Elderly care: Bridging the gap
There is a clear opportunity for community pharmacists and their teams to lead best practice when it comes to supporting the ongoing health needs of older people
- Around 1.4 million older people are not getting the care they need, a figure that has risen by 19 per cent (to nearly one in seven older people) in the space of just two years1
- Spending in adult social care in the UK fell by 9.9 per cent between 2009/10 and 2016/20172
- Around 400,000 fewer adults were receiving social care services in 2013/14 than in 2009/10, with local authorities prioritising funding for people with the most severe care needs3
- Based on current spending, a funding gap of £18bn in social care is predicted to open up by 2030/314
We all know that an expanding older population is putting a lot of pressure on community services, says Derek Taylor, chair of the UKCPA Care of the Elderly group. It is a situation he is all too familiar with in his role as assistant director of pharmacy – governance and risk with the Royal Liverpool and Broadgreen University Hospitals NHS Trust.
“We are seeing this on a day-to-day basis in hospital pharmacy, whether that is through admissions from care homes or people living at home with more complex care needs,” he points out.
Community pharmacies could prove to be the vital link in this chain, Taylor says, by bringing their knowledge of older patients and skills into play more often and in new ways. For instance, the UKCPA group he chairs has run a number of courses aimed at highlighting the crucial role of pharmacy in older people’s services.
“In most cases people will visit the same local pharmacy for years,” he says, “so the staff are ideally placed to help them manage their health more effectively, as well as liaise with other health professionals who may already be involved in their care by assisting with any transition to a new care environment, say, or working more closely with GPs to monitor patients.”
Things have already moved to this new footing in hospitals, says Tahir Masud, a consultant physician and professor of geriatric medicine at Nottingham University Hospitals NHS Trust, who recently became president of the British Geriatrics Society.
“Pharmacists have become a really important part of the team on hospital wards,” he says, “working closely with other medical staff as part of a multidisciplinary routine. Although it is already happening in the community to some extent, I can see a clear case for reinforcing this further.”
So what does this more integrated type of community pharmacy actually look like in terms of older people’s care?
It is about taking an individualised approach to medicines optimisation, says Derek Taylor, with pharmacists assuming more of a lead role in reviews of the issues that typically affect older people, such as inappropriate prescribing, as well as supporting medication compliance and rationalising polypharmacy.
At present, polypharmacy (often defined as the use of four or more medicines) and compliance constitute the biggest medication problems in elderly patients that hospital services encounter, says Tahir Masud.
“As a simple by-product of longevity, people are experiencing a number of differing health issues as they age, which might see them visiting a cardiologist, gastroenterologist or endocrinologist and receiving multiple prescriptions. If these specialists happen to be unaware of each other, there is an increased risk of side-effects – which can easily lead to confusion, drowsiness or falls.”
As the common port of call, however, a community pharmacist can effectively bridge that gap, highlighting any inappropriate prescribing or warning patients to look out for any possible sideeffects. “This gives people a much better chance of offsetting any issues,” Masud continues, “and avoiding what can easily become a rapid cascade into full-time care.”
Enhanced ties between GPs and community pharmacy may also help initiate new conversations and highlight any issues with compliance – which can be a particular problem for those living on their own or suffering with dementia. “Offering some form of counselling can greatly help to reinforce the [compliance] message,” Masud says, “so it is an area I would be very pleased to see pharmacists taking a more active role in.”
Rationalising medication regimens and, depending on a patient’s views, actually deprescribing in some cases is becoming more widespread. “Statins are a good example of this,” Derek Taylor says, “as they may cause an outcome that is worse in older, more frail patients.” Medication for high blood pressure is another case in point.
“In middle age, it may be perfectly appropriate to prescribe such medication,” says Tahir Masud, “but it can also put an older patient at risk of problems at the opposite end of the spectrum, such as falls if their blood pressure then starts to drop. It is all about achieving a good balance for the individual.”
Medicines use reviews especially are an ideal opportunity for conversations of this kind, according to both Taylor and Masud, with the latter recommending the Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP) system for any rationalising conversation.
“We know that face-to-face medication reviews are particularly effective, especially when they are performed by a patient’s regular pharmacist,” Taylor says.
“Visiting a health centre, GP practice, person’s home or running a group session in the pharmacy are all good options for enhancing community ties. At my own hospital, we already operate a similar multidisciplinary approach, where a community pharmacist comes in and undertakes medication reviews during our falls clinic.”
