Senior Care Pharmacists Research Articles

Heart Failure in Older People Part 2: Guideline-Directed Medical Therapy.

Heart failure is a common cardiovascular disease that affects older people and has a high rate of mortality. Treatment for heart failure has evolved in the past 10 years to include novel evidence-based agents as well as changes in how medications are initiated and up-titrated. Despite evidence of the importance of using four guideline-directed medications, older people are often undertreated with these lifesaving therapies. Senior care pharmacists play an important role in heart failure management among older people by providing therapeutic recommendations; monitoring therapeutic interventions; and educating patients, caregivers, and/ or providers.

Heart Failure in Older People Part 1: Disease State Review and Lifestyle Interventions.

The care for patients with heart failure (HF) has evolved greatly over the past decade. While new guidelines have provided more clarity on categorization and staging, and novel agents have been approved for use, there are still questions surrounding the optimal strategies as they relate to diet and exercise. Additionally, overall health care costs have increased for patients, driven in part by medication therapy. Given the myriad comorbidities associated with the diagnosis of HF, senior care pharmacists are positioned to positively impact the care for patients with HF, regardless of setting. As the guidelines continue to evolve, addressing a wider spectrum of the disease, including iron deficiency, mental health, and pain, so must the pharmacist's role in caring for patients with HF. Senior care pharmacists engaged in the management of older people with HF must be especially attuned to the unique and individualized care each patient needs, offering guidance and education in balancing treatment modalities across all aspects of care. In this three-part series, we will explore a number of areas central to the management of HF. This first section will focus on the cost of treatment, pathophysiology, and non-pharmacologic management. Series two and three will address guideline-directed medication therapy and special population management, respectively.

Telehealth and Pharmaceutical Care for Older People: Today and Tomorrow.

As pointed out in pieces published in this edition of The Senior Care Pharmacist, although health care services have been provided remotely for a long time, it was only with the advent of the internet that health care practitioners and their patients had the means to conduct virtual consultations. Even more sophisticated processes such as remote health monitoring have become available, and indeed to a degree, expected, by patients.

Antipsychotics in Perspective: Past, Present, and Future.

For more than half a century, there has been controversy and conflict over using psychotropic medications ("psychotropics") as strategies to modulate behavior, enhance mood, and address cognitive issues for nursing home residents. The current situation reflects a long history of investigation, reports, discussions, government and professional activity, and other attempted improvement. Although attention has focused primarily on the use of antipsychotics, particularly to manage symptoms associated with dementia, there are much broader issues. The use of all psychotropics has arguably been challenging and inconsistent. Although antipsychotic use in nursing homes has been reduced substantially, many controversies and concerns remain, such as the continuing significant use of other psychotropics. It is tempting to conclude that efforts to reduce the use of these medications might have been deliberately stymied, and that more drastic-if not coercive-measures are needed to correct these issues. However, many other compelling considerations must be defined accurately and addressed. Further improvement in the current situation requires reconsidering some current beliefs and approaches. A pause and reopening of meaningful discussion is needed. This 3-part series (in this and the next 2 issues of The Senior Care Pharmacist) will examine the history of the issues (this month), various perspectives on the issues (part 2), and lessons and recommended approaches for the future (part 3).

Diversification and Expansion of Clinical Pharmacy Services: Is it Time for Senior Care Pharmacists to Step Into the Light?

According to the American Board of Medical Specialties, there were 7,123 certified geriatricians practicing in the United States in 2021. The Health Resources and Services Administration estimates a shortage of 27,000 geriatricians in 2025. Only 43% of geriatrics fellowship spots were filled in 2022. With this forthcoming decrease in medical providers, the role of the senior care pharmacist must expand and diversify to provide an equitable level of care that older patients will need-especially with the expansion of antipsychotic, antimicrobial, and opioid stewardship programs. Senior care pharmacists possess a diverse range of skills and knowledge that are indispensable to the health care team. It is time to move beyond the consultant role, expanding both clinically and operationally, to provide the quality health care that older patients need.

