European Society of Clinical Pharmacists International Workshop on Geriatrics

Abstract

The European Society of Clinical Pharmacists (ESCP)held its third annual international meeting on May 5 and 6 in Utrecht in The Netherlands. This year the focus was on geriatrics. It was chaired by Louise Mallet (Montreal, Canada) who coordinated the scientific committee, which included Annemie Somers (Belgium), Ulrika Gillese (Sweden), Marcel Bouvy (The Netherlands), Hannelore Kreckel (Germany), Erik Gerbrands (The Netherlands) and Piera Polidori (Italy). The attendance was mainly composed of clinical pharmacists who have an interest in geriatrics. A number of the 110 participants were present at this workshop from different countries around the world. The 2-day meeting was organized around plenary sessions, interactive workshop sessions, oral communications and poster presentations. The plenary sessions explored four topics, namely the appropriateness of prescribing in older patients, the specific needs for research in geriatrics, frailty in the elderly and an update on dementia in the elderly. Cecilia Bernsten, president of ESCP, welcomed the participants on May 5 by emphasizing the growing role of pharmacists in taking care of older patients.

Medication review in the elderly

This workshop, entitled medication review in the elderly: a personalized medication review, was conducted by Annemie Somers, clinical pharmacist at Ghent University Hospital in Belgium. Drug consumption in older patients is high among others as a result of polypathology. In combination with pharmacokinetic and pharmacodynamic changes, drug-related problems in older adults are common. As a consequence, careful and thorough assessment of drug therapy in this population is necessary to detect and to prevent negative outcomes associated with drug therapy. The goal of this workshop was to gain experience in performing medication review in geriatric patients. A total of 33 persons participated in the workshop, with participants having different backgrounds and experience in performing medication review.

In the introduction, a brief presentation of the different aspects of medication reviews was given. Then the workshop leader presented information from the literature on how to perform a medication review and the different working methods, using a practical example. A review process was proposed using the following steps:

• • Step 1: create a patient database;

• • Step 2: review each medication for indications, effectiveness, safety, monitoring, errors, cost, underuse, overuse, appropriateness, adverse effects and poor compliance;

• • Step 3: create a problem list and set priorities;

• • Step 4: create a plan for each identified problem;

• • Step 5: implement the plan;

• • Step 6: follow-up on plan and make interventions as needed.

Using a systematic approach adapted from the Medication Appropriateness Index, eight questions per drug prescribed should be asked:

• • Is there an indication?

• • Is there a contra-indication?

• • Is the drug a good choice?

• • Is the dose correct?

• • Are the route of administration and the posology correct?

• • Are there adverse drug reactions?

• • Are there significant drug–drug interactions?

• • Is the duration of therapy correct?

Using case studies, the participants worked in small groups using two cases with different pharmacological classes and patients from different settings, either ambulatory care or hospital. In the plenary discussion, each drug was analyzed for whether it should be continued, adapted, stopped or switched to another drug, in relation to the patients‘ profile (e.g., medical history or decreased renal function). Drugs of choice to be used in the elderly according to different diseases, for example for Type II diabetes and coronary disease, were discussed. From this discussion, it was found that proposed drugs varied a lot between different European countries.

In summary, it is important to perform medication review in a systematic way, namely by looking for under-treatment, contra-indications, adverse drug reactions, dosage adaptation and drug–drug interactions. Furthermore, for each drug, the duration of therapy should be questioned (is there still an indication?) and it should be questioned if the drug prescribed is the best choice for our geriatric patient.

Assessment of renal function in the elderly

This workshop on the assessment of renal function in the elderly was presented by Vincent Launay-Vacher, Service ICAR-Department of Nephrology, Pitie-Salpetriere Hospital, Paris, France. The objective was to present the literature on which formula should be used to assess renal function in the elderly.

The aging kidney progressively loses its filtration capacities and the prevalence of renal failure is expected to be higher in the elderly. However, not all elderly patients present with decreased renal function and a number have normal or close-to-normal renal function. A reliable evaluation of renal function is important in clinical practice, given the fact that it is not possible to actually measure renal function routinely. Several formulas to estimate renal function are used. In the elderly, it is not clear which formula should be used.

During this workshop, participants from several countries (Austria, Belgium, France, Germany, Greece, The Netherlands, Romania and Switzerland) shared their knowledge and views on five clinical cases from real life. During this 3 h session, it was made clear that, to date, none of the formulas are ideal in the elderly.

According to current data, the abbreviated Modification of Diet in Renal Disease (aMDRD) formula (four variables MDRD formula or simplified MDRD formula) should be used in the elderly, including the very old elderly and obese/overweight patients [1]. In these patients, the Cockcroft–Gault formula has important limitations, which makes it inappropriate [2].

New tools are needed to appropriately evaluate renal function in the elderly: new formulas or new markers of renal function (e.g., cystatin C, alone or combined with serum creatinine). Research is ongoing. In practice, it is recommended:

• • To calculate the BMI, since none of the formulas are valid when the BMI is lower than 18.5. In those patients, a measure of creatinine clearance with a 24 h urine collection should be performed;

• • aMDRD provides a result in ml/min/1.73 m². This value must be used as such for the diagnosis of kidney disease and its stratification according to the international definition and stratification of chronic kidney disease by the Kidney Disease Outcomes Quality Initiative-Kidney Disease: Improving Global Outcomes;

• • For adjustment of drug dosage, results must be converted to ml/min, using the body surface area of the patient. This is one of the most frequent sources of error in clinical practice;

• • When the estimated glomerular filtration rate with aMDRD appears to be inappropriate (i.e., estimation >140 ml/min), the question of the quality of the serum creatinine dosage should be asked.

Participants also shared online tools they are using for estimating renal function: in German (the formula used is a modified Cockcroft-Gault, not aMDRD) [101]; in Dutch and soon in English (aMDRD and Cockcroft-Gault) [102]; and in French and English (simultaneous calculation with Cockcroft-Gault and aMDRD with automatic conversion from ml/min/1.73m² to ml/min for aMDRD) [103].

Frailty in the elderly

Andrea B Maier, from the Department of Gerontology and Geriatrics at Leiden University Medical Center in Leiden, The Netherlands, presented a plenary session on frailty in the elderly. The aging process is associated with a number of comorbidities. The ‘geriatric giants‘, such as cognitive impairment, depression, sensory loss, mobility impairment, falls and urinary incontinence, are often observed in older patients. Frailty is not well defined; Rockwood [3] and Fried [4] have proposed two different definitions of frailty. In Rockwood‘s definition, the patient should have two items of the following: cognitive decline, disabilities in activities of daily living or urinary incontinence [3]. Fried proposed three items of the following: exhaustion, weight loss, slow gait velocity, low handgrip strength and low physical activity [4].

Decreased muscle strength and cognitive impairment appear to be essential components of frailty according to recent studies. As an example, treatment of hypertension can be less aggressive in order to preserve muscle strength. More studies are needed in this field. Maier also summarized the studies on family histories, which indicate that genetic components appear to be important factors for vitality.

Conclusion

This symposium was a success. Participants and speakers had a chance to discuss geriatric issues. It is clear that more research needs to be done in the different themes that were presented during this workshop. The take-home message is that pharmacists have to be involved in the management of medications in elderly patients.

The European Society of Clinical Pharmacists will hold the fourth ESCP symposium on clinical in Dublin, Ireland 19–21 October 2011 [103]. The theme is Connecting Care and Outcomes. From 31 May to 1 June 2012, ESCP will also hold an International workshop in Infections Diseases in Leuven, Belgium.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.