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Medicare drug benefits were a central theme of last year’s presidential election. While then-Texas Governor George W. Bush and Vice President Al Gore struggled to find the policy that would win them the most votes, health care advocates fought to keep the health issues surrounding pharmaceutical care for seniors central to the debate.
Now, the debate continues in Congress as legislators work to shore up the beleaguered Medicare system. Researchers from the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University Hospital in Philadelphia are urging case managers to add their voices to those debating the future of health benefits for American seniors and to make sure any Medicare drug benefit adopted by the federal government recognizes the special pharmaceutical needs of this patient population.
"The problem is that many seniors are on multiple medications, and no one is coordinating their pharmaceutical care — no one owns this piece of the health care system," says David B. Nash, MD, MBA, FACP, associate dean of Jefferson Medical College, director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University Hospital, and principal author of Why the Elderly Need Individualized Pharmaceutical Care.
Nash and co-author Mary Lou Chatterton, PharmD, fellowship and project director with the Office of Health Policy and Clinical Outcomes, note that the pharmaceutical needs of the elderly are unique for the following reasons:
• High incidence of comorbidity. Most Americans over age 55 have more than two chronic conditions, says Nash. Roughly 30% of patients 75 or older with two or more chronic conditions take at least five prescription drugs daily, he adds. "Patients with multiple conditions require multiple medications," explains Nash. "Not only does this mean the elderly run a high risk for drug interactions," he notes, "but it also increases the likelihood that the patient is seeing more than one physician and that no single physician and no single pharmacy has access to information about all the medications the patient is taking."
• Physiological changes. As the body ages, age-related changes affect the outcomes of drug therapy, says Chatterton. "Drug absorption rates fluctuate as the organs age," she notes. "For example, changes in the gastrointestinal tract affect the absorption of drugs taken orally, and drugs taken through the skin may be slowed due to decreased vascular function."
Slower blood-flow through the liver is also common in older patients. Drugs that depend on blood-flow through the liver, such as lidocaine, should be started at lower doses in the elderly and then increased as necessary to reach the desired therapeutic effect.
In addition, Chatterton and Nash say the body maintains less lean body tissue and more fatty tissue as it ages, which affects the dosage needed to produce the desired therapeutic effect.
• Variation in drug actions. The elderly react uniquely to medications, say Nash and Chatterton, adding that for any single drug, an elderly patient may experience an enhanced effect, a diminished effect, or an adverse affect due to factors associated with the aging process. "As a group, the elderly have unique reactions to many common medications," explains Nash. "That simply means that a strict formulary will not work for an elderly population, and as we draft health care policy for the elderly we must keep this in mind."
Chatterton adds that a policy change that provides reimbursement for pharmaceutical counseling would also help improve drug therapy outcomes in the elderly. "Pharmacists aren’t compensated for patient counseling except for certain exceptions which provide counseling for groups, such as diabetics," she notes. "Time is a real barrier to patient counseling. If a pharmacist spends 30 minutes or more counseling an elderly patient on their prescription drugs, that’s time spent away from dispensing."
Chatterton and Nash stress that case managers must gain a better understanding of the differences in how the elderly react to medications. In addition, Nash notes that case managers are in a position to play a vital role in helping their older patients become better-educated pharmaceutical consumers. "You must provide good patient education on these issues. Part of your responsibility as case managers is to promote consumer education," he stresses.
Nash and Chatterton suggest several steps case managers can take to help older patients receive better pharmaceutical care:
An unexpected change in the health status of an elderly client may signal a drug-related issue, Chatterton says. "One of your first lines of attack should be to eliminate the possibility of a drug reaction or interaction," she says. Chatterton recommends case managers ask their patients these questions:
If there is a single message that Nash and Chatterton hope is received by policy-makers, consumers, and health care professionals who read their recently released paper, it’s this: Elderly people react uniquely to medications and require a wide range of choices to get a good therapeutic fit.
"Monetary issues are always a concern," admits Chatterton. "But, as we continue the debate over Medicare drug benefits, I hope that the special pharmaceutical needs of the elderly are put above those monetary limitations."
For more information about the report Why the Elderly Need Individualized Pharmaceutical Care, contact the Office of Health Policy and Clinical Outcomes, Thomas Jefferson University, 1015 Walnut St., Suite 115, Philadelphia, PA 19107-5099. Telephone: (215) 955-6969. Fax: (215) 923-7583.