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Pharmacists can improve the care patients receive in memory disorder clinics

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Loren Bonner

Few neurology practices in the United States have embedded pharmacists on their care teams, but a study published December 11, 2022, in the Journal of the American College of Clinical Pharmacy demonstrates how clinical pharmacists could positively affect patients in these settings.

Out of 180 patients included in the study, pharmacists made recommendations for nearly half of them, most commonly laboratory monitoring recommendations or medication discontinuations or substitutions.

“We were struck by the large number of [potentially inappropriate medications] that were identified—332 in 180 patients, which is a little less than 2 per patient,” said lead author Traci Aladeen, PharmD, BCPP, clinical pharmacist at DENT Neurosciences Research Center in Amherst, NY. “This speaks to the acute need for medication optimization in this patient population.”

Of the 192 total pharmacist recommendations, 32% were accepted by providers within the memory disorder clinic, a subspecialty clinic located within a neurology group practice.

Aladeen said many patients in these clinics are taking anticholinergic medications, which can exacerbate cognitive problems. Other medications can increase fall risk or require age-related dose adjustments, for example.

“We are learning more about the potential impact that medications can have on risk for Alzheimer disease, with some research now showing that anticholinergic medications can increase risk of [Alzheimer disease] long before cognitive problems present,” said Aladeen.

Additionally, new medications for Alzheimer disease with complex monitoring parameters are entering the market.

Aladeen and her team were also struck by the disparity between the number of potentially inappropriate medications that were identified during initial screening using tools like the Beers Criteria (332) versus how many were deemed actionable by clinical pharmacists (111).

“This speaks volumes to the complexity of delivering appropriate and actionable recommendations to prescribers,” said Aladeen. “While tools such as the Beers Criteria can help provide a starting place, it is clear that they require careful interpretation in order to perform a risk/benefit analysis considering individual patient characteristics.”

The task can’t be automated by electronic medical record alert systems either, she said, or delegated to those without pharmacotherapeutic expertise or access to medical records.

Memory disorder clinics

Patients with memory disorders or dementia are particularly vulnerable to adverse effects from potentially inappropriate medications. In her clinic setting, where the study was carried out, Aladeen said the team frequently comes across patients with memory disorders who could benefit from a medication review by a pharmacist.

“Patients can connect with the clinic for an examination and evaluation of their memory problems including neuroimaging and cognitive testing, and work with the clinic to develop a treatment plan,” said Aladeen.

The clinic staff consists of a neurologist specializing in the treatment of memory disorders, physician assistants, nurse practitioners, social workers, a neuropsychologist, and a care coordinator.

“Although this was outside of the scope of our study, it would be great to see a similar study conducted in a controlled fashion with a comparator group and scheduled follow-ups to collect outcomes such as cognitive testing, falls risk assessment, and hospitalizations consistently to better evaluate the effect of pharmacist interventions,” said Aladeen.

She noted that future studies could explore opportunities to improve how recommendations by pharmacists are accepted by providers.

“The intervention studied here was conducted via chart review prior to the patient visit,” said Aladeen. “Based on studies in inpatient settings and more highly integrated outpatient settings, it is possible that the recommendation acceptance rate would have been higher if we had been able to conduct interventions involving direct patient contact and delivered concurrently with a prescriber visit.

"This may have further improved trust, communication, and coordination between the pharmacist, prescriber, and patient.”

Tailored care

Aladeen said that one of the neurologists they collaborate with shared that the drug–disease interaction information received from embedded clinical pharmacists in the clinic was much more tailored than the calls received from retail colleagues, which primarily concern major drug–drug interactions.

“While these sorts of drug interactions are important, the neurologist found the enhanced medication review provided by the embedded clinical pharmacists were more comprehensive, clinically relevant, and useful in practice,” she said.

“We hope pharmacists, pharmacist trainees, and training programs will consider neurology as a viable clinical specialty for pharmacists, and that pharmacists as well as prescribers and other stakeholders will recognize the great impact that pharmacists can make within this specialty,” Aladeen said. ■

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