Health care needs for the aging population are growing faster than the current limited resources can provide. With the shortage of trained geriatricians, pharmacists can fill in the gaps by addressing medication-related issues to optimize the care of older patients with multiple conditions and needs.
Pharmacists are an integral part of an interdisciplinary team in the patient-centered medical home (PCMH), as they are experts in medication management and are familiar with the pharmacokinetic and pharmacodynamic changes in the geriatric population. The pharmacists’ patient care process (PPCP) is an excellent tool that allows comprehensive and interdisciplinary collaboration, communication and documentation of relevant medical history. Furthermore, it aids in the collection of patient history, medication assessment, design and implementation of a patient-centered plan, while also providing continuous follow-up. PPCP can be implemented in a formal team setting such as a PCMH, in a separate encounter under a collaborative practice agreement (CPA) or independently with recommendations communicated to the physicians involved. The five domains of the comprehensive geriatric assessment (CGA), as proposed by the American Geriatrics Society (AGS), will be incorporated and described in the steps of the PPCP: collect, assess, plan, implement and follow-up. Patient assessment tools pertaining to the aging patient are suggested in the “collect” and “assess” steps. The Screening Tool of Older Persons’ Prescriptions (STOPP), Screening Tool to Alert to Right Treatment (START) and the Beers Criteria are utilized to develop the “plan” to ensure safe and appropriate use of medications in the older adult population. Application of these tools are described in a patient case as we describe the PPCP steps in this article.
By using the PPCP with geriatric-specific assessment tools, pharmacists can ensure comprehensive and optimal medication management for the geriatric population.
Geriatric Health Care Needs
Our population is aging faster than ever before. Currently, people are living into their mid-80s.1 The World Population Ageing 2020 report projected that the global number of persons aged 65 or over by 2050 will more than double, with the share of older persons increasing from 9.3% in 2020 to 16.0% in 2050. Furthermore, 1 in 6 people will be aged 65 or over by midcentury. While this may have a significant impact on access to health care, there are also benefits and opportunities with this aging population, including the contributions to their families, such as support for adult children or grandchildren; and to society with their voluntary work.2 However, health is the critical piece to the extent of contribution this population can provide; therefore, it is important to optimize health not only for the individual’s quality of life, but also for society.
Understanding the needs of older patients as a population is essential in designing a program that will maintain their well-being. As a population, the aging patient suffers from concurrent health problems that further increase their needs. In 2016, the Centers for Disease Control and Prevention reported that 21.8% of noninstitutionalized seniors in the U.S. 65 years or older were in fair or poor health.3 Approximately 85% of older adults manage at least one chronic condition, while 60% of older adults are managing two or more chronic conditions.4 In addition, geriatric syndromes such as dementia, delirium, falls, urinary incontinence, depression, malnutrition and insomnia are complicated to evaluate and are often affected by other diseases (Figure 1).5
Comprehensive geriatric assessment (CGA) is a process in geriatric medicine that is intended to improve a patient’s overall well-being, including physical, psychosocial, functional capabilities and social circumstances.6 The principles of CGA are practiced in PCMH programs where a highly trained interdisciplinary team of specialists works together to address the primary care needs of patients. By focusing on care that is comprehensive and patient-centered, the PCMH model delivers core functions of primary care.7 Compared to the general population, older adults require higher frequency and intensity of care to properly diagnose, assess and tailor treatment regimens specific for the individual. By ensuring this population’s health is well-managed, the opportunity exists to decrease emergency room visits and hospitalizations, which occur more with this age group than with any other.3
Burden of the Aging Population on Health Care
Due to the medical needs of a rapidly aging population, health care costs are rising. Many seniors are living on fixed incomes and cannot afford expensive medical bills and treatments. In a recent study by De Nardi et al.,8 it was found that geriatric patients needed to finance 13.2% of their medical care expenses out of pocket, while Medicare and Medicaid programs subsidized 65.5%, and private insurance/other sources contributed 21.3% of the health care expenditures in 2010. In particular, the estimated Medicare expenditure for patients over age 65 was 54.4% of the total personal health care costs of $800 billion in 2010. Between ages 70 and 90, medical expenses can more than double. Health care costs are particularly high for medical procedures and hospital stays, which compounds with hospital readmissions. Therefore, it is imperative to try and optimize medical treatments for geriatric patients early to minimize costs of managing uncontrolled health conditions and complications and to lessen the burden to the health care system.