Technology may hold the key to solving the challenge of keeping track of older patients as they move between care settings.
“When a person has been admitted to hospital and then goes to an intermediate care unit as part of the reablement process, they can very easily slip through the net,” Derek Taylor explains. “That is a real problem because a community pharmacy needs to be aware of their changing care needs and working to ensure maximum levels of medicines optimisation at all times.”
His own hospital is working to combat this by trialing an electronic discharge package through PharmOutcomes. The package contains essential notes on discharge as well as any changes to medications or possible side-effects that can go straight to a patient’s GP and local pharmacist.
“Traditionally, this has always been a weak point in the relationship between hospital and community pharmacy,” he says, “but technology is negating the usual problem of time and workload, and giving care providers the opportunity to receive essential patient updates. Through extending the role of PharmOutcomes, we are hoping to increase the level of patient tracking to include admissions as well.”
Technology now gives community pharmacy the opportunity to considerably enhance the level of medicines advice depending on the care setting of the patient, says Taylor.
There is already good evidence to show that this type of improved communication does have an effect on reducing hospital readmissions, he says. “Making community pharmacists part of this conversation would only enhance this. In the scheme of things, this doesn’t just benefit a patient but the system as well, generating some much-needed cost savings. That must be good news for everyone.”
- Look at ways to promote more independent living in older people
- Watch for signs of social isolation or loneliness
- Understand the distinction between different mental health issues
- Display details of and recommend relevant community groups
- If there are any serious concerns about a health issue in an older person, raise it with the patient’s GP at the earliest possible stage
Better mental wellbeing
Depression affects one in five people5 and is especially common in older age groups. Symptoms include:
- Lack of interest and an inability to enjoy things normally enjoyed
- Being reluctant to engage in usual activities or leave the house
- Feeling tired and/or sleeping too much or too little
- Loss of appetite or eating more than usual
- Losing or gaining weight over a relatively short time
- Losing confidence and feeling life is pointless
- Being self-critical and feeling guilty
- Having suicidal thoughts.
In cases where depression is suspected, customers who have experienced some of the symptoms of depression on most days for two to four weeks should be advised to visit their GP.
Improving community ties has been shown to boost mental wellbeing in older age groups and pharmacy can help promote such services by displaying posters and offering leaflets. Key initiatives include Call in Time, No One Should Have No One at Christmas from Age UK, the University of the Third Age and the Men’s Sheds Association – as well as numerous, more targeted, local and national health groups.
Supporting people with dementia
Two-thirds of patients living with dementia in the UK live in the community, making the pharmacy sector integral in both helping to identify the early signs of dementia in older people and providing ongoing support. The Alzheimer’s Society’s Dementia Friends programme offers targeted advice for pharmacy teams. To date, more than 2,345 pharmacies have signed up, creating around 65,200 Dementia Friends across the UK.
Dementia remains incurable, of course, but with cognitive decline believed to begin up to 10 years before any diagnosis, most research is centred on early detection. This includes a new study by University College London, which found a straightforward neck scan could well hold the key to highlighting risk by measuring pulse strength.6
Technology is also integral to the Alzheimer’s Society current thinking, with the organisation reporting that artificial intelligence is showing promising results by interpreting brain scans and speech patterns. Working in partnership with the University of Oxford’s Big Data Institute, it is calling on people to download and use GameChanger – a new brain games app – for just five minutes a day over one month in order to help with this research.
Better independent living is widely linked to improved health and wellbeing, with older people able to benefit from straightforward walking sticks or scooters to smarter gadgets that can help them monitor their own health as well as assist with daily tasks.
These include sensors to monitor water intake, bathroom aids and rails, as well as shaped cutlery and kitchen tools. Pharmacy teams can prove invaluable to achieving better quality of life by highlighting their availability to relevant older customers and their carers.
Common ailments in older people
Urinary incontinence is common in both older men and women, with bladder weakness brand TENA estimating that 24 per cent of older people in the UK are affected. 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, says Donna Wilson, TENA training and brand manager.
Urinary incontinence can also be a symptom of certain long-term 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, she says. These will provide good security and odour protection, and require less changing for the patient or their carer.
Constipation is often experienced by older age groups. This can be due to diet, lack of fluids, low levels of exercise or, in some cases, a side-effect of medication. Dietary changes are recommended as a first step, with plenty of wholemeal and wholegrain ingredients for more bulk-forming fibre and at least five portions of various fruit and vegetables per day.
