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1 Challenges in Geriatric Care |
27
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| Fundamentals of Geriatric Pharmacotherapy
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2
E
S
C
SUSAN W. MILLER
L O
1. Apply the tenets of biomedical ethics to ethical dilemmas commonly encountered in providing pharmaceutical
care to geriatric patients.
2.
Explain issues related to communication in the care of the geriatric patient, including informed consent, privacy
and confidentiality, and surrogate decision making.
3.
Describe patient, caregiver, family, and legal issues associated with end-of-life decisions.
4. Explain the effects of socioeconomic issues on access to pharmacy care by geriatric patients.
5. Describe medication financing options (including affordable medications) available for geriatric patients.
K T D
AUTONOMY: Respect for autonomy obliges healthcare professionals to honor the choices of adults with
decision-making capacity, allows for a patient’s right to self-determination, avoids paternalism, allows for the
acceptance of the free choice of the patient, and ultimately permits the patient to make final decisions relating
to his or her healthcare.
BENEFICENCE: Beneficence obliges healthcare professionals to help others and promote their welfare.
BOXED WARNING: A notice in the prescribing information of a prescription medication that alerts prescribers
and patients of severe or fatal side effects of the medication; often added retrospectively following identifica-
tion of side effects in the routine use of the medication. This was previously known as a “black box” warning.
CULTURE: The group to which one belongs; extends beyond race and ethnicity to include age, gender, religion,
and health beliefs.
DNR: Do not resuscitate; an order that states cardiopulmonary resuscitation (CPR) is not to be performed in the
event of cardiac or respiratory arrest.
ETHNOGERIATRICS: Healthcare for geriatric patients from diverse populations.
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| Fundamentals of Geriatric Pharmacotherapy
INFORMED CONSENT: A process in which a person learns key facts about a healthcare treatment, including
potential risks and benefits, before deciding whether or not to accept the treatment.
JUSTICE: An obligation to treat patients who are equal, in relevant respects, in the same manner; giving what
is due to patients.
LIVING WILL: A written, legal document that conveys the wishes of an individual in the event of a terminal
illness; can convey the wishes of one who is no longer able to communicate.
MANAGED CARE: A system created with the intent to control the cost of healthcare that uses financial incen-
tives and management controls to direct patients to providers who are responsible for giving appropriate care
in cost-effective treatment settings. Financial risk is shared among the providers.
NONMALEFICENCE: An obligation to not intentionally inflict harm on others nor to engage in actions with
foreseeable harmful effects; “At least, do no harm.”
PROXY: A person authorized to act for another.
I
E
thical and socioeconomic considerations are
integral components in the delivery of
healthcare to geriatric patients. Often, the care of
a geriatric patient centers on important decisions
regarding healthcare choices and end-of-life
issues for those who lack the mental capacity or
physical ability to effectively communicate their
personal choices. Access to healthcare, health-
care disparities, and financing healthcare are
vital socioeconomic issues for older citizens. This
chapter will describe ethical issues and socio-
economic considerations related to geriatric
patients.
E B
E
Biomedical ethics is the branch of ethics
concerned with the life of the patient, and at the
core of biomedical ethics are issues regarding
the protection of life.
1
Table 2-1 provides exam-
ples of many important biomedical issues. The
promise to adhere to the principles of biomedical
ethics is contained in the various oaths affirmed
by healthcare professionals, including pharma-
cists. Of the various tenets of biomedical ethics,
four are particularly applicable in geriatric phar-
macy practice: respect for patient autonomy,
nonmaleficence, beneficence, and justice.
Ethical dilemmas arise when these tenets are in
conflict, and a choice between two “rights” must
be made. Biomedical ethics often involves situ-
ational ethics, in which a particular clinical condi-
tion may cause both patient and caregiver values
to evolve in order to cope with changing circum-
stances. Ethical dilemmas are often encoun-
tered during geriatric patient care because treat-
ment options are rarely straightforward.
Pharmacists are obligated to apply the
tenets of biomedical ethics when providing
pharmaceutical care for geriatric patients. For
example, by providing full disclosure regarding
the risk-benefit profile of medications, thus
allowing the patient to make a personal choice
as to whether to consume a particular medica-
tion, the pharmacist is providing patient care
as well as respecting autonomy and acting
with beneficence and nonmaleficence. The
use of medications with a boxed warning in
the prescribing information can be a particu-
larly difficult ethical dilemma for the pharmacist
providing care for geriatric patients. Recently
approved drugs may be more likely to have
unrecognized adverse drug reactions (ADRs)
than established drugs, especially in older frail
patients. Serious ADRs commonly emerge after
FDA approval, and the safety of new agents
cannot be known with certainty until a drug has
been on the market for several years. Yet, physi-
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2 - Ethical and Socioeconomic Considerations |
31
cians often prescribe new pharmacotherapeutic
agents with the promise of improved efficacy
and ease of dosing compared to older agents.
2
For example, the use of thiazolidinediones can
be problematic in the geriatric diabetic patient.