Barriers to Health Care Access
As our geriatric population continues to expand inverse to the rest of the population, the demand for health care resources increases. Health care for older adults is recognized as complex, with limited resources specific for the aging population. According to policy research at the RAND Corporation, there is a short supply of geriatricians in the U.S., with fewer than four certified geriatricians per 10,000 individuals age 75 or older.9 Living with multiple chronic conditions is associated with higher incidence of mortality and morbidity, increased health care cost as well as a poor quality of life.10 As access to primary care providers and geriatricians becomes more difficult, older patients may also receive an inadequate level of care.
Physician extenders have an opportunity to become an integral part of healthy aging by addressing medical problems early and preventing them from progressing to more complex, costly issues. Pharmacists are well positioned as physician extenders based on their expert pharmacologic knowledge. Incorporating the PPCP and tailoring medication management strategies to the older adult population, pharmacists can improve older patients’ functionality, independence and overall health in settings such as a PCMH, a collaborative practice or independently.
The AGS developed a set of guiding principles for clinicians to provide optimal care for older adults with multimorbidity. These principles align with the patient-centered approach and include five domains: patient’s preference, interpretation of evidence, patient’s prognosis, clinical feasibility and optimization of care plans.11 A comprehensive tool such as the PPCP12 (Figure 2) allows pharmacists to be systematic in optimizing medical management of multiple chronic diseases while addressing the five domains suggested by the AGS. Table 1 identifies how the AGS domains may be incorporated in the steps of the PPCP.
Pharmacists’ Patient Care Process (PPCP) in the Aging Population
The PPCP is a resource guide released by the Joint Commission of Pharmacy Practitioners in 2014 and endorsed by 13 national pharmacy organizations. It is a patient-centered approach that allows pharmacists to collaborate and communicate with other health care team members to optimize health and medication outcomes.12 Since 2016, the PPCP has been incorporated as a standard in the Accreditation Council for Pharmacy Education (ACPE) and adopted by schools of pharmacy into their curriculum to prepare students to provide patient-centered collaborative care. In addition, it is also an American Society of Health-System Pharmacists (ASHP) accreditation standard for postgraduate year one PGY1 and year two PGY2 pharmacy residency programs to ensure safe and effective patient care.
Past Medical History: RT is an 89yo male with history of atrial fibrillation, hypertension, Alzheimer’s disease, coronary artery disease, stage 3 chronic kidney disease, chronic obstructive pulmonary disease, decreased hearing, depression, diabetes with peripheral neuropathy, medication noncompliance, gastroesophageal reflux, transient ischemic attack, hyperlipidemia, hypothyroidism, falls, left hip replacement, mitral valve insufficiency, osteoporosis, pacemaker implant, peripheral vascular disease, anxiolytic and sleep aid dependence and benign prostatic hypertrophy.
Social History: Widowed two years ago and currently lives alone; former smoker; occasional whisky
Current Compliant: “Can I get off some of these medications? I don’t have a memory problem, I don’t know why the doctor gave me Alzheimer’s medicine!”
