Older people may have been seen less often in pharmacies because of Covid – but out of sight shouldn’t mean out of mind

Older people have felt almost invisible at times during the pandemic due to so many tucking themselves away in order to try and reduce their chances of contracting Covid-19. Yet it is that very vulnerability that has brought this section of the population into the public consciousness in a way that hasn’t been the case for a long time, with many people helping an elderly neighbour with their grocery shopping, for example, or video calling a relative when visiting in person isn’t possible so they don’t feel isolated.

Community pharmacy has played a huge part in looking after older people during the pandemic, supplying and delivering medicines (and other essentials), as well as being on the frontline of healthcare as never before due to reduced access to GPs and other primary care providers. Lesley Carter, clinical lead for professionals and practice at Age UK, urges pharmacy teams to think carefully about how to best serve this demographic at this time – and that is not only being concerned with their medicines.

“People’s lives have become much narrower, so pharmacists are very important in giving advice, saying what to do and spotting potential problems,” she says. “People are relying on pharmacy teams to provide older patients and their carers with the help and support they need.”

Medicines management in older people has generally become much better over the last few years, adds Carter, but communication between hospitals and primary care may not be as good as it should be at the moment due to the pressures and restrictions caused by Covid-19. 

“This means it is more important than ever for pharmacists to check older patients’ medications, particularly if someone has just been discharged from hospital. The is especially true for those who are having their medicines delivered. Make sure someone knocks on the door and asks how the person is and if they need anything.”

Justine Tomlinson, doctoral training fellow at Bradford University, suggests taking it a step further when practical. “Before lockdowns and tier restrictions I used to go into a patient’s home,” she says. “This tells you a lot about how they are managing their medication and their life more generally. Some people are very organised. I met a woman who put her day’s medication around the edge of a plate to resemble a clock face so she remembered to take everything at the right time, while others can be very chaotic. 

“Some are very medicalised, with boxes of dressings piled up, grab rails and medical equipment all over the place, and cupboards given over to medicines. That insight is vital; we need to put medicines’ use into the context of people’s lives. Saying ‘take two tablets four times a day’ can be confusing or meaningless, but if you explore what that looks like to the individual through a two-way conversation and lots of open questions, they will be able to make sense of it so that it fits into their everyday life.”

Such insights are invaluable – particularly given the findings of a recent review by academics from Swansea University. This found that poorer, older people who keep a social distance from their doctors or pharmacists suffer more adverse drug reactions than the general population.

“It is very unfortunate that the combination of keeping a social distance between doctors and older patients who are often poorer, and treatment based on prescribing drugs without regular patient contact or examinations, increases the risk of medication errors and adverse drug reactions,” says Professor David Hughes. 

“I am also very concerned that this situation is much more common during the pandemic, as patients in care homes are more likely to be subject to movement restrictions, often without direct contact with their doctors.”

The review concludes that these patients need to be “systematically monitored to protect them from suffering reactions that may lead to excessive
tranquillity, falls, or [conditions similar] to Parkinson’s disease”. It recommends that Swansea University’s Adverse Drug Reaction Profile tool can be used as a potential solution.

Discharge problems

Beth Fylan, senior lecturer in patient safety at Bradford University, is another to highlight hospital discharge as particularly problematic. The “bumpiness” that can be experienced during the transition from secondary to primary care is increasingly well documented, she says. 

“People can quickly become deconditioned, losing the functions of everyday living such as mobility and doing really simple things for themselves like making a drink. It can be very difficult to re-establish this independence, especially when feeling tired and run down.”

While it is crucial to smooth the transition of care at a systemic level, many people take action to anticipate and prevent problems and being readmitted to hospital. “This health resilience needs exploring,” she says – something her National Institute for Health Research-funded work is doing. 

“Patients undertake all kinds of activities, such as comparing old and new medicines to better understand what they are taking, creating checklists for medicines so they take them on time, taking old medicines to the pharmacy for disposal so they don’t mix them up, actively checking prescriptions to ensure the GP has prescribed the right items… this is invisible work that props up the system, and we need to better understand it and how the system can support more people to do more of the things that are helpful.” 

