Pharmacotherapy – Medication Management

Common Psychiatric Disorder Treated with medicines include:

  • Anxiety Disorders
  • Depressive Disorders
  • ADHD
  • Bipolar Disorders
  • Psychotic Disorders
  • Sleep Disorders.
  • Panic Disorders
  • Phobias
  • Schizophrenia
  • PSTD
  • Obsessive Compulsive Disorders
  • Dementia

A systematic review examined the role of the pharmacist in polypharmacy reduction of older patients, which identified 14 studies at the time with varied aims and outcome measures.

The studies showed clearly favorable results of pharmacists’ services on polypharmacy reduction and prescribing quality, but most were not designed to demonstrate the impact of these results on patients’ health or quality of life of older adults. More recently, enhanced research with better study design has clearly validated pharmacists’ services of polypharmacy reduction and improved medication management leading to positive patient-oriented health outcomes. Therefore, there is strong evidence for the role of pharmacists in providing geriatric care to reduce polypharmacy and clinical consequences of polypharmacy, including medication errors, nonadherence, adverse drug events, drug–drug interactions, urgent or emergent visits, and hospitalization.

As older adults acquire multiple chronic conditions, they accumulate a number of prescribing providers for those conditions. It has been shown that as the number of prescribers increased, the number of potentially harmful medications and adverse drug events reported by older adults increased. Older adults need a health care advocate and medication expert who can make sense of the treatment plans and prescriptions that are given by the multiple prescribers. Pharmacists can certainly play the role of this expert advocate, and yield safer and more effective medication regimens for the growing older adult populations.

Chronic disease management

Older patients most often suffer from chronic diseases, including asymptomatic conditions, such as hypertension and dyslipidemia. Pharmacists having extensive knowledge of medications to treat chronic conditions and an up-to-date stance on clinical guidelines can provide impactful care to older populations. Favorable impacts of pharmacist care have been delineated by 30 studies included in a systematic review previously mentioned leading to reductions in blood pressure, total cholesterol, low-density lipoprotein cholesterol and smoking. Pharmacist care consisted of patient education, adherence interventions, cardiovascular risk assessment, medication management with communication to providers, or provider education. Among many conditions experienced by older adults, hypertension is the most commonly occurring chronic disease. Effective management of hypertension by pharmacists has been clearly demonstrated in the literature, with sensitive association of reductions in systolic blood pressure shown.Other examples include diabetes, heart failure, COPD, anticoagulation, and osteoporosis. Clearly, there is a role for pharmacists to provide chronic disease management to older adults within various health care systems and teams.

Medication-error prevention during transition points

Preventable medication errors are highly prevalent during transition points in older patients’ care, whether they are moving from home to hospital, or hospital to home, rehabilitation facility, or nursing home. One study found that repeated medication errors were common (37.3%) in the nursing home, which occurred more often in older (≥75 years) and cognitively impaired residents, and were associated with greater harm than unrepeated errors. Most frequently repeated errors included wrong dosage and wrong administration.Medication errors around transition into a nursing home were assessed by a study conducted in the USA, with over 27,000 medication errors reported in the 3-year period and 11% of the errors occurring during transition points.Through multivariate logistic regression, the study authors found that errors taking place during transition caused more harm to the patient than errors arising away from transition.

In Northern Ireland, an integrated medicine-management service delivered by pharmacists at admission, inpatient stay, and discharge significantly lowered length of stay by 2 days over a 2-month period (P=0.027), and increased time to readmission by 20 days (P=0.036). The integrated medicine-management service’s data analysis indicated a number needed to treat of 12.Kilcup et al assessed post-discharge medication reconciliation performed via phone by pharmacists within patient-centred medical homes and impact on patient readmission and cost savings. Significantly decreased readmission rates at 7 and 14 days and financial savings of US$35,000 per 100 patients who received the intervention were realised. These positive findings from medication reconciliation by pharmacists around hospital transitions that led to decreased readmission rates and cost savings can be translated to older patient populations who are more vulnerable to transition-related medication misadventures. Several studies included in the current review have focused the pharmacists’ effort on transition points and have found clinically significant benefits, solidifying their role.