Acetaminophen-codeine 325-25 mg q4-6h as needed
Albuterol inhaler HFA 108mcg /actuation 2 puffs q4h as needed
Allopurinol 100mg daily
Amlodipine 10mg daily
Anoro Ellipta® 62.5/25mcg 1 puff daily
Aspirin 81mg daily
Atorvastatin 40mg daily
Buspirone 5mg BID
Carvedilol 6.25mg daily
Donepezil 5mg daily
Finasteride 5mg daily
Furosemide 20mg daily
Gabapentin 100mg 2 capsules qHS
Glimepiride 4mg BID
Ibuprofen 600 mg TID prn
Levothyroxine 75mcg daily
Losartan 100mg daily
Loratadine 10 mg daily
Pantoprazole 20mg daily
Risedronate 35 mg weekly
Terazosin 5mg BID
Tramadol 50mg daily as needed
Warfarin 3mg 2 tabs daily or as directed
(Reported history of GI intolerance to metformin)
BP: 150/84, HR: 89 bpm, RR: 18, Temp: 96.9oF
Height: 5’6”, Weight: 184 lbs
Incorporating AGS Recommendations and Geriatric Assessment Tools in the PPCP for RT:
Step 1 of PPCP — Collect
The first step in the PPCP is to collect relevant subjective and objective information. In this step, it is important to identify the patient’s prognosis and treatment preference, as recommended by the AGS (Table 1).11,12 Tools appropriate for the aging patient are available to determine current medical conditions, status, adherence and response to the previous care plans. As part of the CGA, these tools13–21 (Table 2) can be utilized to identify the current status of the patient. The Geriatric Depression Scale (GDS) is recommended to screen for depression and determine its severity.14 Both the Cognitive Impairment Screening (Mini-Cog) and Mini-Mental State Examination (MMSE) can also be used to determine a patient’s mental status. These are often helpful in patients with Alzheimer’s disease or dementia.15,16 In order to determine the amount of assistance a senior needs, one can use the checklist of activities of daily living (ADL).17 To assess the risk of falls in older patients, the Get Up and Go Test will identify patients who need further evalulation.18 The Mini Nutritional Assessment (MNA) may be given to determine if a patient is malnourished and may need assistance from a nutritionist.19 For pharmacists in particular, Adherence Rating Scales (ARS) will help determine if a patient is adherent or nonadherent to their medications, which may also give insight to barriers to medication usage.20 If the patient has been recently hospitalized, a Length of Stay, Acuity, Comorbidities (LACE) test can also be performed to assess the risk of readmission. The LACE score can be used to determine how aggressive a patient’s postdischarge health care should be to prevent rehospitalization.21 While collecting the prescription medication history, reconciling nonprescription medications, supplements and nutraceuticals, it is also important to identify inappropriate drug use or interactions. Medication reconciliation is particularly important during transitions from one facility to another. According to the 2020 National Patient Safety Goals from the Joint Commission,22 it is a process of comparing medications that a patient should be taking to the newly ordered medications. This allows identification of duplicated, omitted, interactive and appropriateness of continuing the current medications. Lastly, socioeconomic factors, lifestyle habits, cultural and religious beliefs, health literacy and insurance (or lack of) coverage, will all play a role in a patient’s care plan and should be investigated and documented.
Step 2 of PPCP — Assess
The second step of the PPCP is to assess the collected information and analyze the clinical effects of previous interventions while also considering the patient’s therapeutic goals and preferences. In this step, the appropriate AGS domain to include is interpretation of high-quality evidence and apply it in patient care (Table 2).11,12 To assess for geriatric syndromes, information from the screening tools performed in Step 1 will help determine if the patient has had recent physical, mental or cognitive changes. For the case patient, information gathered from the Geriatric Depression Scale,14 cognitive impairment screening,15 Mini-Mental State Examination,16 Get Up and Go Test,18 ADL,17 and Adherence Rating Scales20 will all help to evaluate the patient’s status and determine causative factors for the falls.
