Pharmacy management of Elderly Care

It is well documented that an expanding older population is putting a lot of pressure on community services and on hospital admissions either from care homes or from those living with more complex needs

Community pharmacies could prove to be the vital link in this chain, by bringing their knowledge of older patients and skills into play more often and in new ways. Most communities in Ireland view their local pharmacist as an extended member of the family, and therefore are in an ideal position to be more directly involved in their care.

This article looks at some of the most commonly presenting issues within the context of ‘Care of the Elderly’ and the role pharmacy may play within them.

Osteoporosis is commonly known as “the silent disease” because there are no signs or symptoms before a person starts to break bones. However, this disease is NOT silent. The effects of undiagnosed/untreated
osteoporosis are devastating.
20% of people aged 60+ who break their hip will die within 6 to 12 months, due to the secondary complications of breaking a bone.

50% of people aged 60+ who break a hip will lose their independence. They will be unable to wash or dress themselves or walk across a room unaided. These statistics are why it is so important that people take responsibility for their bone health and check to see if they are at risk.

Only 15% of people in Ireland are actually diagnosed with bone loss, leaving 280,000 undiagnosed and facing losing their independence.

Osteoporosis can affect the whole skeleton, but the most common areas to break are the bones in the back, hip and forearm. The disease affects all age groups and both sexes – it is not just a female or old person’s disease.

At present it is estimated that 300,000 people in Ireland have osteoporosis. One in 4 men and 1 in 2 women over 50 will develop a fracture due to osteoporosis in their lifetime. The disease can also affect children.

A broken bone from a trip and fall or less is known as: an osteoporotic fracture, a low trauma fracture or a fragility fracture.

However, broken bones can be prevented in most cases, and is a treatable disease in most people. Early diagnosis is essential for the best results.

Signs and Symptoms of undiagnosed osteoporosis
Usually the first sign of Osteoporosis is a fragility (low trauma) fracture e.g. a broken bone due to a trip and fall from a standing position or less.

Symptoms that a person may have undiagnosed osteoporosis include upper, middle or low back pain, especially if the pain is intermittent. Loss of height is another potential symptom. It should not be considered normal to lose height as people age.

Someone with their head protruding forward from their body, shoulders becoming rounded, the development of a hump on the back and / or a change in body shape (waist appears bigger or a pot belly develops) are also symptoms.

Most people have no pain till a fracture occurs, but a very small percentage of people have had back or hip pain, prior to a fracture.

Treatments and Vitamins
For both men and women at increased risk of fracture, the most widely prescribed osteoporosis medications are bisphosphonates.

Bisphosphonates are also known as Antiresorptive medications. These are non-hormonal drugs which help maintain bone density and prevent further bone loss. The patient receives this medication in the form of tablets, an injection or by means of infusions.

Side effects such as nausea and abdominal pain are much less likely to occur if the medicine is taken properly and pharmacists can help advise patients on this.

Denosumab is a Monoclonal antibody which binds to RANK Ligand, inhibiting the maturation of osteoclasts, therefore protecting the bone from degradation.

Compared with bisphosphonates, denosumab produces similar or better bone density results and reduces the chance of all types of fractures. Denosumab is delivered via a shot under the skin every six months.

Those who take denosumab, might have to continue to do so indefinitely. Recent research indicates there could be a high risk of spinal column fractures after stopping the drug.

There are oestrogen replacement therapies for women going through the menopause which help to maintain bone density and reduce fracture rates for the time they are on the treatment. Oestrogen therapy and oestrogen with progesterone hormone therapy are approved for the prevention of Osteoporosis in postmenopausal women provided there are no contraindications. They are usually recommended for postmenopausal symptoms to help improve the person’s quality of life. They may also be prescribed for premenopausal women who have amenorrhea and low levels of oestrogen.

In men, osteoporosis might be linked with a gradual agerelated decline in testosterone levels. Testosterone replacement therapy can help improve symptoms of low testosterone, but osteoporosis medications have been better studied in men to treat osteoporosis and thus are recommended alone or in addition to testosterone.

Here are the four vitamins that, in addition to vitamin D, are important to bone heath.

Vitamin A is a fat-soluble vitamin that is important to building strong, healthy bones. Both osteoblasts (bone building cells) and osteoclasts (bone breaking down cells) are influenced by vitamin A. Despite its good effects, most clinical research links higher vitamin A levels with lower bone density and fractures. Too much vitamin A (more than 3,000 mcg or 10,000 IU/day) can lead to headaches and has been linked to bone loss.

Vitamin B12 appears to have an effect on bone building cells. A recent study showed that low levels of vitamin B12 are linked to a higher risk of osteoporosis in both men and women. Vitamin B12 is found in meat and fish, making vegans, who don’t eat meat or dairy, at risk for bone loss. People who have had a gastric bypass or have gastrointestinal disorders that cause poor absorption of fat lose the ability to absorb B12. Elderly people in their 80s and 90s may develop changes in the linings of the stomach that prevents them from absorbing iron and B12.

