Pharmacists can resolve polypharmacy—just ask Denmark

Through the Danish Pharmacy Standard, accredited pharmacists resolve polypharmacy issues among older patients

Denmark is different from the United States in many ways, but one thing is the same: if pharmacists are put in the right position at the right time with the right patient, care can be improved, cost lowered, and quality increased.

Evidence for that concept comes from the Asheville Project, Diabetes Ten City Challenge, and other U.S.-based studies. For Denmark, support for the notion came even earlier. Based on the success of the community pharmacy program conducted in the late 1990s, the Danish Pharmacy Standard was adopted nationwide.

In Denmark today—where community pharmacies play a key role in counseling the public by providing information on medication use, self-care, and disease prevention—the majority of pharmacies are accredited to provide the Danish Pharmacy Standard.

Rapidly aging populations around the world

The number of people 65 years or older is rising rapidly. By 2050, the worldwide number of people older than 65 years will be greater than the number of people younger than 5 years for the first time in history, according to the National Institute on Aging. The challenges this presents to the global health care system are apparent even today.1 

Older adults typically have multiple chronic medical conditions for which they have frequent hospitalizations and physician, home health, and emergency department visits, and for which they take multiple medications.2 In older patients, the use of multiple medications is exacerbated by the pharmacokinetic and pharmacodynamic changes that occur with aging. Polypharmacy raises the risk of duplication of therapies, adverse reactions, drug–drug interactions, and nonadherence and is associated with decreased quality of life and increased risk for physical decline and mortality.3

Chronic disease on the rise

In 2005, 133 million Americans had one or more chronic conditions—a number that is expected to increase to 157 million by 2020.4 Among Medicare beneficiaries, more than 50% have five or more chronic conditions.5 According to CMS, more than 63% of those aged 65–74 years, 78% of those 75–84 years, and 83% of the those 85 years or older had two or more chronic conditions.2

In 2012, CMS reported that the 10 most common chronic conditions in people aged 65 years or older were high blood pressure, high cholesterol, ischemic heart disease, arthritis, diabetes, heart failure, kidney disease, depression, chronic obstructive pulmonary disease, and Alzheimer disease. Many of these conditions are comorbid in older patients, and most require ongoing prescription drug therapy (Figure 1).2

Age, chronic disease, polypharmacy

Easily identifiable risk factors predict polypharmacy: advanced age, diagnosis of one or more chronic conditions, number of visits to health care providers, and visits to multiple providers.3 With more chronic conditions come more physicians. Medicare patients with one chronic condition see 4 physicians, whereas those with five or more chronic conditions see 14 physicians annually.

An associated increase is found in the number of medications taken by patients with multiple chronic diseases. Medicare beneficiaries with two chronic conditions have prescriptions filled for an average of 18 medications annually, while those with five or more chronic conditions have prescriptions filled for an average of 49 medications.

A large national survey conducted in 2006 found that polypharmacy was most common among the population of adults older than 65 years, 28% of whom were taking five or more prescription medications.7 These findings are consistent with a large European study of older patients (mean age 82.2 years) showing that over 50% took more than six medications daily.

National standard in Denmark

In Europe, a multicenter international study conducted in seven European countries took an approach that was different from the few existing studies of polypharmacy in older patients.8,9 

The study was a randomized, controlled, longitudinal, clinical trial performed over 18 months. It looked at the outcomes of a structured pharmaceutical care program delivered by community pharmacists to patients with chronic conditions who were 65 years or older. A total of 104 pharmaceutical care intervention pharmacies and 86 control pharmacies participated, with a total of 1,290 intervention and 1,164 control participants. In the study, pharmaceutical care consisted of the involvement of community pharmacists in designing, implementing, and monitoring therapeutic plans in a collaborative effort with primary care physicians and other health professionals.

In Denmark, one of the participating countries with a successful outcome despite the declining health of an aging population, the study was carried out in 28 pharmacies between 1996 and 1999 with 523 participants aged 65 years or older.9 Pharmacies were randomly assigned to be an intervention or control site, with 14 pharmacies in each group. Intervention pharmacies recruited an average of 1.5 patients. A training manual was developed to standardize activities in the different pharmacies. Before beginning the intervention, pharmacists underwent a training program on use of the manual and quality assurance with regard to drug therapy in older patients. 