Characterizing the Complexity of Senior Care Pharmacy.

Professional practice in any complex health care delivery can proceed at a hectic pace. There are often competing demands for the allocation of time and expertise. Senior care pharmacists are among several subsets within the pharmacy profession who shoulder the responsibility to provide care for and to protect older people who can be at grave risk for health problems from a variety of sources, in particular: medication-related problems. This was elegantly elaborated by influential pharmacy practitioners in practice and academia a little more than 30 years ago.

The Essential Role of Senior Care Pharmacists in Antimicrobial Stewardship: An Updated Position Statement on Behalf of the American Society of Consultant Pharmacists and the Society of Infectious Diseases Pharmacists.

Senior care pharmacists are well-positioned to lead and drive antimicrobial stewardship (AMS) initiatives, not only through audit and data collection, but also through communication, collaboration, and cooperation with prescribers and nurses to influence prescribing behaviors. Senior care pharmacists are in a unique position to take a leadership role within the interprofessional team to achieve AMS goals. They should engage with the interprofessional team to promote the judicious and appropriate use of antimicrobials at their practice sites. This position statement is an update of the 2017 version by the American Society of Consultant Pharmacists (ASCP) Antimicrobial Stewardship and Infection and Prevention Control Committee and the Society of Infectious Diseases Pharmacists (SIDP).

Infectious Disease: Historic Triumphs and Future Tragedy?

With each new source of infection has come increased understanding of the means of transmission and the development of vaccines and antibiotics to combat them. In this month's penultimate edition of Policy Currents, the author provides resources on infectious diseases for senior care and consultant pharmacists.

Pharmacists Working to Avert an Avoidable Apocalypse.

A recently published novel paper explored the frightening prospect of living in an imaginary world where antibiotics can no longer fulfill their valuable function in modern medicine. The authors of this piece demonstrate an interesting approach that they feel might motivate health care professionals to contemplate more carefully what can be done to preserve the utility of antimicrobials. In what is perhaps a more pragmatic approach, in this edition of the journal, we publish a joint position statement addressing the role of senior care pharmacists in antimicrobial stewardship. The position statement addresses a range of concepts, but of importance overall it speaks to the need for pharmacists to play an important role in preserving the efficacy of antibiotics.

Chronic Obstructive Pulmonary Disease, Part 5: Clinical Pearls for Comorbid COPD.

Chronic obstructive pulmonary disease (COPD) is often diagnosed with other comorbid conditions. This can complicate therapy overall by contributing to adverse events leading to poor outcomes to not only COPD, but other comorbid conditions. This manuscript will discuss common comorbid conditions often seen with COPD, update vaccination recommendations for COPD patients, and provide information regarding smoking cessation in COPD. The senior care pharmacist has an important role where they can recommend medication adjustments to potentially avoid these adverse events, immunize their patients appropriately, and provide assistance with smoking cessation to improve not only COPD outcomes but outcomes associated with other comorbid conditions.

A Clinician's Roadmap to the Research and Data Acquisition Process Within the Veterans Health System.

Objective Identify and address potential obstacles to initiation of older population-related research within the NF/SG VHS through the provision of a concise flowchart. Setting North Florida/South Georgia Veterans Health System (NF/SG VHS). Practice Description The Department of Veterans Affairs (VA) Research Service with connection to the University of Florida facilitates research that contributes to improving the delivery of inpatient/outpatient care to veterans and their families. Practice Innovation A compendium of a senior care pharmacist's experiences will be compiled and reviewed by other specialists within the field while attempting to submit research protocols for publication within the VHS through the use of data platforms such as VINCI (VA Informatics and Computing Infrastructure) and the Corporate Data Warehouse. Main Outcome Measurements Impact of navigating research websites affiliated with and directly pertaining to the NF/SG VHS upon clinicians attempting to begin research processes within the institution. Results It was determined that for the most expeditious publication experience to result the following six steps had to be pursued sequentially: VA Institutional Review Board (IRB) Net documentation/ submission, local myIRB submission, Data Access Request Tracker/VINCI access request, setup of VINCI workspace, drafting of VINCI cohort specification, data analysis and tracking, statistical methods, abstract, and manuscript production. Conclusion This study outlines a consistent/clear method from first-hand experiences on how to navigate, more efficiently, complex research processes to produce successful future impacts on patient care.

