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Australian Journal of Pharmacy : February 2005
medication management in review by Bill Kelly CEO, Australian Association of Consultant Pharmacy Ndue deference to Laurence Binyon’s elegy ‘For the Fallen’ and the RSL’s ‘The Ode’ taken therefrom, while age shall not weary them—the aged, how- ever, may well weary us. Latest statistics1,2 demonstrate that peo- ple older than 65 are a growing and increasingly significant proportion of the Australian population; a diverse group of people with a diverse range of health issues. They are an important and poten- tially significant user of health resources and it is important that pharmacy recog- nises this and is able to respond in a timely and appropriate manner to their needs. Never was this made more obvious than at last October’s Pharmacy Australia Congress in Adelaide at which the keynote speaker, Francis Sullivan, CEO of Catholic Health Australia, in highlighting the future needs of the frail aged identified and challenged pharmacists to become strong advocates for the frail aged. More on this in later paragraphs but first some definitions. Aged or older or…? Who or what constitutes an ‘aged’ or ‘older’ person or, for that matter, an infant, a child, and so on. A recent com- mentary in Medscape Pharmacists3 pro- vided a US view of this defining, from a medical aspect, of neonates, infants, child and adolescence. All reasonably straight- forward and as expected. When it came to defining the category of elderly, how- ever, things weren’t so clear cut. While the US Census Bureau defines ‘older people’ as 55+ years and ‘elderly’ as 65+ years, a National Council of Age- ing Survey found that 42 per cent of those aged 65+ thought of themselves as mid- dle-aged or young. As the author com- mented, definitions of ageing are based on an external event and are not necessarily The aged may weary us I related to physical ageing. Thus, there is a growing appreciation and awareness that not everyone ages at the same rate or in the same way—and that there is no such thing as ‘normal ageing’. Understanding ageing is also made even more difficult in that most studies on the ageing process compare individuals of different ages with group averages rather than any studies following cohorts of peo- ple longitudinally as they age. As well, dose-related data from clinical trials is, more often than not, based on a ‘stan- dardised’ patient. In many cases, such data is subject to considerable interpreta- tion when it comes to determining or identifying the geriatric dose. A population at risk Without reproducing reams of statistics from various government publications, it is suffice to say that key demographic indi- cators present a generally positive picture of an older Australia, with a diversity of health conditions but increasing longevity, life expectancy and falling death rates. While the onset of ill health is generally inevitable for many in old age, delaying its onset, reducing the levels of disability rate and increasing prevention strategies through screening and management of health risk all contribute significantly to this upward trend. In the latest edition of their text Essen- tials of Clinical Geriatrics, Kane, Ouslanders and Abrass,4 in discussing common prob- lems in the diagnosis and treatment of an aged population, recalled their ‘I’ check- list: immobility, instability, incontinence, intellectual impairment, infection, impairment of vision and hearing, irrita- ble colon, isolation (depression), inanition (malnutrition), impecunity, insomnia, immune deficiency, impotence and last, 86 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 FEBRUARY 2005 but not least, iatrogenesis. They remind us that the most pre- ventable problem in caring for older peo- ple is iatrogenic disease, that is, from treatment or care that has been provided. The aged are frequently prescribed mul- tiple drugs in complex dosage schedules for multiple chronic medical conditions and in line with practice or therapeutic guidelines. Add over-the-counter medica- tions and complementary medicines and the picture becomes even more complex. A narrowing window between thera- peutic dose and toxic dose, a predisposi- tion to side effects and adverse reactions, a reduced capacity for metabolising and excreting drugs creating high or abnor- mal blood levels, a fear of over medicat- ing (and hence under medicating with sometimes profound consequences), non- compliance issues and so on, all con- tribute to the high risk status of the older population from medication-related problems, and especially where polyphar- macy is involved. A challenge to embrace Now let me return at this point to Francis Sullivan. He asserted that pharmacists needed to ‘embrace the challenge to claim their professional care role in aged care homes, on standards committees and within policy setting bodies’. ‘There was a real opportunity to be the professional guardian of best practice medications in aged care… and that given the growing pressure on the capac- ity of health professionals to meet the demands of an ageing population, phar- macists should insist that they have a rightful place in the system to provide pri- mary care services on site,’ he said. The opportunities of accredited consul- tant pharmacists in supporting the aged