Vitamin C is important for healthy gums and healthy bones. Vitamin C is essential to the formation of collagen, the foundation that bone mineralisation is built on. Studies have associated increased vitamin C levels with greater bone density. Vitamin C is water-soluble and the most common reason for low levels is poor intake. Some people with poor absorption will have lower levels of vitamin C. The elderly who are in nursing homes tend to have lower levels of vitamin C. Smokers also tend to have lower blood levels of vitamin C because their intestines do not absorb vitamin C normally.

Vitamin K is important to normal bone growth and development. It helps attract calcium to the bone. Low blood levels of vitamin K are associated with lower bone density and possibly increased fracture risk. However, clinical
trials have not shown vitamin K supplementation to be helpful in improving bone density.

The current pandemic has seen the importance of Vitamin D in overall health. Not only is vitamin D essential for bone health, but it helps to regulate cell growth and the immune system. It is the only vitamin that does not have to be consumed in food or supplements as it can be manufactured through the skin when exposed to the sun. Low levels of Vitamin D have been linked to: multiple forms of cancer, TB, MS, osteoarthritis and Type 1 Diabetes. Low levels of Vitamin D mimics the symptoms of Fibromyalgia (therefore Vitamin D levels should be checked on those diagnosed or thought to have possible Fibromyalgia).

Calcium and Vitamin D supplementation have been shown to reduce the risk of fracture and falls and improve muscle function in the elderly.
How much Vitamin D is needed?

Babies 0-12 months breast fed or formula fed = 5μ/200 IU *
Children 1-18 years= 10μ/400 IU per day***
Adult women 19-49 years = 10- 20μ/400-800 IU per day**
Adult women 50+ years = 20- 30μ/800-1000 IU per day**
19+ years pregnant and/or breastfeeding = 20-30μ/800-1000 IU per day**
Adult men 19-49 years =10- 20μ/400-800 IU per day**
Adult men 50+ years =20-30μ/800-1000 IU per day**

Medicines Management Challenges
There is a fairly high prevalence of swallowing difficulties in poly pharmacy patients visiting their local community pharmacy, highlighting the need for a better communication between patients and health professionals for addressing such issues. Anyone at any stage of their lives from infants, children and adults, can be affected by dysphagia.

Those affected includes:
• 95% of people with Motor Neurone Disease;
• 68% of people with dementia in care homes;
• 65% of people who have had a stroke;
• 50% of people with Parkinson’s Disease;
• 33% of people with multiple sclerosis.

As dysphagia is not a single disease, but a symptom of an underlying medical problem, it is difficult to estimate how many patients are suffering from it. Stroke is considered to be one of the major causes of dysphagia. In many patients, the swallowing function will recover within two months. In a small group, recovery of swallowing function may take many months to several years. In several cases of stroke patients this recovery does not occur.

A sufferer may present to a member of the pharmacy team and identify that they are having difficulty swallowing medication. This is an opportunity to establish whether they have difficulty swallowing food or liquids and whether there has been any associated weight loss. A patient with these symptoms can then be referred via GP services to speech and language services.

Knowledge of dysphagia and interpreting the various stages of fluid and consistency of foods can assist pharmacists in advising in the most appropriate and safe manner in administering medication to patients with dysphagia. Medication administration in people with dysphagia is complex.

Key questions to ask
• Is the medication necessary?
• Is it making the swallow worse (dry mouth, confusion, reduced alertness)?
• Could the medication actually be assisting the swallow?
• If the medication is necessary what is the best method of drug delivery? This will depend on where the problem is in the swallowing process and the severity of the dysphagia.
• Drug interactions, available formulations, enteral feed and tube/drug interaction are all important areas. Mechanical factors are also key, what bore is the tube, the smaller the gauge, the greater the risk of blockage.
• For those who are able to take medication orally, are tablets feasible or not?

Parkinsons Disease Risk
People with Parkinson’s disease are at greater risk of hip fractures and other non-vertebral fractures due to balance problems and poorer bone health, a recent review study found.

The researchers argue that these findings support making fracture risk assessment a part of standard care for Parkinson’s patients.

Published in the journal Bone, the review analysed data from 18 studies including more than 2.3 million people to assess whether patients with Parkinson’s are at greater risk of fractures compared to the general population.

“Neurological conditions are emerging as important risk factors for fracture and this metaanalysis confirms that people with Parkinson’s are at significant risk,” says our nurse consultant, Sarah Leyland.

“They should be considered for fracture risk assessment, as well as falls risk assessment, and advised appropriately to prevent future fractures,” she added.

Bladder weakness
Urinary incontinence is common in both older men and women. This is due to changes in the body that occur as people get older, such as weakened pelvic floor muscles and loss of sensitivity in the nerves that control the bladder.
Urinary incontinence can also be a symptom of certain longterm health conditions such as multiple sclerosis and Alzheimer’s disease. For elderly patients with dementia, it is wise to suggest the use incontinence pants rather than pads. These will provide good security and odour protection, and require less changing for the patient or their carer.
* HSE 2011
** National Osteoporosis Foundation USA
*** American Academy of Paediatrics

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