Community pharmacists’ roles in supporting older people has changed drastically in the last 10 years, as Kathy Oxtoby discovers…

When Lindsey Fairbrother, owner and superintendent pharmacist of Goodlife Pharmacy in Derbyshire, realised one of her older patients hadn’t turned up for his flu jab she didn’t hesitate to rang his home to see if he was alright.

“A paramedic answered the phone. He said that the gentleman had had a fall,” she recalls. “It was important that I was looking out for him. It’s what community pharmacists do - supporting older people, because we care.”

With an ageing population – there were nearly 12 million people aged 65 and above in the UK in 2018, according to the ONS – the need for community support has never been greater.

And pharmacies are well placed to offer valuable support to older people, Caroline Abrahams, charity director at Age UK, believes. “As well as advising on common ailments and medicines they can also help people access the right services at the right time,” she says.

Pharmacists embedded in their communities are in a “great position to provide tailored support to help older people stay as well as possible; whether that’s encouraging someone to take part in regular exercise, eat a balanced diet or cut down on smoking and alcohol consumption.

“They can also help to identify and offer support to older people who are living with frailty, who are at risk of malnutrition or falling, or who may be socially isolated or lonely,” she says.

Community pharmacists’ role in supporting older people has changed “drastically” over the last decade, says Lila Thakerar, superintendent pharmacist, Shaftesbury Pharmacy, Harrow. “We have more clinical responsibilities, and are encouraged to monitor older people’s adherence to medications, their compliance, and their overall wellbeing.”

Managing long term conditions and looking at adverse reactions to medication such as diuretics and non steroid anti-inflammatories, and falls awareness, are just some of issues pharmacists need to aware of when caring for older patients, says Sid Dajani, of Wainrights Chemist, Bishopstoke, Hampshire.

However, a key responsibility is being taken away from pharmacy contractors in England to the detriment of older people’s care, warns Ms Fairbrother. “The NHS in its wisdom is removing MURs from the remit of community pharmacists. This will make it more difficult to have good conversations with older people about their medications,” she says.

She points out that the relationship with older people and their community pharmacist is “unlike anything else in the NHS”, and that transferring MURs to “GP surgeries means that, while GP pharmacists might have access to older people’s records, they won’t have the same long term relationship and rapport.”

Polypharmacy and overprescribing

And yet it has never been more crucial for community pharmacists to be able to review older people’s medicines in the light of concerns about polypharmacy and overprescribing. More harm than good: why more isn’t always better with older people’s medicines, a report by Age UK, found that in England more than one in 10 people aged over 65 take at least eight different prescribed medications each week.

This increases to nearly one in four people aged over 85. It is estimated that up to 50 per cent of all medicines for long term conditions are not taken as intended and around one in five prescriptions for older people living at home may be inappropriate.

“We risk undoing the many benefits of medicines and treatments if they are: prescribed in excessive numbers (where this is not clinically justified or safe); in unsafe combinations; without the consent and involvement of the older person themselves; and without support to use them properly.

“Sadly, this is the situation too many older people find themselves in and it is causing them avoidable harm,” the Age UK report said.

The report warns that older people are being admitted to hospital as an emergency from avoidable health problems including an increased risk of falls and confusion. This can follow adverse reactions to medicines or be caused by unchecked prescribing of multiple medications that each cause dizziness, nausea or that affects cognition, having a serious cumulative effect.

Recommendations by the charity include zero tolerance to inappropriate polypharmacy, that older people must be fully supported and involved in decisions about their medicines, and that high quality medicines reviews should be routine for all older people taking long-term medicines.

Pharmacists are “central to tackling polypharmacy and ensuring older people are getting the best from their medications, including advising people about how to take medications correctly, undertaking medication reviews and supporting people to manage side effects”, says Ms Abrahams.

Given the scale of inappropriate polypharmacy, “pharmacists should be at last as focused on ‘deprescribing’ as prescribing”, says Graham Phillips, superintendent pharmacist for the Manor Pharmacy Group in Hertfordshire.

“In many cases GPs are following prescribing protocols that fail to take account of the individual patient. For example, why continue to prescribe a statin for an elderly person with late-stage dementia. It will likely cause side-effects and make no contribution toward quality of life.

“Prescribing for older people needs to be reconsidered based on individual risk and the potential of being harmed by prescribing decisions. The paradigm ‘NNT vs NNH’ (numbers need to treat vs. numbers needed to harm) is very different in frail, older people.

“If we had full access to patients’ medical records and tests that would be fantastic. We would be able to fulfil our key role in medicines optimisation so much better,” he says.