Ian Maidment, Royal Pharmaceutical Society spokesperson on dementia and mental healthcare through pharmacy, advises pharmacy teams to be particularly vigilant with older people on complex regimens. “There is a real burden for patients and carers but it is hidden. People struggle along, trying to cope and not getting the support they need.”

It is important not to make assumptions, he says, describing how people who appear knowledgeable might not only find something difficult to get to grips with that seems relatively straightforward – laxative dosing, for example – but may also be reluctant to ask for help for fear of being a burden, or not wanting to appear incapable or incompetent. 

Pretty much everyone working in a pharmacy has a story of a relative or friend contacting them with a straightforward health query and it is easy to think that it is because of the sector’s expertise in medicines. “But would those questions have been asked of someone else had they not had a personal relationship with the person working in a pharmacy? And what about those individuals who don’t have those close contacts?” he asks. 

Common sense

Maidment, who is also a reader in clinical pharmacy at Aston University and who led the Memorable project, which explored medicines management in older people, says that community pharmacists might doubt their clinical pharmacy skills – but actually a lot of what is needed is old-fashioned common sense. “It is about developing the confidence and experience to use professional judgement rather than rigidly sticking to what some regard as rules but is actually clinical guidance, as opposed to something that is set in stone.

“Work with patients and their carers, and listen to them: what do they need and how can they be supported? It might involve an advanced clinical review, but the chances are that a few little things will make a big difference, like getting their prescription on time or sorting out the right formulation so they can actually take the medicine. Look at ways in which the burden [of medicines taking] can be reduced, because for many patients it is a big issue.”

Age UK’s Lesley Carter draws attention to digital exclusion. “Don’t rely on electronic forms of communication: things need to be written down too. And this isn’t just about old people – in fact, they may well have embraced technology with help from their adult children and grandchildren. But people in their 50s and 60s with long-term conditions might not have got to grips with using IT, so won’t necessarily be able to access information online.”

Pharmacists and their teams are doing a really good job, probably more so than they realise, and lots of people couldn’t manage without them, she says. “But it isn’t always easy for people, particularly those who are older, to navigate pharmacies and healthcare more generally. So get information together that people can access and understand, whether they have come into the pharmacy or are at home, and make sure you identify their hidden vulnerabilities by being vigilant, knowledgeable and interested.”

Don’t rely on electronic forms of communication – things need to be written down too

Preventing falls

Meanwhile, up to one in 20 older people with a history of falling sustains a fracture annually, with some being admitted to hospital or needing to move to a care home. One in three people with a hip fracture dies within a year, with this type of fracture alone costing the NHS over £2bn per year. 

Worryingly, however, population screen and treat programmes, often recommended to prevent older people falling, have been found to have
no impact on reducing fractures by researchers from the University of Warwick and University of Exeter. 

The study examined two screen and treat programmes, which are prescribed regularly for older people:

• Multi-factorial fall prevention (MFFP)
• Exercise for people at increased falls risk. 

People living in the community were screened for falls risk and invited to attend the programmes. Multi-factorial fall prevention involved a one-hour assessment with a trained health professional for eight risk factors for falls. Following this, participants would either be given specific advice, see their GP for a detailed medication review, or be referred for physiotherapy-led exercise. The exercise programme ran for six months during which they were seen by a physiotherapist and exercised at home. 

The trial recruited 9,803 people aged 70 years and older who were living in the community (i.e. not in a care home). They were asked to complete a questionnaire to determine their individual risk of experiencing a fall and those with a higher risk were provided with a falls prevention advice booklet, then randomly assigned to take part in either the six-month exercise programme, the multi-factorial fall prevention programme, or there was no further intervention beyond the advice booklet. By taking a population-based screening approach, the researchers felt they could build a realistic picture of the broader impact of these programmes on all older people.

Using data from NHS Digital combined with GP records and reports from the participants themselves, the researchers determined how many times people went to hospital or attended A&E with a fracture over the course of 18 months.

When they compared fracture rates from both screen and treat programmes to those who had only received the advice booklet, they found no reduction in fracture rates between them.

“Whilst this is a disappointing result, it shows that we must continue to invest in research and development to reduce fractures in older people,” says lead author Professor Sallie Lamb. “We need to think about the broader causes of fractures, and also understand more about what happens to cause falls.”

