New research has found that effective pharmacist-doctor collaboration is a necessity in providing quality care to the elderly in residential facilities. Megan Stoyles reports.
Doctors treating 56 residents in a Victorian residential aged care facility, who were taking an average of nine medications, ignored almost one in three pharmacist recommendations to review, change or discontinue the medications, despite the potential dangers caused by polypharmacy, according to a recent Australian study.
However, the researcher involved has emphasised that this is an improvement on previous findings in other health care settings.
The investigating pharmacist had made 196 recommendations for medication changes, with the more medications the residents were on the more likely the pharmacist recommended changed medication management.
The study was undertaken after the start of a Residential Medication Management Review program (RMMR), which encourages and funds collaboration between pharmacists and medical practitioners in order to support resident care.
Dr Hanan Khalil from Monash University's School of Rural Health wrote in the Australian Journal of Primary Health that alteration to drug monitoring to reduce potential side effects and control symptoms was the main reason (49 per cent) for the pharmacist recommendation.
Drug monitoring occurred when residents were due to have their six monthly or 12 monthly liver and renal function tests if they were on drugs such as diuretics, anti-epileptics, long-term use of antibiotics, antidiabetics medications and immune-suppressants.
Other examples of alterations to drug monitoring can involve residents who are taking low therapeutic index medications such as digoxin, lithium and thyroxine, and who had not had blood levels done for six months or more.
Discontinuation of drug treatment (19 per cent of cases) was the second significant reason for the pharmacist recommendation. Examples included where there was no clear indication listed for the resident in the notes, or where the resident's condition had improved and no longer needed the particular medication. Examples of such drugs included proton pump inhibitors, steroid creams and benzodiazepines.
In some instances, some of the medications were started earlier and some were added on to the residents' medication list after they had been admitted to hospital and had not been reviewed since.
Examples of reducing potential side effects were when a resident was on a regular angiotensin converting enzyme inhibitor and a diuretic and had been prescribed a non-steroidal anti-inflammatory drug or when residents were prescribed two classes of drugs that will synergistically cause sedation or hypotension.
The drugs that were associated with most of the recommendations belonged to cardiovascular, anti-platelets/anticoagulants and psychotropic classes.
These drugs are also among the most widely prescribed drugs for elderly people because they have various indications, such as hypertension, heart failure, angina, stroke, depression, insomnia, dementia and psychiatric disorders.
Most of the drugs that belong to these classes usually require regular monitoring of renal and hepatic functions and also have several significant clinical drug interactions.
Dr Khalil reported that the reasons for doctors not taking up the required recommendations varied: some were due to patients not in favour of them, others were implemented earlier and some of these recommendations were simply not taken up.
She believes that appropriate prescribing in older people is 'challenging'.
"Most elderly people generally tend to avoid further diagnostic testing and hospitalisation," she wrote.
"Furthermore, most treatments are mainly palliative, which are consistent with life expectancy, benefits of treatment and goals of care... Hence, goals of care can be challenging for the treating doctors."
Falinski found that "as 70 per cent of the pharmacist's recommendations were being implemented by general practitioners... pharmacist-doctor collaboration is effective in managing elderly people in aged care facilities.
"While this study has provided valuable information about the Australian RMMR model in aged care facilities, more work is required to ensure that pharmacist recommendations are aligned with current evidence based practice."
Comment