Exploring pharmacist-led medication optimisation strategies for older patients with polypharmacy : from medication scheme to medication review

Chapter 1, starts with describing the challenges in optimising older patients’ medication use. The older population is growing and since ageing depends on different factors such as personal characteristics, our genetic inheritance, the physical and social environments in which we live and the local health policy in combination with our access to healthcare there, there is a great diversity in ageing. Combined with age-related changes in pharmacokinetics and pharmacodynamics, reduced physical functions or disabilities, multimorbidity and consequently the use of multiple medications at the same time (i.e. polypharmacy, which is generally described as the use of at least five chronic medications simultaneously) older people are more vulnerable to drug-related problems (DRPs) such as inappropriate medication use, interactions, adverse drug reactions and nonadherence. This means that benefits and risks should be carefully weighed for every medication being used in this older population. When medication risks prevail (e.g. therapy is not evidence-based or optimised according the patient’s clinical conditions or needs and/or without careful monitoring) this can be considered as ‘inappropriate polypharmacy’. This inappropriate polypharmacy results in an increased risk of DRPs and has been associated with negative outcomes such as adverse drug events, geriatric syndromes, hospital admissions, increased healthcare costs and even mortality. Another challenge is the lack of evidence-based guidelines for patients with multimorbidity that can guide healthcare professionals in this process. Importantly, some patients have higher risks for negative outcomes than others. Therefore, we should focus our medication optimisation strategies on these high-risk situations or patients to increase the effectiveness of our interventions. High-risk situations can be medication-, patient-, disease-, or healthcare professional-related and are often identified by the presence of certain factors such as taking multiple medications simultaneously (e.g. five to ten medications), using high-risk medication (such as anticoagulants, NSAIDs, agents working on the central nervous system), multimorbidity, dependent living situation and nonadherence. Pharmacists can expand their role as medication experts by initiating medication optimisation strategies for older patients in primary care. A first pharmacist-led optimisation intervention can comprise medication reconciliation (constructing and communicating the patient’s most accurate medication list by resolving detected discrepancies) with for example ‘medication regimen simplification’, performed at care transitions or when medication is changed. The construction of an up-to-date and accurate medication list can be seen as the first step in performing pharmacist-led medication reviews, which is a second example of a medication optimisation strategy. A medication review can be described as a “structured evaluation of a patient’s medicines with the aim of optimising medicines use and improving health outcomes. This entails detecting DRPs and recommending interventions”. A medication screening tool such as the GheOP3S -tool can support the detection of DRPs during medication reviews. Key aspects in these strategies are the patient-tailored (reflecting the patient’s wishes and needs) approach and the interprofessional collaboration (e.g. with physicians, nurses) to allow for shared decision-making. The general aim of this doctoral thesis, exploring pharmacist-led medication optimisation strategies for older patients with polypharmacy, and the aims of the different studies performed in this doctoral thesis are described in Chapter 2. In Chapter 3, the role of the community pharmacist in constructing an up-to-date and accurate medication scheme for older patients with polypharmacy was investigated. This study demonstrated that a reference or family pharmacist can contribute to safe medication use by reconciling medication and by performing medication regimen simplification to construct accurate medication schemes. Participating pharmacists mainly added indications, generic or brand names, moments of intake (in relation to food) and instructions for usage to the original (nurse) medication schemes. Potential further improvements could consist of (1) checking for potential omissions of medications not present on the original medication schemes such as ‘as needed’ medications, inhalers, eye drops and insulin. (2) In addition, as the standardised medication scheme contains 14 potential moments of intake, pharmacists should be encouraged to simplify the patient’s medication scheme (to reduce medication complexity) by for example reducing the number of administrations per day (dosing frequency), while (3) checking the correctness of these intake moments (e.g. medication effectiveness in relation to food or other medications, i.e. food and drug interactions). (4) Furthermore, more efficient interprofessional communication on potential DRPs such as adverse drug reactions and drug-drug interactions may contribute to safer medication use. Chapters 4 and 5 describe pharmacist-led medication optimisation strategies, more specifically the performance of medication reviews in the nursing home setting (Chapter 4) and in community dwelling older patients (Chapter 5). In Chapter 4, pharmacist-led medication reviews type 1 (a simple medication review based on the available medication history) using the GheOP3S -tool and with face-to-face multidisciplinary meetings for nursing home residents were investigated. The pharmacist detected a median (IQR) of 3 (2-5) GheOP3S-criteria per resident. Most prevalent criteria concerned the use of benzodiazepines/Z-drugs, antidepressants, anticholinergics with constipation and antipsychotics, which mainly resulted in recommendations to stop or substitute medications. The level of acceptance (45%) and implementation (27%, corresponding to 54% of accepted recommendations) of pharmacist recommendations were relatively low. Most common reasons for rejecting recommendations were the general practitioner’s perception of the necessity or potential benefit of the patient’s medication and the general practitioner perceiving the recommendation of inferior priority. Most frequently reported reasons for not implementing accepted recommendations were patient refusal and postponement of the intervention. Although the implementation rate was poor, the number of chronic medications and the anticholinergic/sedative burden was lower at follow-up. In Chapter 5, we explored pharmacist-led multidisciplinary medication reviews type 2a (an intermediate medication review based on the available medication history and a patient interview) with the GheOP3S -tool for community dwelling older patients. In this study, 21 pharmacists collaborated with 44 general practitioners and detected 470 DRPs with a median (IQR) of 6 (4-8) per patient in 75 patients (about half ‘GheOP3S -related DRPs’ and half ‘other DRPs’). Most prevalent types of DRPs (according to the PharmDISC classification system) were ‘contraindication’, ‘interaction’ and ‘missing patient documentation or information’, which primarily led to pharmacists’ recommendations to stop and substitute medication, to monitor therapy and to adjust the dose. The acceptance of pharmacists’ recommendations during the face-to-face pharmacist-general practitioner meetings was relatively high (67%). Nevertheless, implementation (43%, corresponding to 56% of accepted recommendations) at follow-up could be improved. The most common reasons for non-acceptance and non-implementation were the same as in Chapter 4. At follow-up, the number of GheOP3S -criteria and the anticholinergic/sedative burden significantly differed from baseline. Overall, patients’ and pharmacists’ experiences were positive, although pharmacists declared that further optimisation in the medication review process should be considered before implementing this process on a larger scale. Chapter 6 describes the revision and update of the GheOP3S -tool. We first collected users’ comments to improve the usability and appropriateness of the original GheOP3 S-tool. Next, a two-round modified Delphi process according to the RAND/UCLA appropriateness method was organised. This included a literature review, a round zero meeting, a first written round (with 15 international experts) and a second round (meeting with 11 experts) to alter, delete or add GheOP3S -criteria. An additional third round with 14 community pharmacists was set up to preserve criteria applicable in the current community pharmacy practice. This resulted in an updated tool containing 64 criteria (instead of the original 83 criteria) divided over five lists of DRPs and a new addendum containing medications that should be avoided or used with caution in older people with a reduced renal function. In Chapter 7, we conclude that pharmacists positively contributed to safe medication use in older patients by constructing up-to-date and accurate medication schemes and by performing medication reviews with the use of a supportive tool such as the GheOP3S-tool. The main strengths and limitations of our studies are also mentioned here, along with some points of attention and potential improvements for future interventions. And lastly, in Chapter 8, the findings of the performed studies were considered in a broader international context with their relevance and with future perspectives