Recommending more fluid (8-10 cups per day) can also help soften the stools and make them easier to pass. Dried fruit also contains elevated levels of sorbitol, a naturally occurring sugar that helps draw water into the gut. When appropriate, increased exercise could be suggested. If required, laxatives may be recommended in the short-term. Always advise customers not to strain.
Reinforcing the importance of a well-balanced diet is essential. Left untreated, vitamin and nutrient deficiencies can impact overall health, weaken the immune system and accelerate any musculoskeletal weakening. Nutrients that older people might have too little of include vitamin C, vitamin D, folate, iron and zinc. Fibre intakes may also be low.
Dietary sources are always preferred, although supplements may be taken in an effort to help with any perceived shortfalls. This is particularly useful in the case of vitamin D, where 10mcg is recommended per day for everyone to slow any bone density loss.
It is important to note that some older people experience a deterioration in their ability to taste or enjoy food, while those living with dementia may change their preferences. The Caroline Walker Trust offers a free guide7, which may prove useful to recommend to carers or customers looking for tailored advice on nutrition and effective ingredients. More information on Eating Well: Supporting Older People and Older People with Dementia’, which contains comprehensive information on nutrition and recipe ideas, can be found on the Caroline Walker Trust website cwt.org.uk.
While dry eye doesn’t tend to be serious, it can be irritating and unwelcome. Common signs include: feelings of dryness, grittiness or soreness in both eyes that gets worse throughout the day; burning and red eyes; sticky eyelids; temporarily blurred vision. Some people also experience watering eyes.
Eye drops, gels or ointments to lubricate the eyes are widely available as OTC products, with preservative-free drops recommended for very regular use, contact lens wearers or anyone with severe dry eye disease. People visiting the pharmacy reporting an extreme sensitivity to light (photophobia), very painful or very red eyes, or a deterioration in their vision should be referred to a GP immediately.
Earwax can become harder as a person ages, causing symptoms such as earache, difficulty hearing, itchiness, dizziness, ear infections or tinnitus. Hearing aids and earplugs can also exacerbate the problem by pushing wax further in. OTC eardrops can help soften wax and allow it to drop out, although these are not recommended for use by anyone with a perforated eardrum.
The use of cotton buds, fingers or other objects is not advised as these can push wax deeper inside the ear. The regular use of eardrops can help ward off future problems. In severe or persistent cases, referral to a GP may be necessary.
Haemorrhoids (piles) are a typical by-product of constipation in older people. Characterised as enlarged blood vessels inside or around the anus, haemorrhoids are usually small, round, discoloured lumps that appear through straining.
In many cases, piles will shrink and disappear on their own, but in severe cases they may require GP intervention. Dietary changes, such as those recommended for constipation (see above) should help reduce the pressure on the anal passage during bowel movements. OTC creams can help reduce any pain or itchiness, with corticosteroids also present in some ointments. Use of the latter should not exceed seven days due to the risk of irritation. Any customer reporting persistent haemorrhoids or blood from their anus should be referred to their GP immediately.
In older people, joint pain and stiffness that gets steadily worse is usually a sign of osteoarthritis. This is the commonest type of arthritis in the UK and may affect just one joint or many, but is typically seen in the knees, hips and small joints of the hand. Some people may also experience swelling, tenderness and a grating or crackling sound when moving the affected joints.
Mild symptoms can sometimes be addressed with simple measures including regular exercise, achieving an individual’s recommended body weight, wearing suitable footwear (and insoles), pain management aids and heat therapy. Customers experiencing persistent problems should see their GP.
- Age UK article: 1.4 million older people aren’t getting the care and support they need
- The Institute for Fiscal Studies and the Health Foundation (2018). Securing the future: funding health and social care to the 2030s
- Charlesworth A, Thorlby R, Gershlick B (2017). Election briefing: NHS and social care funding – three unavoidable challenges. The Health Foundation
- ‘What’s the problem with social care, and why do we need to do better?’ – Institute for Fiscal Studies, The King’s Fund, Nuffield Trust and The Health Foundation
- Age UK article on depression and anxiety
- Neck scan could predict dementia. University College London: ucl.ac.uk/news/ headlines2/November-2018/121118-neck-scan-Alzheimers.