Chronic Obstructive Pulmonary Disease Part 3: Inhaler Technique and Counseling Pearls.

Chronic obstructive pulmonary disease therapy management can be complex given the various types of inhaler devices available, even within a therapeutic class. Appropriateness of an inhaler relies on many patient-specific factors. Senior care pharmacists can positively impact patient care by providing appropriate inhaler assessment as well as education on inhaler technique to ensure maximal benefit from therapeutic treatment choices.

Improving Care for Opioid Use Disorder in Nursing Facilities.

As this issue of The Senior Care Pharmacist focuses on elder abuse, it is critical to recognize that people with opioid use disorder (OUD) are federally protected under the Americans with Disabilities Act (ADA). This was affirmed in 2022 by physician and Director of the Office of National Drug Control Policy, Dr. Rahul Gupta, in a recent public workshop on medications for opioid use disorder (MOUD) hosted by the National Academies of Sciences, Engineering, and Medicine. While the ADA specifies that discrimination against those with OUD is illegal, it also affords legal protection to access to health services and treatment for those with OUD that includes skilled nursing facilities (SNFs). The policy guidance document from the US Department of Justice Civil Rights Division titled “The ADA and Opioid Use Disorder: Combating Discrimination Against People in Treatment or Recovery” explicitly states that if a SNF refuses to admit a patient with OUD predicated on the patient taking a clinician prescribed MOUD or the SNF prohibited any of its patients from taking MOUD, then this exclusion/prohibition would be in violation of the ADA. Refusal to provide care for patients experiencing a drug overdose at emergency departments or to provide health services for a patient with OUD are also in violation of the ADA. The refusal of a city to open an OUD treatment center on the basis of hostility toward people with OUD may also be in violation of the ADA.

What Is the Role of a Pharmacist in the Management of Complexity as It Applies to the Older Patient?

The theme of this issue of The Senior Care Pharmacist is complexity of the older patient. As a clinical pharmacologist working in the Australian health care system, I see the vital role of pharmacists in the management of complexity in older patients, and I imagine that there are similar potential contributions in other health care systems. The terms complicated and complex are frequently used interchangeably, but they imply distinct entities and understandings.

Chronic Obstructive Pulmonary Disease, Part 1: Disease State Review

In 2018, chronic obstructive pulmonary disease (COPD) was estimated to affect 16.4 million people, or 6.6% of adults in the United States alone. In older people, the estimated prevalence is even higher with reported rates as high as 14.2% in adults older than 65 years of age. COPD is a preventable disease caused by repetitive exposure to noxious particles, especially inhaled toxins from cigarette smoke. It is associated with decreased quality of life, increased hospitalization, increased mortality, and significant financial burden to patients and health care systems. Senior care pharmacists are well-suited to provide assessment, treatment, and patient education related to COPD and smoking cessation. Early and frequent interventions can decrease symptom burden, reduce costs, and improve the lives of those with COPD.

How Low Should We Go? Managing Hypertension in Older People.

This issue of The Senior Care Pharmacist includes the first of three articles related to hypertension management. These review key clinical trials regarding the evidence for treating hypertension, with a focus on older people. The first part of the series covers three key clinical trials that provide evidence related to intensive blood pressure control (below the systolic target of 140 mm Hg and closer to 120 mm Hg) in adults older than 75 years of age: HYVET, SPRINT, and STEP. These trials reiterate that older people can gain cardiovascular and mortality benefits from intensive blood pressure-lowering--but at what cost? Antihypertensive agents come with risks, most commonly hypotension, syncope, falls, electrolyte abnormalities, and acute kidney injury or failure. Pill burden is a concern, as many older people need multiple antihypertensive agents to control their blood pressure. Parts two and three of this series will explore some of the negative outcomes that can occur from going too low with intensive blood pressure control and will discuss aspects of deprescribing.

