137 Specialist Medication Review as Part of the Comprehensive Geriatric Assessment in the Day Hospital Setting

Abstract

Introduction Medication use in older people is complex. Consequently, regularmedication reviews as an integral part of healthcare provision forolder people are necessary. Patients attending consultant-led,multidisciplinary, day hospital clinics have specialist medicationreviews undertaken by our senior clinical pharmacist. "PharmacyInterventions" (PIs) are suggested and typed prior to physician-led patient review. Method Data collected by our senior clinical pharmacist were reviewedincluding patient demographics, clinical characteristics, types of prescribed drugs and PIs. Clinical severity of PIs was assessedusing the NCC MERP Medication error index and American JournalHealth-Syst Pharm Medication error index. Scores, ranging inclinical severity from A-I (A = capacity to cause error, I = may havecontributed to death) and 0-10 (0 = no potential effect, 10 = death)were assigned by the pharmacist and two physicians. Results 100 patients were included, mean age 82y (range 65-99y). 62%were female and 63% were first time attenders. Mean number of regularly prescribed medications was 7.2 (range 1-16), 10%reported compliance issues. The most commonly prescribed drugsbelonged to the "Alimentary tract and metabolism" class (24%),including PPIs, laxatives and blood-glucose lowering medications.16% and 15% were on regularly prescribed neuroactive and psychoactive medications, respectively. Of suggested PIs, 46% were acted upon during physician review, a further 4% wereacknowledged in clinical notes. PIs covered many prescribingissues including drug-drug interactions, incorrect dosing, drugmonitoring and administration timing. The average PI scoresassigned by the pharmacist, physicians 1 and 2 differed, at 6.4, 3.2and 4.8, respectively. Conclusion PIs suggested at senior pharmacy level are an importantcomponent of the comprehensive geriatric assessment,highlighting multiple complex prescribing issues. Clinical severity of PIs was scored lower by physicians, perhaps indicating anunderestimation of prescribing errors. Senior pharmacyinvolvement in the care of frail older outpatients is an invaluableresource.