based for- attention paid to physical issues (e.g. put- • Review medication profile of patients • Provide the same information visually • Belief that drug is not needed or per- whose clinical condition has changed.
ceived lack of efficacy - Explain the pur- • Monitor regularly and have a high index • Provide positive feedback (avoid criti- pose of the medication, how the drug will of suspicion for adverse reactions (symp- toms may present atypically or be attrib- • Attend to visual and auditory needs e.g.
effects of not adhering. If the patient is uted to medication) and interactions, par- allow plenty of light, larger print, etc.
still unconvinced, negotiate with them for drugs and during times of acute illness.
that the drug is working, such as regular • Assess medications of elderly patients cation (e.g. What is the generic or brand blood pressure readings or checking pulse.
• Drugs (particularly psychoactive drugs) improve their quality of life (even if they should be started at the lowest dose pos- feel they have little time left). Suggest Improving Compliance: To assist
they also discuss this with their physician.
• Aggressively review psychoactive med- medication adherence in elderly patients, • Fear of side effects - Elderly patients recognize that drugs have side effects and tiate effects of psychoactive medications.
identified. During counselling, the phar- medications that may result in falls.
effects and warn patients of this potential.
of side effects, it is better to clearly state • Where possible, reduce polypharmacy. ety of factors/reasons that will contribute the risk. “One in 100,000” is better than • Avoid drugs with high risk of cognitive saying “occasionally” or “a few people.” effects such as hypnotics, narcotics, drugs how to deal with specific reasons for non- of these generalizations. It is more impor- • Note the constipation effects of many • Misunderstanding the purpose or belief a discussion of the benefits of the drug.
• Involve the patient and care-giver in care.
• Cost - Fortunately, in Canada, most eld- • Ensure the patient can use administra- potential effects of not adhering, e.g. risk of stroke if daily ASA is not taken.
• Negotiate a regimen the patient can tol- • Forgetfulness - Use dosettes or charts Teaching/Learning Strategies: Because
relation to their normal daily activities that patients will occasionally have to pay elderly patients may have cognitive, hear- (e.g. take after walking dog in the after- for medications. Clearly justify the bene- fits (or recommend an alternative that is and unwell, attention needs to be paid to • Adverse effects - Identify when adverse covered) and if possible refer the patient drug reactions are occurring, but also dis- vided. The following strategies should be COUNSELLING GERIATRIC PATIENTS
inappropriate use of prescription medication in appreciative of pharmacy services, and it 12. Virani A. Drugdaze – How to prevent or manage drug-induced cognitive impairment.
Pharmacy Practice 2003;19(10):35-43,47.
1. Martin-Matthews A. Health Canada. The Health Transition Fund. Synthesis series: Senior’s health.
Available online at www.preventionsource.bc.ca/ Available at www.hc-sc.gc.ca/htf-fass/english/ source/003b.html. Accessed April 8, 2004.
seniors_en.pdf. Accessed April 6, 2004.
14. Rantucci, M. Tailoring counseling. In: 2. Selected Highlights from a Portrait of Pharmacists Talking with Patients – A Guide to Seniors in Canada. Statistics Canada. Available Patient Counseling. Williams & Wilkins, Baltimore Community and Family Support:
online at www.statcan.ca/english/ads/89-519- The patient’s environment and support of XPE/link.htm. Accessed April 6, 2004.
15. Peterson DA. Facilitating education for family, friends and care-givers are impor- 3. Sellors J, Kaczorowski J, Sellors J, et al. A older learners. San Francisco, Jossey-Bass, 1983.
randomized controlled trial of a pharmacist con- 16. Moore, SR. Cognitive variants in the eld- sultation program for family physicians and their erly: An integral part of medication counseling.
elderly patients. CMAJ 2003:169(1):17-22.
Drug Int & Clin Pharm 1983;17(Nov):840-2.
4. Canada’s Aging Population, report pre- selling sessions and provided with written pared by Health Canada in collaboration with are identified, they should be involved in Seniors Issues. Available online at www.hc-gc.ca/ 18. Powers R. Emergency department patient literacy and readability of patient-directed seniors.aines/pubs/fed_paper/pdfs/fedpager_e.pdf.
materials. Ann Emerg Med 1988:17(2):124-6.
sion of the patient). If there is no such 5. Health care delivery. In: The Merck manual 19. Tindall W, Beardsley R, Kimberlin C.
of diagnosis and therapy. Sec. 21. Special sub- Communications in special situations. In: Communication Skills in Pharmacy Practice. 3rd jects. Geriatric Medicine. Available online at Raising Awareness: Elderly patients
Ed. Lea & Febiger, Baltimore, 1993: p.141-57.
www.merck.com/mrkshared/mmanual/section21/ 20. Tjam E, Fletcher P, Chi I. Cultural and gen- and their families are not always aware of chapter293/293b.jsp. Accessed April 7, 2004. der diversity in health. Stride 2004;6(1):4-9.
the increased risks posed by drug therapy 6. Pavlakovic, R. Geriatrics: Special pharma- 21. Coe R, Professional perspective on the aged.
cotherapy considerations. CE lesson in Pharmacy In: Aging, the individual and Society, Ed. Quadagno potential risks and valuable services phar- J. 1980, St. Martin’s Press, New York. p.472-81 22. Smith P, Andrews J. Drug compliance not elderly. In: Drugs and Aging. Butterworths, reviews, dosettes or unit-dose packaging, so bad, knowledge not so good: The elderly after hospital discharge. Age & Ageing 1983;12:336-42.