Dealing with loss

Everyone will have experienced some sort of loss this year, says Age UK’s Lesley Carter, and pharmacists and their teams need to be attuned
to this in their older patients.

“It might be a friend or relative to coronavirus, but it might be a pet passing away – even if it was old and unwell and the death wasn’t a surprise – or missing seeing family or looking after grandchildren, as well as other events like unemployment,” she says. 

“Many people will be feeling guilt, perhaps because they consider they didn’t do enough or give someone a good send-off because of the restrictions around funerals. Some will be struggling because they didn’t get to say goodbye to someone who died. There has been a lot to deal with this year.

“This all has a knock-on effect. Bereavement, of course, accumulates. As people get older, it is something that they experience more and more, and that increase in frequency can really affect their ability to cope. There is also the downward spiral that can easily happen – someone feels down so they don’t go out, which in turn means their mobility reduces, and then they get fearful about leaving the house. 

“They start shopping online or perhaps someone drops off their groceries, which means they stop making those little decisions you make when you are buying food in the shops, and this has an impact on cognition. Life can feel much less exciting, and so social isolation, anxiety and depression can set in, [so it is important to] keep an eye on people and be alert to the signs that they might be on this slippery slope.”

The NHS website has some useful resources on coping with grief, including links to other organisations. Age UK also has information and advice on combating loneliness, including guides on using digital technology for shopping, ordering prescriptions and making video calls, and how to support someone who may be feeling isolated.

Obese patients over the age of 60 years can lose an equivalent amount of weight as younger people using only lifestyle changes, according to a new study from the University of Warwick and University Hospitals Coventry and Warwickshire NHS Trust.

A study of patients attending a hospital- based obesity service showed no difference in weight loss between those under 60 years and those aged 60-78 years. When compared, the two groups were equivalent statistically, with those aged 60 years and over on average reducing their body weight by 7.3 per cent compared with a body weight reduction of 6.9 per cent in those aged under 60 years. 

Both groups spent a similar amount of time within the obesity service, on average 33.6 months for those 60 years and over, and 41.5 months for those younger than 60 years.

“Weight loss is important at any age, but as we get older we are more likely to develop the weight-related co-morbidities of obesity,” says Dr Thomas Barber of Warwick Medical School at the University of Warwick.

“Service providers and policymakers should appreciate the importance of weight loss in older people with obesity for the maintenance of health and 

Reducing dementia

Forty per cent of dementia cases in this country could be prevented or delayed by targeting 12 risk factors throughout life, according to a paper published this summer in The Lancet. The factors identified are:

• Early life education
• Hearing loss
• Brain injury
• Hypertension
• Excessive alcohol intake
• Obesity
• Smoking
• Depression
• Social isolation
• Physical inactivity
• Diabetes
• Air pollution. 

Fiona Carragher, director of research and influencing at Alzheimer’s Society, welcomed the news but said that stopping thousands of people from being stripped of their memories, relationships and identities will rely on more than just this. 

“We can take action now to tackle the risk factors within our control, including excessive drinking, obesity and high blood pressure… [but] we need public health policies to address other factors such as air pollution and inequalities in childhood education.” 

Carragher, a former deputy chief scientific officer at NHS England, is calling on the Government to put greater investment in further research as a matter of urgency. 

Karen Harrison-Dering, head of research and publications at Dementia UK agrees, saying that a lot of dementia is caused by aspects we don’t yet fully understand.

“The management of risk factors is everyone’s responsibility. Lifestyle aspects like exercise, and how we eat and drink are in the lap of the individual, but health and social care has a role in looking at ways to contribute to the wider good of society.

“Pharmacists have become the forefront health discipline this year, due to restricted access to GPs as a result of the coronavirus pandemic. For years, doctors have been seen as the pinnacle of healthcare, but there is now a greater sense that similar knowledge and skills are shared across many other health disciplines. 

“Pharmacists are also often working in the hearts of their communities. They can make a big difference because they are accessible to some of the most vulnerable individuals, who may have multiple risk factors. For example, if there is a big BAME population locally, there may be a higher incidence of diabetes and perhaps high levels of smoking and poverty as well. 

“It would be great to see pharmacists make the most of this shift in the power base that has happened in healthcare and maximise their capacity for health promotion, because this can have a really profound effect on older people.”