To perform therapeutic assessment, pharmacists need to have collected adequate patient-specific details in the first PPCP step12 and examine the evidence for drug therapies11 in order to weigh the benefits versus risks of treatment options. Identification of patient-specific risk factors and goals must occur, followed by the prioritization of problems. When applying evidence from medical literature to geriatric patient treatment plans, the AGS recommends asking the eight questions listed in Table 3 in order to determine the validity and applicability of the information in the older population.11
Polypharmacy, commonly defined as taking five or more medications,23 is a potential problem that must be assessed when treating an older patient with multiple conditions and medications, as it may lead to higher risk of drug-related problems. Using the STOPP/START geriatric assessment tool is recommended in order to determine whether to discontinue or begin a medication. Both STOPP and START have been demonstrated to reduce polypharmacy, reduce adverse drug reactions, lead to fewer falls and decrease medical costs.13 The Beers Criteria is also widely used by clinicians to identify potentially inappropriate medication (PIM) use in older adults to minimize adverse effects based on aggravating conditions, drug interactions and renal function. Specific drug categories that can increase the risk of falls and fractures are listed in Table 4. Their use should be avoided or deprescribed, if appropriate.24
The following questions are suggested by the AGS to ask as part of medication reconciliation and assessment to confirm the appropriateness of treatment:11
Is a medication prescribed to relieve the adverse effects of another?
Is the primary medication necessary?
Considering the metabolic interactions, liver and kidney functions of a patient, is the response to medications exaggerated due to pharmacokinetic or pharmacodynamic changes in the aging process?
Is there a reasonable “time horizon to benefit” or reasonable length of time needed to accrue an observable, clinically meaningful risk reduction with a specific intervention or will the benefit of the therapy be realized within the life expectancy of a patient?
While there are many geriatric assessment tools available, their use should be tailored based on the patient’s medical needs, goals of care and life expectancy. For example, a typical baseline assessment can utilize tools such as the ADL, Get Up and Go Test, the Patient Health Questionnaire-2 (PHQ-2) for depression and MMSE. Except for reconciling medications with STOPP and START, each of these tools should only take minutes to complete. More specific tools can be used as problems are identified, and the same can be repeated over several visits to determine consistency or to catch subtle or hidden problems.
Step 3 of PPCP — Plan
The third step in the PPCP is to develop a care plan that is patient-centered, while collaborating with other health care providers and caregivers.12 As part of the AGS Domains, it is essential to keep in mind the patient’s preference to allow for some level of control by the aging patient as well as to determine the feasibility of the care plan.11 It is also important to consider the family’s wish or paid caregiver’s capability in designing an appropriate care plan. The intervention level should be appropriate for the patient’s prognosis and preference; the treatment should be affordable and practical; and the patient or caregiver should be able to implement the care steps with minimal difficulty. In designing the care plan, one should consider potential interactions not only among medications, but also between drug to nutrients, drug to diseases and disease to disease interactions, carefully avoiding the “prescribing cascade” by adding a medication to manage the side effects of another. Proposed interventions should address one modification at a time, “starting low and going slow” with new therapies and include deprescribing therapies that are ineffective or causing undesirable effects.
A comprehensive plan should also include developing strategies for providing education to patients and their caregivers regarding comorbidities, risks and benefits of medication therapy, self-management steps and an alternative plan. This may require both written and verbal instructions and may need to be repeated during each visit. Only when patients understand their diseases, status, treatment goals and treatment plans will they adhere to their prescribed regimens. Effective communication between the patient and/or caregiver and the care team providers is essential in this step to arrive at a mutually agreeable care plan that is feasible and sustainable.
Step 4 of PPCP — Implement
The fourth step in the PPCP is the implementation of the plan.12 It is anticipated that pharmacists will work collaboratively with other health care professionals to meet the multiple needs of an older patient. In particular, coordinating efforts across disciplines to promote common and nonconflicting therapeutic goals, and working as a cohesive team so the patient may benefit from a streamlined approach will be important to achieve positive outcomes instead of being under or over treated. The patient and/or caregiver should be educated and empowered to participate in the care plan. In addition, they should understand preventive measures to avoid adverse events and strategies to take in case of worsening status.