The thiazolidinediones can cause or exacerbate
congestive heart failure and contain a boxed
warning in the prescribing information about this
effect. Pharmacists have an ethical responsibility
to inform patients of these potential effects and
suggest the use of alternative oral antidiabetic
agents that may be more appropriate and have
fewer adverse effects in their specific situation.
However, it is difficult for the community pharma-
cist who may lack detailed information about the
patient’s history, physical findings, and labora-
tory results to know when the risk outweighs the
benefit for an individual patient. Thus, an ethical
dilemma must be resolved.
Another example involves the use of atypical
antipsychotic agents, such as risperidone, ziprasi-
done, and quetiapine, that are often prescribed off
label to manage behaviors in elderly patients with
dementia. Their use is associated with increased
mortality in elderly patients with dementia-related
psychosis, mostly due to cardiovascular events
or infectious diseases. The prescribing informa-
tion for atypical antipsychotic agents contains this
information in a boxed warning. Pharmacists have
the ethical responsibility to provide complete drug
information to patients and/or surrogate decision
makers regarding potential nonpharmacologic
and alternative pharmacotherapeutic options for
behavior management. This particular situation
is fraught with ethical issues, as the patient with
dementia may have difficulty providing input for
his or her preferences, nursing home staff and
family are frequently frustrated with behavior prob-
lems, and busy physicians may not adequately
evaluate all components driving the behaviors.
An additional example involves the use of the oral
anticoagulant dabigatran to manage patients with
nonvalvular atrial fibrillation. Postmarketing reports
of bleeding with dabigatran were at a higher
rate than reported in the FDA approval process,
and this adverse event presents a challenge in
medication management because of the lack of
an available reversal agent for the anticoagulant
effects and the continued need for an agent to
manage the atrial fibrillation.
3
The ideal scenario is
for the pharmacist to participate in patient assess-
ment meetings with other healthcare providers,
including patients and surrogate decision makers,
and having each participant explain the problems
objectively and discuss potential solutions. These
interprofessional interactions result in a carefully
chosen treatment plan devised with consideration
of the risks and benefits to the patient.
Table 2-1. Issues in Biomedical Ethics
Biomedical Issue Specific Examples
Healthcare Quality of life, public health issues
Patient rights Privacy issues, decision making regarding care options
Research in humans Geriatric patients enrolled in clinical trials, translating research from
younger cohorts into geriatric cohorts, obtaining informed consent
Organ transplants Qualifications for receiving an organ transplant
Stem cell research Cures for disease
Addiction Treatment alternatives
Mental health Use of psychotropic medications, involuntary treatment
Aging Rationing of healthcare resources
Death and dying Advance directives, dying with dignity
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| Fundamentals of Geriatric Pharmacotherapy
Pharmacists practicing as consultants for
institutionalized geriatric residents of skilled
nursing facilities have a responsibility to make
recommendations to add, modify, or discontinue
pharmacotherapies in these patients following
evidence-based medicine, disease manage-
ment practice guidelines, algorithms, or sound
clinical judgment. The pharmacist should
strive for a balance between beneficence and
nonmaleficence in adhering to practice guide-
lines and making recommendations regarding
drug therapy. Prior to the pharmacist making a
recommendation to prescribe an antihyperlip-
idemic agent, such as a statin, for prevention
and/or management of hypercholesterolemia in
a specific geriatric patient, the life expectancy,
effectiveness of therapy, adverse effects, and
time to benefit should be taken into consider-
ation. At issue is the general lack of high-quality
evidence to use in assessing the risks and bene-
fits in patients over the age of 80 years for most
practice guidelines.
When the needs of two individuals in similar
circumstances are unequal, the obligation is to
treat them in a fair manner and to act with justice.
This means that those who have a greater need
may rightly receive more of a particular resource
than those with less need.
4
Pharmacists who
immunize patients should follow the guidelines
for administration of these vaccines. During the
vaccination period prior to influenza season,
pharmacists should apply the tenet of justice
to provide protection for the most susceptible
patients and prevent vaccine shortages. Justice,
when applied to resource allocation in the provi-
sion of healthcare, is central to the debate over
the rationing of healthcare and whether health-
care is a right or a privilege.
Principles of Ethical Decision
Making
Three principles of thinking that frame ethical
decision making and are applicable in the patient
care setting have been described by Kidder:
ends-based thinking, rules-based thinking,
and care-based thinking.
5
Ends-based thinking
follows the maxim “Do whatever produces the
greatest good for the greatest number.” Deci-
sions regarding the allocation of pharmaco-
therapy resources, as in cost-benefit analysis,
are often rooted in ends-based thinking. Prac-
tical examples of ends-based thinking include
implementation of therapeutic substitution within
a formulary and the use of tiered copays in phar-
macy benefit programs. Administration of influ-
enza vaccine in all institutionalized patients will
provide the best protection for that population
against the disease. However, some patients
may object or may be allergic to components
of the vaccine, causing a fallacy in this line of
thinking.
