Innovative collaborative practice to optimize pharmacotherapy for frail older patients.

Medication use among older persons presents a double-edged sword. Pharmacotherapy is an important component in the management of chronic disease, and it can reduce morbidity and mortality.1-3 At the same time, adverse drug events are common in this population, resulting in functional impairment and increasing morbidity, mortality, and health care costs.4-7 Reported rates of adverse drug events in older populations range from 10% to 30% for ambulatory and inpatients alike.8-12 Inappropriate prescribing, as indicated by explicit criterion-based or implicit judgment-based measures, increases the occurrence of adverse drug events.9,10,13-15 Therefore, the identification of inappropriate prescribing is important, as it can allow avoidance of preventable adverse drug events and optimization of pharmacotherapy for the frail older individual. Frail older adults have interacting medical and social problems that occur in conjunction with mobility issues and polypharmacy, a situation that can give rise to complex medical needs.16 Advanced age is associated with accumulation of mul tiple comorbidities, many of which are managed with medications; as a result, polypharmacy is exceedingly common in frail older adults.17 As the number of medications increases, so does the risk of drug–drug interactions and adverse drug events. Individuals with many medications tend to self-report poor health, are more likely to have cognitive impairment, and have lower functional status.18 Because polypharmacy is highly prevalent among older adults who are frail, pharmacists working with patients in this age group have an opportunity to take a leadership role in monitoring for adherence, efficacy, and toxic effects and in helping those who are frail to manage their medications effectively.19 Randomized controlled trials have shown that the involvement of pharmacists in the care of older persons not only improves the appropriateness of medication regimens but also reduces drug-related morbidity. For example, in the Senior Care Study there was a 17% absolute risk reduction in the use of inappropriate medications when a pharmacist was incorporated into a multidisciplinary geriatric assessment team.20 These data have been confirmed by subsequent studies showing similar improvements in medication appropriateness when drug use was evaluated by a clinical pharmacist.21,22 Furthermore, there was an absolute risk reduction in drug-related morbidity of 10% to 20%, as measured by hospital readmissions over a 3-month period, when clinical pharmacists provided collaborative care to older patients.23-25 This finding translated into a number needed to treat of 5 to 10; that is, when a clinical pharmacist was fully integrated into the multidisciplinary team, 1 hospital readmission was avoided for every 5 to 10 older patients discharged. A comprehensive geriatric assessment can be used to assess an older person’s medical, psychosocial, functional, and cognitive resources and problems26 and is an integral part of geriatric medicine. This assessment is an evidence-based process, based on information from the patient and collateral sources, that assesses a person’s medical conditions and corresponding medications to ensure that each medication is used for an appropriate indication. It also assesses cognition, mood, mobility (including balance and falls), bowel and bladder function, nutritional status, sensory function (especially vision and hearing), overall function (basic and instrumental activities of daily living), and social circumstances.27 Use of this assessment has significant effects in terms of improving mortality, living location, physical status, and cognitive status.27 Such assessments are typically carried out by nurses, nurse practitioners, medical residents, and physicians.28 This article describes a collaboration between a pharmacist and a team of rotating geriatricians in the performance of comprehensive geriatric assessments at a community hospital and the impact of such assessments on the appropriateness of pharmacotherapy used by the frail older patients seen through the collaborative service.