Building Demand for Deprescribing Expertise: Pharmacists as Deprescribing Care Coordinators.

A number of barriers to deprescribing exist, with knowledge, skills, and self-efficacy often highlighted by prescribers within an interrupted, siloed nature of the existing health care system. Thus, deprescribing is not likely to occur without a change in the system. Pharmacists are extremely well positioned to positively impact the deprescribing process, and particularly senior care pharmacists given familiarity with population-specific pharmacodynamic and pharmacokinetic characteristics of medications. Similarly, our health care partners have endorsed pharmacists to not only collaborate but to drive the deprescribing trials. Therefore, no other profession is better positioned to advocate for the value of deprescribing as a core component of the pharmaceutical care process.

Severe olanzapine-induced liver function test elevation.

Dear Editor:We read with great interest the case report1 on identifying olanzapine-induced liver injury in the setting of acute hepatitis C. We wanted to bring to the attention of the Mental Health Clinician readers our similar case report entitled “Olanzapine-induced elevated liver function tests in an older person with antidepressant-induced mania”, who similarly experienced significant liver function test (LFT) elevation thought to be related to olanzapine that was published in The Senior Care Pharmacist in September 2022.2Although an increase in LFTs is a known adverse effect of antipsychotics including olanzapine, this is an underappreciated adverse effect, especially as the LFT elevation can be severe. Furthermore, there is no standard of care for monitoring LFTs at baseline or how frequently during antipsychotic treatment LFTs should be monitored.Brelje et al1 cites that olanzapine-induced liver injury has been shown to occur anywhere from 12 days to 8 years after initiating olanzapine, which is similar to what we found in published reports.1,2 In the case that Brelje et al reported, LFT elevation occurred after 6 days of olanzapine therapy and ALT peaked at 1510 IU/L.1 This is similar to the case recently published in The Senior Care Pharmacist of a 67-year-old male where LFT elevation began on day 6 of olanzapine treatment and peaked on day 8 with an AST of 2024 IU/L and ALT of 1508 IU/L.2If drug-induced liver injury or adverse effects of antipsychotics are topics of interest to the reader, we encourage you to read the Brelje et al1 article in the Mental Health Clinician as well as the Reid et al2 article in The Senior Care Pharmacist. The latter article reviews potential mechanisms of olanzapine-induced LFT elevation such as via a toxic intermediary metabolite or in relation to nonalcoholic fatty liver disease.2 Reid et al2 also summarizes 9 additional cases of olanzapine-induced LFT elevation.Brelje et al1 cites “large psychiatric professional societies have refrained from recommending widespread asymptomatic testing”(p213) of hepatic enzymes. However, both articles highlight how significantly elevated LFTs can become within 1 week of starting olanzapine treatment. We encourage readers to incorporate baseline monitoring and consider rechecking within 1 to 2 weeks of initiation with continued monitoring of LFTs in patients treated with antipsychotics including olanzapine into their routine practice.

Responding to "Assessing the Impact of the Consultant Pharmacist on Pneumococcal Vaccine Administration in a Long-term Care Facility".

In this letter to the editor, Dr. Cross responds to an article in the November issue of The Senior Care Pharmacist and discusses the onsite, embedded long-term care facility pharmacist model, which is under development and due to launch nationally in 2023 in Australia.

Responding to "Senior Care Pharmacists Must Be the Disruptive Force that Reduces Adverse Drug Events in Older People".

Assistant professor Nadia Khartabil from West Coast University responds to the guest editorial written by assistant editor Jonathan H. Watanabe in the July issue of The Senior Care Pharmacist. And Dr. Watanabe provides a complementary response to their letter.