8. MacKinnon N. Early warning system – How pharmacy, make presentations to seniors’ vigilant pharmacists can prevent drug-related short mental status questionnaire. Can J on morbidity in seniors. Pharmacy Practice 2002; nursing agencies to raise awareness of the 9. Howard M, Dolovich L, Kaczorowski, Sellors C, Sellors J. Prescribing of potentially inappropriate Association, 2002. Available from the Canadian prescription medications for community dwelling Pharmacists Association, www.pharmacists.ca.
seniors. Presented at the CPhA Conference, 25. Blunt T. Evaluating just checking as a practice tool for community pharmacists. CPJ 10. Forster A, Clark H, Menard A, et al.
T IS IMPORTANT THAT PHARMACISTS ARE
Adverse events among medical patients after dis- charge from hospital. CMAJ 2004;179(3):345-9.
elderly. 13th Annual Report of the Geriatric and 11. Coambs R, Jensen P, Her, M et al. Review of the scientific literature on the prevalence, conse- Coroner for the Province of Ontario, 2002.
quences, and health costs of noncompliance and Pharmacy Connection 2004;11(2):30-1.
1. Pharmacists deal with many elderly
2. Regarding DRPs in the elderly, the
contributing to the patient’s DRPs?
patients because of all of the following
following is/are TRUE.
a) Increasing age is related to increasing a) There is an increasing number of seniors.
b) Seniors demand extra health services.
c) Up to 90% of seniors have at least one d) The elderly have six medical conditions 4. In Case 1, which of the following appears
to be an issue for the pharmacist, BB, in
e) Geriatric patients mostly have chronic dealing with CK, the elderly patient?
3. In Case 1 (in the lesson), which is a factor
COUNSELLING GERIATRIC PATIENTS
following considerations EXCEPT
a) Avoid overwhelming detail of information b) Schedule a long appointment to provide b) Workers deal with elderly in poor health 5. In what way could the pharmacist in
c) Avoid printed materials in English until Case 1 accommodate CK and improve
sure of VL’s ability to read English.
d) Provide multiple methods of education.
d) Elderly tend to be rude and uncoopera- e) Involve her daughter in educational efforts.
e) Tendency to stereotype elderly as rigid c) Suggest a home visit (by pharmacist or 10. Given what is known about VL and her
medications, which reason for noncompli-
ance would be MOST likely for VL?
16. Which statement(s) is/are TRUE about
learning and cognitive ability in the elderly?
6. All of the following classes of drugs are
b) Relating new information to previously particularly noted to result in cognitive
learned information assists problem solving.
dysfunction in the elderly EXCEPT
c) Providing long lists of information helps 11. The pharmacist arranges for VL’s
daughter to come with her mother to the
pharmacy for a medication review. Which
e) A quick demonstration of inhaler use is issue(s) should the pharmacist focus on
in the review?
17. In Case 3, which counselling techniques
VL is a 4-foot, 98-pound, 87-year-old, Asian and tools should the pharmacist use?
patient. She lives alone and is on the follow- a) Teaching strategies to maximize learning ing medications: lorazepam 1 mg HS, digoxin d) Possibility to reduce number of medica- 0.25 mg OD, ASA 325 mg OD, sennosides b) Involve care-givers or family in education OD, acetaminophen with codeine 30 mg q4h PRN, paroxetine 20 mg OD, hydrochloroth- d) Identify factors that may contribute to iazide 25 mg AM and multiple vitamin OD. 12. All of the following are cultural issues
She seldom comes to the pharmacy, but her the pharmacist should consider when
neighbour, and occasionally her daughter, dealing with VL EXCEPT
pick up prescriptions. The daughter calls the a) Potential for genetically inherited traits 18. To accommodate the needs of elderly
pharmacy to say her mother has just been patients, pharmacists should take all the
released from hospital after a fall causing a following actions EXCEPT
broken ankle and needs all her medications refilled, all of which are covered by the provin- c) Offer to dispense medications in dosettes 7. What recommendations would you make
d) Provide written information sheets to all to VL’s daughter?
DS is a 72-year-old patient who has pain medication close to her bedside.
reduced visual acuity, even when wearing glasses, and suffers from severe arthritis. 19. Pharmacist LP is planning a presenta-
tion to a local seniors’ group on safe
c) Get a three months’ supply of all med- 13. What accommodations should the
medication use. What should he/she con-
pharmacist consider when counselling DS?
sider when preparing the presentation?
a) Visual and hearing abilities of audience 8. Regarding VL, which issue(s) would the
pharmacist consider when checking for DRPs?
14. Which assumptions that the pharmacist
may make about DS are probably NOT true?
20. Which drug effects should be focused
on in a medication review with an elderly
c) Possible vision and hearing disability patient?
9. VL’s daughter asks the pharmacist to
provide some information to VL about
15. Health-care workers may feel frus-
paroxetine. The pharmacist should plan
trated and uncomfortable working with
the education session with each of the
elderly patients due to all of the following
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COUNSELLING GERIATRIC PATIENTS
Not valid for CE credits after June 30, 2007 11. a b c d e
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Type of practice
Feedback on this CE lesson
1. Do you now better understand how to counsel geriatric patients?
2. Was the information in this lesson relevant to your practice? 3. Will you be able to incorporate the information from this lesson 4. Was the information in this lesson. ❑ Too basic 5. Do you feel this lesson met its stated learning objectives? 6. What topic would you like to see covered in a future issue? _____________________ Please allow 6-8 weeks for notification of score. Fax Mayra Ramos at (416) 764-3937
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Material Safety Data Sheet 54 E. Spring Valley Pike For Poison Control Information, Dayton, OH 45458 please contact your regional Poison Control Center. Product Identity: Fura-MS Section I. Hazardous Ingredients / Identity Information Furazolidone 100% CAS #67-45-8 Section II. Physical/Chemical Characteristics Boiling Point: Not available Specific Gravity (H20 = 1)