526857
research-article2014
AOPXXX10.1177/1060028014526857Annals of PharmacotherapyRojas-Fernandez et al
Article
An Interdisciplinary Memory Clinic: A Novel Practice Setting for Pharmacists in Primary Care in Ontario, Canada
Annals of Pharmacotherapy 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028014526857 aop.sagepub.com
Carlos H. Rojas-Fernandez, PharmD1-4, Tejal Patel, PharmD1,3,4, and Linda Lee, MD, MCISc(FM)1,3,4
Abstract Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care–based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care–based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists’ activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic. Keywords aging, Alzheimer disease, clinical pharmacy, geriatrics, ambulatory care
Introduction Pharmacists have made great strides in developing innovative practice models in various settings as singular providers and/or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure programs, geriatric clinics, primacy care practices, and hypertension, hyperlipidemia, and diabetes clinics to name a few.1-4 Conversely, there is a paucity of literature describing the role of a pharmacist in interdisciplinary memory clinics, and less is known of a pharmacist practicing in interdisciplinary, primary care–based memory clinics.5-7 It is important to disseminate the pharmacist’s role in new clinic models in appropriate detail to guide others on how to address challenges or to assist in the development of similar models. The purpose of this article is to describe how clinical pharmacists provide collaborative care to patients presenting with cognitive concerns in a primary care– based, interdisciplinary memory clinic. To provide sufficient detail in this report, detailed analyses of medication interventions will be published separately as this research is in progress.
Rationale for Pharmacist’s Direct Involvement in the Care of Older Adults With Cognitive Impairment and Dementing Illnesses As the population ages, the incidence and prevalence of Alzheimer’s disease and related dementias will increase in a dramatic manner. For example, in the United States, the 1
University of Waterloo School of Pharmacy, Kitchener, ON, Canada Schlegel-University of Waterloo Research Institute for Ageing, Kitchener, ON, Canada 3 The Centre for Family Medicine, Kitchener, ON 4 Department of Family Medicine, McMaster University. 2
Corresponding Author: Dr. Carlos Rojas-Fernandez, Schlegel Research Chair in Geriatric Pharmacotherapy, Schlegel-UW Research Institute for Ageing & School of Pharmacy, University of Waterloo, 10 Victoria St S, Room 7004, Kitchener, ON, N2G 1C5, Canada. Email: [email protected]
Downloaded from aop.sagepub.com at VANDERBILT UNIV on April 28, 2014
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Annals of Pharmacotherapy
prevalence of Alzheimer’s disease among those >65 and >85 years old was recently reported to be 13% and 38%, respectively, whereas the annual incidence rates among those 65 to 74, 75 to 84, and >85 years old are 53/1000, 170/1000, and 231/1000, respectively.8,9 Compared with other chronic conditions, dementia is more difficult to manage partly because of the existence of comorbidities, related polypharmacy, inherent adherence concerns accompanying dementia, and the burden of behavioral and psychological symptoms of dementia.9-11 Dementia thus complicates the care of older adults and is associated with significant health care use.10 Unrecognized dementia also increases the risk of medication nonadherence or errors, adverse drug events, delirium, caregiver burnout, premature institutionalization, financial difficulty, motor vehicle accidents, and increased health care costs.10-15 From the pharmacotherapeutic perspective, the challenges are numerous. Cognitive impairment or dementia rarely exists in isolation of other complex chronic conditions.16,17 Adverse drug events leading to emergency room visits and hospitalizations are of particular concern because such events may be attributable to inappropriate medication management by patients at least partly because of their underlying dementia.14,18 Appropriate medication prescribing is of paramount importance in patients with dementia, given their high risk for additional cognitive impairment, delirium, and falls and their complex medication regimens, which further increase these risks.19-24 Appropriate medication use in complex older patients requires significant clinical expertise because of agerelated pharmacodynamic and pharmacokinetic changes, differences in disease presentation in frail elderly and because it is often difficult to sort through appropriate prescribing given that guidelines are designed for single-disease states, not for combinations of diseases.25-29 As such, properly trained pharmacists would be in the best position to assess these patient’s pharmacotherapeutic regimens and design and implement appropriate regimens.5-7,30 Compared with regular medical care, that is, primary care provision by a single provider, the effectiveness of multidisciplinary approaches in the care of various populations has been demonstrated.1-4,31,32 Pharmacists practicing in memory clinics represent an expanded scope of practice within primary care, a novel and exciting direction that most disciplines are taking, consistent with the recent patient-centered medical home concept involving multidisciplinary teams in primary care.33 It is imperative that pharmacists evolve in their professional roles and become involved in initiatives aimed to improve the care of older people with cognitive impairment and/or dementia.6,7,30,34,35
Rationale for a Primary Care–Based Interdisciplinary Memory Clinic The diagnosis of dementia remains challenging, as illustrated by data from the Canadian Study on Health and Ageing, which
suggests that
research-article2014
AOPXXX10.1177/1060028014526857Annals of PharmacotherapyRojas-Fernandez et al
Article
An Interdisciplinary Memory Clinic: A Novel Practice Setting for Pharmacists in Primary Care in Ontario, Canada
Annals of Pharmacotherapy 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028014526857 aop.sagepub.com
Carlos H. Rojas-Fernandez, PharmD1-4, Tejal Patel, PharmD1,3,4, and Linda Lee, MD, MCISc(FM)1,3,4
Abstract Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care–based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care–based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists’ activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic. Keywords aging, Alzheimer disease, clinical pharmacy, geriatrics, ambulatory care
Introduction Pharmacists have made great strides in developing innovative practice models in various settings as singular providers and/or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure programs, geriatric clinics, primacy care practices, and hypertension, hyperlipidemia, and diabetes clinics to name a few.1-4 Conversely, there is a paucity of literature describing the role of a pharmacist in interdisciplinary memory clinics, and less is known of a pharmacist practicing in interdisciplinary, primary care–based memory clinics.5-7 It is important to disseminate the pharmacist’s role in new clinic models in appropriate detail to guide others on how to address challenges or to assist in the development of similar models. The purpose of this article is to describe how clinical pharmacists provide collaborative care to patients presenting with cognitive concerns in a primary care– based, interdisciplinary memory clinic. To provide sufficient detail in this report, detailed analyses of medication interventions will be published separately as this research is in progress.