Referral to other health disciplines should be made as the need presents. In this process, open communication with patients and other providers should continue so that the care plan can be carried out seamlessly. In the PCMH model, the physical or cognitive dimension is best managed by the primary care providers, geriatric nurse practitioners, physician assistants or specialists; the functional dimension of a patient is managed by the physical therapists, occupational therapists, dietitians and social workers; and the effects of medications influencing these dimensions should be managed by the pharmacists.
In the case of a patient who fell and is status post-hip surgery, for example, a geriatrician, a pharmacist, a nurse, an occupational or physical therapist and a social worker would need to collaborate. Together, they can ensure the patient’s recovery by addressing medical conditions and therapies, functional and nutritional status and a safe home environment during the recovery process. With interdisciplinary collaboration, the AGS Domain of optimizing outcomes will be satisfied by implementing a comprehensive plan that addresses the evolving needs and treatment goals for an aging patient.
Step 5 of PPCP — Follow-Up
The last step of PPCP is to follow-up.12 Here the pharmacist continues to monitor and evaluate the response to the medical treatment. Based on the changing status of the patient with multiple therapies and comorbidities, the care plan will also need to be adjusted accordingly. New evidence, new therapeutic goals and patient’s new preferences should be considered. In this respect, a PCMH program follows up with regular case conferences to reassess priorities and provide necessary resources for each patient in a timely manner. Different team members may address different needs at different times; the intensity of interventions may also change as the aging patient continues to live with chronic conditions. The last AGS Domain that aligns in this step is the evaluation of all domains,11 which is encompassing and indicates a continuum of assessment that is necessary for the changing status in an aging patient.
Application of AGS Principles and PPCP in the Patient Case
During the visit with RT, the pharmacist collected the necessary information regarding his medications and health status. A medication reconciliation was performed to get an accurate list of medications that the patient was and was not taking. Based on RT’s age and past medical history of Alzheimer’s disease, falls and osteoporosis, he was eligible to take six tests from Table 2: Geriatric Depression Scale,14 cognitive impairment screening,15 Mini-Mental State Examination,16 Adherence Rating Scales (DAI-10),20 ADL,17 and the Get Up and Go Test.18 The patient received the following scores:
The next step is to assess the patient using the information gathered from the geriatric assessment tools and medication reconciliation to assess any changes that should be made. According to the low scores on RT’s cognitive impairment screening and MMSE,15,16 he has mild cognitive impairment, which may inhibit his ability to take his medications consistently. Supporting this finding is RT’s DAI-1020 score of −2, which indicates medication nonadherence. Although the patient is able to perform most of the ADL17 independently, according to his performance on the Get Up and Go Test,18 RT continues to be at risk for falling.
Based on the START criteria, RT should be supplemented with 1,200 mg calcium and 800 IU of vitamin D3 daily due to his history of osteoporosis, potential for future falls and bone fractures.13,25 According to the STOPP13 and Beers Criteria,24 several medications are potentially inappropriate and should be considered for discontinuation. Nonsteroidal anti-inflammatory drugs like ibuprofen could enhance the risk of bruising and bleeding in RT because he is on warfarin and aspirin. Proton-pump inhibitors such as pantoprazole should be evaluated for its indication and need because its long-term use may increase the risk of C. difficile infection, pneumonia, bone fractures and hypomagnesemia in older patients. Chronic use of acetaminophen with codeine and tramadol is discouraged, especially for RT who has a history of falls. In addition, when loratadine or gabapentin is taken with tramadol and acetaminophen with codeine, patients are at risk of depressed mood and confusion, which may worsen RT’s depression and Alzheimer’s disease. Therefore, all four of these medications should be evaluated for their indications and benefits versus adverse effects to determine if they should be kept as part of RT’s regimen.
