There are now more people aged over 65 than there are children under 15 years, and more centenarians than ever before. Victoria Goldman considers pharmacists’ role in the care of the elderly

The over-65s are the fastest growing age group in the UK. According to the Office for National Statistics (ONS), there were just 2,420 people over the age of 100 in 1981 across England and Wales. In just over 30 years, the figure has shot up to 12,320 and there are now 610 people aged 105 or more.

The definition of older people is changing, and retirement is no longer seen as a precursor to physical and mental decline.

Many over-65s lead full working and social lives and stay healthy and active well into their 70s and 80s. However, as people get older they become more prone to chronic diseases and disabilities, which can eventually affect their independence and lead them to become more frail.

In July 2013, the Department of Health sought views on a set of proposals to radically improve care for vulnerable older people. The proposals included better support for older people to stay healthy (with a particular focus on the diagnosis, management and self-care of chronic conditions), improving access to primary care, better sharing of information and joining up services.

Accessible professionals

According to Pharmacy Voice, responding to the Department of Health’s consultation, community pharmacists are the most accessible healthcare professionals, available without appointment, and typically see patients more frequently than any other healthcare provider. This means pharmacists and pharmacy staff can be the first to notice when things are amiss.

Older people are the biggest users of healthcare services and tend to visit pharmacies more regularly than any other age group. They are more likely to develop one or more chronic condition with advancing age, which increases the chances of polypharmacy, poor compliance and safety concerns. According to the Royal Pharmaceutical Society (RPS), only 16 per cent of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need. Ten days after starting a medicine, almost a third of patients are already non-adherent – of these, 55 per cent don’t realise they are not taking their medicines correctly.

Medicines optimisation is high on the pharmacy agenda. It looks at how patients use medicines over time and considers opportunities for lifestyle changes and non-medical therapies. Ultimately, medicines optimisation can help encourage patients to take ownership of their treatment.

“Generally speaking, medicines optimisation is about putting the patient at the centre,” says RPS spokesperson Lelly Obeh, a consultant pharmacist who specialises in the care of older people. “Medicines management always looked at activity related to medicines and prescribing the right medicines most cost-effectively. Medicines optimisation takes this a step further. Rather than treating people as just a collection of symptoms, it gives consideration to how the patient feels and their experience with their medicines in the context of their life.”

Nina Barnett, consultant pharmacist (older people) at North West London Hospitals Trust, says that the New Medicine Service (NMS) and MURs enable pharmacists to further develop their relationship with customers. “While some people have practical issues and may benefit from practical help, such as a pill organiser, large labels or help with delivery, others will have their own beliefs and concerns about why they should or shouldn’t be taking their medicines, and these need to be addressed,” she says.

Opening up a conversation

Pharmacists need to consider patients’ experiences and expectations when it comes to taking medicines. “For example, a stroke patient may believe that their medicines, which are given to reduce the risk of further strokes, will help them get mobility back in their affected limbs and, when they find they aren’t doing that, stop taking them. Questions such as: ‘What do you want your medicines to do for you?’ and, ‘What changes have you noticed since taking your medicines?’, can open up a conversation.”

Nitin Makadia, condition category manager for Lloydspharmacy, says that older people often have difficulties understanding when and how to take their medicines. “It may be that they simply can’t read the small text and need assistance with this, but more crucially they may be getting confused by the raft of medication that they are taking,” he says.

And many older people may be troubled by minor side-effects that stop them from taking their medicines correctly. Pharmacists should stock a good range of tablet organisers, monitored dosage systems and automatic dispensers. “However, it’s equally as important to guide your patients on how to use these, as is advising them on dosages. To help your patient further, you could see them once a week and organise their pills for them in their boxes to minimise confusion and increase adherence, but this must always be done in agreement with the patient’s GP.”

Management options

Some pharmacy customers may benefit from extra management strategies if they have certain medical conditions – and this may not be something that their GP has picked up on. “In addition to prescribed medicines, pharmacists should always be aware of supplements that can help to maintain health,” says Mr Makadia. “For instance, if a patient is at risk of osteoporosis they should be advised to take a calcium supplement. Should they have arthritis, for example, you could make them aware of local classes for physiotherapy, hydrotherapy or occupational therapy while guiding them on various remedies to help ease the pain.”

Falls prevention is another area in which pharmacists can play a vital role, particularly by identifying customers at risk and recommending strategies to reduce further falls and fractures (eg, vitamin D and calcium supplements and suitable forms of exercise). According to Age UK, more than three million people over 65 in the UK suffer a fall each year.

And a National Osteoporosis Society survey in Autumn 2013, published for the charity’s new ‘Stop at One’ awareness campaign, revealed that all too often GPs and hospital staff are failing to discuss bone health with patients who had broken a bone. One in 10 people who had suffered more than three broken bones said they had never discussed the condition, or their bone health, with the healthcare professionals treating them.

“It’s important to ask whether patients have had a fall in the last year, as this won’t always be apparent,” says Ms Obeh. “Exercise is really important, especially for those who are housebound or have poor mobility, to reduce the risk of falls.” Pharmacists should also check that customers prescribed bisphosphonates are taking them properly.

Deteriorating health

A whole host of social and health issues can impact on an older customer’s quality of life, leading to deteriorating mental and physical wellbeing. In November 2013, the Care Quality Commission revealed that more than 9 per cent of people aged 75 and over were admitted to hospital accident and emergency departments in England in 2012, despite having ‘an avoidable condition’, such as dehydration, the inhalation of food or liquid, abnormal weight loss or urinary tract infection.

“Pharmacists should work with other healthcare professionals to find out the triage signs and red flags in older people,” says Ms Barnett. “For example, a urinary tract or chest infection may be the cause of recent onset confusion. There may also be indicators of frailty that pharmacists can identify, such as a customer losing more than 5 per cent of their bodyweight unintentionally over the past six months, or being unable to walk as far as they used to.”