Rationale for Pharmacist’s Direct Involvement in the Care of Older Adults With Cognitive Impairment and Dementing Illnesses As the population ages, the incidence and prevalence of Alzheimer’s disease and related dementias will increase in a dramatic manner. For example, in the United States, the 1
University of Waterloo School of Pharmacy, Kitchener, ON, Canada Schlegel-University of Waterloo Research Institute for Ageing, Kitchener, ON, Canada 3 The Centre for Family Medicine, Kitchener, ON 4 Department of Family Medicine, McMaster University. 2
Corresponding Author: Dr. Carlos Rojas-Fernandez, Schlegel Research Chair in Geriatric Pharmacotherapy, Schlegel-UW Research Institute for Ageing & School of Pharmacy, University of Waterloo, 10 Victoria St S, Room 7004, Kitchener, ON, N2G 1C5, Canada. Email: [email protected]
Downloaded from aop.sagepub.com at VANDERBILT UNIV on April 28, 2014
2
Annals of Pharmacotherapy
prevalence of Alzheimer’s disease among those >65 and >85 years old was recently reported to be 13% and 38%, respectively, whereas the annual incidence rates among those 65 to 74, 75 to 84, and >85 years old are 53/1000, 170/1000, and 231/1000, respectively.8,9 Compared with other chronic conditions, dementia is more difficult to manage partly because of the existence of comorbidities, related polypharmacy, inherent adherence concerns accompanying dementia, and the burden of behavioral and psychological symptoms of dementia.9-11 Dementia thus complicates the care of older adults and is associated with significant health care use.10 Unrecognized dementia also increases the risk of medication nonadherence or errors, adverse drug events, delirium, caregiver burnout, premature institutionalization, financial difficulty, motor vehicle accidents, and increased health care costs.10-15 From the pharmacotherapeutic perspective, the challenges are numerous. Cognitive impairment or dementia rarely exists in isolation of other complex chronic conditions.16,17 Adverse drug events leading to emergency room visits and hospitalizations are of particular concern because such events may be attributable to inappropriate medication management by patients at least partly because of their underlying dementia.14,18 Appropriate medication prescribing is of paramount importance in patients with dementia, given their high risk for additional cognitive impairment, delirium, and falls and their complex medication regimens, which further increase these risks.19-24 Appropriate medication use in complex older patients requires significant clinical expertise because of agerelated pharmacodynamic and pharmacokinetic changes, differences in disease presentation in frail elderly and because it is often difficult to sort through appropriate prescribing given that guidelines are designed for single-disease states, not for combinations of diseases.25-29 As such, properly trained pharmacists would be in the best position to assess these patient’s pharmacotherapeutic regimens and design and implement appropriate regimens.5-7,30 Compared with regular medical care, that is, primary care provision by a single provider, the effectiveness of multidisciplinary approaches in the care of various populations has been demonstrated.1-4,31,32 Pharmacists practicing in memory clinics represent an expanded scope of practice within primary care, a novel and exciting direction that most disciplines are taking, consistent with the recent patient-centered medical home concept involving multidisciplinary teams in primary care.33 It is imperative that pharmacists evolve in their professional roles and become involved in initiatives aimed to improve the care of older people with cognitive impairment and/or dementia.6,7,30,34,35
Rationale for a Primary Care–Based Interdisciplinary Memory Clinic The diagnosis of dementia remains challenging, as illustrated by data from the Canadian Study on Health and Ageing, which
suggests that