Considerable advice is available on deprescribing. Guidance from the Scottish Government Polypharmacy Model of Care Group, for example, offers a seven step process for reviewing medications (1). Steps include a strong focus on what matters to each patient and an emphasis on empowering and supporting patients in their decision making around medicines.

There are also number of deprescribing initiatives, including the English Deprescribing Network (2), established to share ideas, best practice and learning “to potentially shape policy and drive change across organisations”.

Community pharmacists can also take steps to manage multiple medications in elderly patients. Ms Thakerar stresses the importance of encouraging patients with memory issues to use dosset boxes or to advise their carers how to use them. And Ms Fairbrother advocates challenging GPs if they are prescribing unnecessary medications for older patients – “I say if there’s no reason for it [the medication], then let’s please stop it,” she says.

Dementia care

Dementia care is part of pharmacy’s role, and with a commitment that continues under the new Pharmacy Quality Scheme (PQS). Community pharmacists can make “a real difference” with dementia management in older people, says Paul Edwards, clinical director at Dementia UK.  As well as managing medications and compliance, he advises community pharmacists to identify “people who look frail - particularly if they see no one on a regular basis and if they’re not coping or confused - to see a doctor”.

Given the ability to help manage dementia in older people, Mr Edwards believes there is “not the recognition of how valuable pharmacists can be and should be fully part of a system of supporting people with dementia and their families”. He advocates the importance of pharmacists working in a collaborative way with GPs “to provide advice and reassurance” for these patients.

Small steps can help build a more supportive picture for those looking to help dementia patients. Ensuring all patient-facing staff are dementia friends is one of the criteria under the prevention domain of the PQS.

For pharmacists like Mr Dajani that means appointing a pharmacy lead in dementia, making sure aisles are clear to remove obstacles, counting out money into patients’ hands, and “spending time with them, not rushing them”.

Community pharmacists can help frail people live independently at home instead of in care homes and lengthy stays in hospitals. “We want older people to live at home as long as they are safe to do so. To do that is about being there as that person on the end of a phone or visiting homes when we’re needed and for their relatives to know they can ask for our help any time,” says Ms Fairbrother.

Another aspect of supporting older people is working alongside care homes to improve medicines management. “The risk of medication related harm is particularly pronounced in care homes, with residents taking an average of eight or more medicines every day,” says Ms Abrahams.

“Staff working in care homes are not always equipped with the right training and support to understand or manage polypharmacy appropriately, and there can be confusion over whose responsibility it is to monitor medications.

“Having a trained pharmacist regularly reviewing medicines in a care home, and supporting staff and residents to manage medication regimes can make a significant difference and has been shown to reduce the incidence of falls and unplanned hospital admissions,” she says.

Encouraging exercise is one way community pharmacists can help older people to stay active and well. In September the Chief Medical Officer (CMO) announced new Physical Activity Guidelines, which find “strong evidence” that physical activity contributes to increased physical function, reduced impairment, independent living, and improved quality of life in both healthy and frail older adults. The guidelines also highlight how physical activity in later life can help treat and offset the symptoms of a range of chronic conditions, such as depression, and Parkinson’s disease.

Some of the exercise recommendations include maintaining muscle strength, balance and flexibility on at least two days a week combined with sessions involving moderate aerobic activity. “Each week older adults should aim to accumulate at least 150 minutes of moderate intensity aerobic activity, building up gradually from current levels”, the guidelines advise.

These guidelines give pharmacists an opportunity to encourage older people to be more active, which in Ms Thakerar's experience could include advising such gentle exercises as walking, swimming, or golf. But she also cautions against over exercising in this group as there are a “risk of fractures, cardiac issues and respiratory complications. Patients need to understand what their limitations are – it’s all about the individual”, she says.

A major detriment to older people’s health and wellbeing is falling, and the risk they could fall. “Pharmacists should advise that patients live in a safe environment that is suitably padded, safe from sharp objects and trip hazards. Particular care should be taken with any environment frequented by people with dementia,” says Mr Phillips.

Falls “ring emergency bells in my head”, says Ms Fairbrother “When an older person starts falling it’s probably a red flag for other issues, such as low blood pressure, and a need for an MUR should be highlighted to a GP.”

Patients at risk of falls may already be housebound, which is where a pharmacy can help with home deliveries – a regular occurrence at Ms Thakerar's pharmacy. When it comes to senior health care, community pharmacy goes above and beyond to support older people, because, as Ms Thakerar says, “it’s all about guarding the patient.”

References

1. Scottish Government Polypharmacy Model of Care Group. Polypharmacy guidance, realistic prescribing.3rd ed. Scottish Government 2018.

2. https://www.sps.nhs.uk/networks/english-deprescribing-network/

For further information about Age UK call 0800 169 6565 or visit www.ageuk.org.uk

Picture: Dean Mitchell (iStock)