Interprofessional team care

Interprofessional team-based care has often been posed as a solution to growing older populations with heavy chronic disease and medication burden. The roles of pharmacists have evolved from being a chemist to drug dispenser and basic educator to now direct patient care provider serving as medication expert within interprofessional teams in diverse settings. As emphasized earlier, pharmacists have distinct expertise that can contribute to team knowledge and competence in managing older patients with polypharmacy and multiple chronic conditions. A 2010 Cochrane review identified 43 studies where pharmacist services were targeted directly at patients (n=36) or other health care professionals (n=7). Most studies included in the review favored pharmacists providing medication and therapeutic management, patient education, and provider education to improve clinical outcomes and prescribing patterns. In team care settings, the acceptance rate of pharmacist recommendations is high, as one European study noted, where 80% of 263 valid, documented recommendations were accepted by physicians in a geriatric hospital. The recommendations made most often by pharmacists included dose adjustment, administration time and frequency, and medication discontinuation. Additionally, a systematic review looking at pharmacist care in directed or collaborative fashion to manage heart failure retrieved 12 RCTs that significantly lowered all-cause hospitalization and heart failure-related hospitalization, with collaborative care having greater effects in reducing heart failure-related hospitalization compared to directed care. As mentioned earlier, there is clear evidence for the distinct role of pharmacists and their impact within health care teams that care for older adults. Therefore, one of the pharmacist’s roles should be to contribute valuable expertise to team-based care of older patients.

Tools for pharmacotherapy optimization in elders

Medication misadventure, such as medication errors, inappropriate prescribing, suboptimal prescribing, and adverse drug events, is still common among older patients and continues to occur globally. Multiple validated tools are available for use to ensure appropriate medication use in older adults. Examples include the Beers criteria, STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) criteria, START (Screening Tool to Alert doctors to Right Treatment) criteria,and the MAI.

Many medications are included in the tools for tracking inappropriate medications for older adults. For instance, the 2012 Beers criteria contain 53 medications and medication classes that are considered high risk in older adults, including benzodiazepine, sedative hypnotics, psychotropic agents, and anticholinergics. The STOPP criteria have been developed and are used commonly in Europe, and contain similar medications as the Beers criteria, with more specific details. Patterson et al conducted a Cochrane review to determine the effectiveness of the aforementioned tools in improving appropriate polypharmacy use in older adults, and found that studies using such tools led to reductions in inappropriate use of polypharmacy and inappropriate prescribing. A recently published Italian study reported that using a combination of Beers criteria and STOPP criteria to assess medications of hospitalized older adults led to a higher number of potentially inappropriate drugs identified than either alone. With rampant ageism in modern societies, underuse of potentially beneficial medications is also a problem for older adults, as one study reported occurrence of undertreatment in 62% of the participants. Most frequently omitted medications in the study included nitrates for patients post-myocardial infarction, multivitamins for the malnourished, and inhaled anticholinergic agents for patients with COPD.

One of the included RCTs in the current review sought to measure the effects of pharmacists’ interventions using the MAI, STOPP, and START on prescribing appropriateness for hospitalized older adults and care utilization in a 12-month follow-up period. Significant reductions in PIMs, potential prescription omissions, and MAI score were seen, with positive association detected between MAI and STOPP scores and drug-related readmissions.

Therefore, it was shown that pharmacists’ interventions using such tools have an affirmative impact on older patients and health care systems.

Because many medications causing anticholinergic symptoms are culprits of causing adverse drug events resulting in harmful and costly consequences among older people, multiple scales have been developed to gauge anticholinergic burden in older adults’ medication regimens. A systematic review by Durán et al identified seven risk scales that delineated 47 high-potency anticholinergic drugs and 53 low-potency anticholinergic drugs.

Another recent systematic review by Salahudeen et al aimed to compare anticholinergic risk scales and association with adverse outcomes among older adults. They also identified seven anticholinergic risk scales, but found inconsistencies among the scales in terms of rating the medications’ anticholinergic activity. This review concluded that the Anticholinergic Cognitive Burden scale was validated most frequently for adverse outcomes, as per their citation analysis.In a separate study, Salahudeen et al compared nine published anticholinergic risk scales and their association with negative outcomes in older adults. Even though the prevalence of anticholinergic exposure differed widely among the scales, all nine scales were significantly associated with hospitalization, admissions for falls, length of hospital stay, and general practitioner visits. The Drug Burden Index’s anticholinergic component scores, age 85 years or greater, female sex, and polypharmacy use were the strongest predictors of the adverse outcomes.


Across various practice settings and diseases managed, pharmacists are actively engaged in improving pharmacotherapy for older patients. The current review strongly supports previous findings that showed positive impact of pharmacists’ interventions on older patients’ health-related outcomes. Therefore, there is a clear role for pharmacists’ direct or collaborative care to optimize pharmacotherapy in older adults, and global health care teams caring for elders should involve pharmacists.

Please contact our office at (703) 542-3737 or if you would like to schedule an Online Video psych Consultation for medication management or therapy session.