Medicines Management and Older People:
The Role of Community Pharmacy

Who is included in the term 'Older People'?

The answer to this varies depending upon which document you are reading and to whom you are talking to.

For example:

• The National Service Framework (NSF) for Older People (Department of Health March 2001) has specific targets for people aged over 75 and so perhaps this suggests that 'Older People' are aged over 75
• Many of the figures that are found in the document 'National Service Framework for Older People - a guide for community pharmacists' (PSNC March 2002) relate to patients 65 and over
• Patients aged 60 and over do not have to pay for their prescriptions and so they fall in to a group of patients which it is able to express statistically (e.g. number of prescriptions written for people over the age of 60 expressed as a percentage of total number of prescriptions written)

In addition to this, there is a drive towards primary prevention - that is, helping individuals to remain well. Stopping smoking and reducing obesity are good examples of modifiable risk factors that can reduce the risk of individuals becoming unwell. And, so whilst we might not traditionally think of patients 55 and over as 'Older People', some organisations are using this age characteristic to target individuals for healthcare advice and are using the term 'Older People'.

Governmental and healthcare organisations may choose to group individuals into age categories as a convenient way to describe them and to address them as a group - but it should not be forgotten that they remain individuals. As such their health needs are individual to them.

We all know of the persons, either patients or friends, who have been struck by multiple disease conditions at a relatively young age such that they may require the types of interventions that would more usually associated with someone of more advanced years.

Similarly, we know of 'spring chickens' who, at 80 years of age, are regularly seen to be walking everywhere, fetching errands ….. and even running marathons.

Even so, it can be helpful when discussing services to use age as a broad determinator of need, and when discussing Medicines Management and Older People the rest of this article will be adopting the age definitions of the various sources that it draws upon, most notably the NSF for Older People.

Medicines and Older People - Why is medicines management so important?

• More than £7 billion was spent on prescription medicines in England in 2002/03
• 80% of people over 75 take at least one prescribed medication, with 36% taking four or more medicines [1]
• Approximately 40% of the total NHS budget is spent on caring for people over the age of 65 [2]

The National Service Framework (NSF) for Older People states that all people over 75 should have their medication reviewed annually and those taking 4 or more medicines should have a review six monthly. These medication reviews can be conducted by a number of healthcare professionals and not just the patients' GP.

What are community pharmacists doing to support older people?

The document Medicines and Older People identifies five main types of intervention to support patients and their carers in medicines taking:

• Prescribing support and advice
• Active monitoring of treatment
• Review of repeat prescribing systems
• Medication review with individual clients and their carers
• Education and training (e.g. concordance and carer issues)

As well as helping patients get the best from their medicines, community pharmacists contribute towards disease prevention and helping older people to remain independent by providing advice on many issues, for example:

• Smoking cessation
• Improved diet and nutrition
• Increased physical activity
• Immunisation against influenza
• Independent living aids
• Management of incontinence
• Access to other services e.g. chiropody, opticians, benefits

And, similarly, community pharmacists are able to help older people who are resident within a care home setting.

What more can community pharmacy do?

It has been proposed that medication reviews can be conducted by a number of different healthcare professionals and not just the patients' GP.

In addition, there is concern as to the implications the target in the NSF has on GP workload; community pharmacists have the skills and are well placed to assist with the reviews. There are examples of medication review schemes, involving community pharmacists, in operation across England, for example, in South Derbyshire and in Manchester.

The Task Force on Medicines Partnership has done much to encourage medication review services, and has a website with downloadable tools and materials to enable services to be set up ( http://www.medicines-partnership.org/medication-review/welcome). Research in progress by Medicines Partnership has found that 47% of face to face medication reviews are now being undertaken by pharmacists - although the majority of these are being done by pharmacists employed by PCTs rather than within community pharmacy. In addition, the quality indicators for the new General Medical Services (GMS) contract, which began to be implemented in April 2004, requires general practices to carry out medication reviews every 15 months for patients being prescribed four or more repeat medicines - a task which many may be looking to delegate to pharmacists.

The Task Force on Medicines Partnership is exploring the extent to which medication reviews are being carried out and will be publishing the results in the summer of 2004. They have also recently published a patient guide to Medication Review ('Focus on your Medicines') to inform patients about what to expect and how to prepare for a medication review and to encourage them, where appropriate, to ask for one. Over 350,000 copies of the guide have been distributed through PCTs, patient organisations and Age Concern, and more are available via the Medicines Partnership website (www.medicines-partnership.org).

Medicines Partnership is about to commence a research project, in collaboration with the European Parkinson's Disease Association, Oxford University and Pharmacy Alliance, to set up a network of community pharmacists with a special interest in Parkinson's Disease who would help older people with the disease to manage their medicines by providing information and practical support. It is hoped that the project will create a model for training 'community pharmacists with a special interest', who will be able to provide additional help for people with specialist needs.

In addition, a large randomised controlled trial is due to report in mid-summer 2004 on the feasibility of a medicines management intervention delivered by community pharmacists to patients with a confirmed diagnosis of coronary heart disease (CHD). The findings of this study will be informative in the design of a disease-specific medicines management service. This type of service could be of particular value to older people, since it will be directed towards patients with chronic diseases, for example, heart disease, diabetes and COPD - conditions where prevalence can increase with age. It is more than a medication review - as well as advice on medication regimen and dosage regimen, it includes advice on concordance and lifestyle issues, as well as providing feedback to patient's GP and recommending other useful local sources (e.g. patient groups). More details on this study can be found at www.medicinesmanagement.org.uk

Single Assessment Process (SAP)

A key tool in the future for helping older people to managing their medicines is the medicines domain of the Single Assessment Process for older people. In a number of areas, including London and Devon, pilots are running to involve community pharmacists in undertaking assessments. In both areas, these have found that it is important not only to focus on practical aspects of medicine taking, but also to explore patients' views and understanding of their medicines and ensure that they are fully involved in the process. Further information on this is available from the Medicines Partnership website.

The future: All community pharmacies offer core pharmaceutical services to their local population and patients will also notice that in some areas additional services have been developed in response to need. The Department of Health is currently in negotiations with community pharmacies on the services that they provide; what this will mean for older people is that, once these negotiations are complete, services that help to support independence in older people - such as those listed on the previous page and also services including repeat dispensing, advice on medicines use and advice on compliance aids - will become available from many more pharmacies and will be delivered to a quality assured framework.

References:

   1. National Service Framework for Older People - a guide for community pharmacists, PSNC March 2002, p7

   2. National Service Framework for Older People - a guide for community pharmacists, PSNC March 2002, p1