Participants were randomized to the intervention group (n = 254) or the control group (n = 269). On average they were taking 6.8 prescription drugs, primarily for cardiovascular disease (82.6%), central nervous system disorders (67.3%), and digestive or metabolic disorders (58.3%). Approximately one-third reported adverse drug effects at the start of the study. 

Participants in the intervention arm visited intervention pharmacies and received structured counseling (talks at the counter and telephone consultations) and drug therapy. As part of the study design, they kept a medication diary for self-monitoring at home; received a medication check to discard outdated and useless drugs, an assessment of their drug regimen, and identification of drug-related problems; had regular medication overviews used to foster communication between the pharmacist and other health professionals; and were offered a check of their home medicine cabinet. A personalized intervention and monitoring plan was formulated for each patient following their initial consultation, followed by an intervention encounter at least every 3 months. Participants randomized to the control arm received only routine pharmacy services. 

During the study, participants reported 518 drug-related problems, the most common being adverse effects, unwanted or insufficient effects, poor adherence, or insufficient knowledge about the drug. Interventions for these problems included referral to the patient’s physician and patient counseling.

At the study’s end, significantly better outcomes were seen in the intervention group (Figure 2):

  • Presence of adverse effects declined from 33% to 19% of participants.
  • Problems with swallowing drugs declined from 11% to 6%.
  • Confusion about when to take medications declined from 4% to 2.5%.
  • The average number of prescription drugs and the number of doses taken per day decreased.
  • Hospitalization frequency decreased from 39.8% to 31.3% in the intervention group and rose from 36.4% to 42.3 % in the control group.

Intervention participants reported that the most important effects of pharmaceutical care were increased knowledge of drugs and diseases, increased adherence and self-monitoring, and an increased ability to find solutions for drug-related problems that arise in everyday life. An evaluation of the program by pharmacists showed that they considered their consultations with older participants to be professionally satisfying and informative. The majority of collaborating physicians expressed the opinion that pharmacists possess the necessary skills to counsel patients on medication use. As a result of the study, pharmacists and physicians noted increased contact between members of their professions (10% and 29%, respectively).

Pharmacists: Essential to preventive care

The Danish study was a clear demonstration of the considerable impact that community pharmacists can have in preventing and solving drug-related problems for older patients. The effects were even more far reaching. Participants’ clinical outcomes and psychosocial status were improved, collaboration between physicians and pharmacists was strengthened, and use of health care resources was reduced. In Denmark, the counseling community pharmacist has become accepted as a key member of the health care team and essential to good preventive care.

References

Haub C. World population aging: clocks illustrate growth in population under age 5 and over age 65. www.prb.org/Articles/2011/agingpopulationclocks.aspx. Accessed August 1, 2013.

Centers for Medicare & Medicaid Services. Chronic conditions among Medicare beneficiaries. www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf. Accessed August 1, 2013.

Hajar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–51.

Partnership for Solutions. Chronic conditions: making the case for ongoing care. www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf. Accessed August 1, 2013.

Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff. 2006;25:378–88.

National Academy of Social Insurance. Medicare in the 21st century: building a better chronic care system. 2003. www.nasi.org/usr_doc/Chronic_Care_Report.pdf. Accessed August 1, 2013.

Slone Epidemiology Center at Boston University. Patterns of medication use in the United States 2006: a report from the Slone Survey. www.bu.edu/slone/files/2012/11/SloneSurveyReport2006.pdf. Accessed August 1, 2013. 

Bernstein C, Bjorkman I, Caramona M, et al. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical pare: a multicenter study in seven European countries. Drugs & Aging. 2001;18(1):63–77.

Sondergaard B, Herborg H, Jorgensen T, et al. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care. www.pharmakon.dk/pages/international.aspx?PageID=156. Accessed August 1, 2013.


Responsible use of medications

In October 2012, the IMS Institute for Health Informatics released a landmark report, “The responsible use of medicines: Applying levers for change.” The report was originally intended for a global summit of 30 health system leaders, including ministers of health and senior policy makers, from around the world. Many of the case studies in the report, such as those about adherence, polypharmacy, and prevention of medication errors, are of interest to pharmacists as well. In a series of articles running from July through October, Pharmacy Today will examine several cases in the report from the perspective of the pharmacy professional.