As pharmacists and physicians working in a geriatric day hospital (GDH), we read with interest your November 2010 issue, which covered aspects of care of the elderly, and greeted with enthusiasm the initiative to describe approaches to common geriatric problems.1 We would like to reinforce the need to consider the importance of medication assessment and iatrogenic illness in caring for the frail elderly.
A recent review of 51 medication-assessment consultations completed in our GDH found that our patients (average age 81 years; 39 women and 12 men) were each taking an average of 15 medications (range 6 to 28), with 8.9 drug-related problems per patient identified (range 3 to 19). As Figure 1 shows, patients were commonly taking medications no longer needed and experiencing drug-related adverse effects. Medications commonly found to be no longer needed included the following: acetylsalicylic acid, furosemide, antihypertensives, proton pump inhibitors, and iron. Benzodiazepines were commonly associated with adverse reactions. We found a positive correlation between numbers of medications and numbers of drug-related problems, but did not find such a correlation for age or renal function. A similar study conducted in 1999 for 46 medication-assessment consultations in the GDH described 6.3 drug-related problems per patient, possibly suggesting that the incidence of drug-related problems has increased over time in this population.
Average number of drug-related problems per patient, by type of drug-related problem
Polypharmacy is common in the elderly with reported average medication numbers ranging from 8 to 13, and average numbers of drug-related problems ranging from 2 to 3.2–7 Our patients seem to have higher numbers of medications and drug-related problems, which is perhaps related to their frailty and complex medical comorbidities, the physician’s selected approach for medication review, and the pharmacist’s comprehensive approach. Patients referred to the GDH typically have problems with falls and cognition—both commonly associated with medication use. Patients with apparent polypharmacy, suspected adverse effects, and issues with compliance are referred for a pharmacist-conducted medication assessment and thus represent a select population within a select population. The pharmacist conducts a patient or caregiver interview regarding medication experience, compares medication lists from various sources, uses a structured process to identify drug-related problems, develops and documents a care plan, and carries out the care plan in collaboration with prescribers. Other difficulties in comparing our findings to the literature include differences in settings and patient characteristics, as well as approaches and measures used.8
We welcome periodic medication assessment at the family practice level and believe that collaboration between family physicians and pharmacists could identify potential drug-related problems, preventing polypharmacy and iatrogenic illness. We plan to pursue further research in our own and other GDH environments to validate our findings and measure the effects of our collaborative approach.
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