Based on RT’s multiple comorbidities, cognitive decline and advanced age, the American Diabetes Association has recommended that glycemic control be less stringent, aiming toward a glycosylated hemoglobin (A1C) goal of <8–8.5%, versus the standard <7%.26 In addition, the patient’s current diabetes regimen of glimepiride is identified by the Beers Criteria as a potentially inappropriate medication due to its higher risk of severe prolonged hypoglycemia in older adults.24 Since RT’s A1C is already at 6.7%, we decided to switch from maximally dosed glimepiride to the low dose sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor. Although metformin is a first-line agent, we did not consider this option due to the patient’s previous gastrointestinal side effects with this medication. While sodium glucose co-transporter 2 (SGLT2) inhibitors can reduce the risk of major adverse cardiovascular events in adults like RT with type 2 diabetes and established cardiovascular disease, they are also avoided due to the potential side effects of bone fracture and genital or urinary tract infections.
After assessing RT’s medications and discussing the potential benefits and risks with him and his primary care provider, the plan was to discontinue ibuprofen, acetaminophen with codeine, and tramadol because all of them were taken as needed without any significant pain relief. We suggested that RT take plain acetaminophen 500 mg-1000 mg twice daily for a more sustained pain control while waiting to assess response with the current dose of gabapentin, in addition to a calcium with vitamin D supplement (600 mg calcium-500 IU vitamin D3) twice daily. We also explained the rationale for a more conservative A1C goal, discontinuation of glimepiride and recommended that RT start taking sitagliptin 50mg daily. Furthermore, we suggested a trial of tapering off the pantoprazole because there was no history of peptic ulcer disease, and it was a prescription that was given when RT was discharged from his hip replacement procedure three years prior but continued to be refilled without a clear indication. RT’s performance from the assessment tools was reviewed with him, his caregiver and the care team together to bring awareness of his health status. Furthermore, the pharmacist provided unbiased education regarding the benefits and risks of donepezil, and the patient was encouraged to continue that discussion with his primary care provider regarding this treatment. Lastly, due to RT’s declining cognitive function, we recommended using a pill box or having a caregiver help with medication use in order to improve his adherence. His new medication plan was updated and a medication list with indications, time of administration and amount to be taken was printed for RT’s and the caregiver’s easy reference until his next appointment.
Implementation of the plan should be based on the patient’s comfort level and accessibility (if there are new medications recommended). Although RT agreed to the recommended changes in the treatment plan, upon his follow-up appointment, he reported that he continued taking tramadol due to pain level increasing from 4 to 6 out of 10 without it. Realizing RT’s pain could be multifactorial, a referral was placed to the pain management office. Upon discussing RT’s progress with his primary care provider, it was decided to engage his cardiologist, neurologist, psychiatrist, social worker and physical therapist to assess and address RT’s health care needs as a team.
RT was given regular follow-up appointments with the pharmacist to ensure his understanding and adherence to medications. A laboratory order for A1C and basic metabolic panel was placed to evaluate diabetes control and kidney function in three months. Continuous open communication and sharing of new treatment goals by providers as well as a case management approach allows for appropriate medication adjustment that is patient-centered.
Recognizing the continuous cycle of the PPCP during care transitions and identifying barriers to its implementation are essential for the care of the growing aging population. In addition, the overarching concept of healthy aging should be addressed to optimize overall independence and functionality.27 As seen in the patient case, pharmacists can improve their understanding of geriatric patient needs while collaborating with interdisciplinary team members as well as working with the patient’s family, friends and/or caregivers to identify the needs and feasibility of care plans. To be a competent and valuable team member in the continuum of care for the aging patient population, it is essential for a pharmacist to continue to acquire training in evidence-based therapeutics for the geriatric population, participate in effective care models such as the PCMH and adopt a patient-centered approach.
The overall goal of geriatric health care is to achieve quality of life while aging with grace and dignity. Applying the five steps in the PPCP (Figure 2),11 keeping in mind the five domains from the AGS11 (Table 1) and using specific geriatric assessment tools (Table 2),13–21 we can achieve this goal and promote consistency for the delivery of optimal geriatric pharmaceutical care. Most importantly, adopting a patientcentered approach allows pharmacists to truly meet the needs of the individual aging patient.