The current healthcare system is stressed. As the population ages, the coupling of increased life expectancy with a decreased workforce means that resources (financial, human, medication supply, etc) to care for our citizens are constantly being reviewed and re-allocated.
Over the past 10-15 years, from the courses I took in school to present day, the importance of preventative therapies as a justifiable investment towards future savings has always been stressed. These savings come in the form of doctor’s visits, emergency room visits, hospital admissions, reduction in debilitating illness, or premature deaths. In actual fact, the proper term is ‘cost avoidance’ unless the healthcare system has a bank account somewhere for a rainy day. Although the disease-prevention message wasn’t new when I started, it’s been a mantra with which many of us are familiar. Through aggressive targets for things like cholesterol levels and A1C, we can keep ambulatory patients in their homes longer, and reduce the need for direct nursing care or renovations to the house (ramps, lifts, grab bars, etc).
So what happens once an individual can no longer live alone? Sometimes this is a result of a physical or mental disability, a tragic accident, or a stroke. In these cases, age does not matter. More often than not, however, nursing homes are the residences of our frail and elderly. They are from all walks of life, and from countless backgrounds. They are trusting their healthcare teams to make decisions that better, or at least maintain, the quality of life they have left to experience.
Quality of life has always been a subjective measurement. It can mean something different for each person being measured. An elderly man living at home may see quality of life as maintaining his driver’s license through glaucoma therapy. Conversely, a lady with a hip fracture may see quality of life as avoiding weekly bloodwork for her warfarin regimen. A person with diabetes in the community places priority on treating his/her neuropathy so that they can enjoy walks with their spouse. Whereas a person with diabetes on dialysis may gain enjoyment in sampling a high-sugar treat like that fresh-baked cinnamon bun from the kitchen.
A patient-focused care model certainly helps prioritize our interventions, but what other tools are there? Most guidelines use evidence from demographics representative of the larger population. Unfortunately, frail and elderly patients are usually not amongst those being targeted. I’ll use a diabetes example to illustrate: aggressive blood sugar control is the hallmark of preventing progression of the disease and its resulting sequelae. In the frail and elderly, the risk of falls is much more of a detriment to quality of life. Episodes of low blood sugar are significantly greater with aggressive control, leading to more falls. By relaxing the targets, we can manage that risk.
Fortunately, a new project is on the horizon to address these issues:
Pharmacists are drug experts and have strong opinions on what constitutes appropriate versus inappropriate prescribing. This occurs in every practice and in no way does it denigrate other practices or professions; it’s what we were specifically trained to do. Although the term polypharmacy simply refers to the use of multiple medications by a patient, it lacks a universally consistent definition in literature. It’s often used to describe excessive or unnecessary prescribing that increases the risk of adverse drug reactions, drug-drug interactions, and higher costs.
Thankfully, as pharmacists are finding increasing opportunity to collaborate within healthcare teams, we are able to use our expertise to perform impactful medication reviews in the settings of continuing and long-term care. The polypharmacy site offers a number of clinical tools and guidelines that may help in the decision-making process. Check it out. It’s a public site that anyone can access.
It’s a huge initiative, and pharmacists have the perfect skills-set to educate and implement these interventions.
Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.