Rules-based thinking follows the maxim
“Stick to your principles (the rules) and let the
consequences follow.” Decisions involving the
obligation that the pharmacist owes to the patient
follow rules-based thinking. An example of rules-
based thinking is the provision of complete
factual drug information to patients during coun-
seling, including the most severe, albeit rare,
adverse effects of the medication. This coun-
seling would include boxed warnings.
Finally, care-based thinking follows the
maxim “Do unto others as you would have
them do unto you.” The pharmacist’s feeling of
empathy for the patient is the result of care-based
thinking. Examples of care-based thinking in the
practice of pharmacy include providing drug
information to patients receiving sample medi-
cations or whose insurance plan requires them
to obtain their medications from mail-order phar-
macies. The pharmacist who does not charge
for this information will also not see a profit from
sales of a prescription.
R C
In the process of providing healthcare and phar-
maceutical care to the geriatric patient, multiple
opportunities exist for making choices relative
to this care. Choices regarding the types of
care necessitate full disclosure of the risks and
benefits of each type; choices regarding privacy
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2 - Ethical and Socioeconomic Considerations |
33
and confidentiality affect the delivery of care and
personal heath information; a patient’s culture
can affect his or her healthcare beliefs and
choices; and caregivers and family may take
part in the shared responsibilities of the deci-
sion making. The tenets of biomedical ethics
can be applied to the resolution of dilemmas
that are central to the provision of healthcare
for geriatric patients. The dependent nature
of many geriatric patients can complicate the
issues, as the older patient may require assis-
tance in making choices relative to healthcare.
As a result of cognitive impairment or commu-
nication disorders, geriatric patients are often
unable to express a preference for their health-
care matters. Publicized cases involving ethical
issues have provided guidance for patients,
family, and healthcare providers in the areas
of establishing patient preference regarding
healthcare decision making and the right to die.
6
These cases have dealt with issues related to the
persistent vegetative state,
7
physician-assisted
suicide,
8
and an individual patient’s request for
the right to die.
9
Communication between the pharmacist
and the older patient is an additional factor
involved in resolving ethical dilemmas and
respecting healthcare choices of geriatric
patients. Communicating with older patients can
be especially challenging, secondary to exten-
sive medical histories, multiple medications,
and physiologic barriers that may complicate
the interaction.
10
Pharmacists should practice
compassionate communication with geriatric
patients and their caregivers and should treat
patients with dignity and respect, regardless of
the cognitive or physical condition of the patient.
Accommodations should be made for patients
with hearing or visual impairments, such as
speaking slowly and clearly, maintaining eye
contact, and using visual aids written in a large
type font and/or pictures and diagrams. A reas-
suring and supportive attitude while communi-
cating can make the older patient feel comfort-
able in sharing his or her healthcare choices.
Informed Consent
Autonomy on the part of the geriatric patient
and respect for autonomy on behalf of the phar-
macist are manifest in the precept of informed
consent. Informed consent has replaced pater-
nalism in the decision-making processes of
healthcare and allows the patient to make final
decisions regarding healthcare choices only
after receiving full disclosure regarding the risks
and benefits of the available options.
The seven elements of informed consent
that must be met for the patient to make a
proper decision regarding healthcare choices
are competence (to understand and decide),
voluntariness (in deciding), disclosure (of mate-
rial information), recommendation (of a plan),
assurance of understanding, decision (in favor
of a plan), and authorization (of the chosen plan).
A basic meaning of competence is the ability
of the patient to perform a task, which in the realm
of healthcare is to understand the decision at
hand. Comatose patients and those with signifi-
cant cognitive or psychological impairments lack
competence and are unable to provide informed
consent. This is especially an issue with delirium,
where a patient’s ability to understand may fluc-
tuate. Furthermore, medications may cloud a
patient’s mentation, creating further difficulties.
Voluntariness must be present and must not be
affected by coercion or manipulation by health-
care professionals or relatives, or by medica-
tions or psychological disorders. Confusion can
prevail when multiple family members disagree
on the best choice for a patient, and the patient
is unable or unwilling to oppose a choice which
differs from his or her own perspective. Various
cultures may involve family members or health-
care professionals to a greater or lesser degree
in helping the patient make his or her own deci-
sion, and these differences must be evaluated
to ensure coercion is not present. Disclosure
of information must be appropriate, based on
contemporary professional standards, and must
be what a reasonable person would expect to
be told in a similar situation. Recommendation
of a plan must be based on the best information
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| Fundamentals of Geriatric Pharmacotherapy
obtainable. Assurance of patient understanding
must be determined by the healthcare provider.
Understanding may be difficult to measure,
and the circumstances in which the informa-
tion is disclosed may affect the patient’s under-
standing. If a patient has poor health literacy,
information must be disclosed in a manner he
or she can understand. To assess comprehen-
sion, the clinician should have the patient explain
what he or she understands about the choices.
Furthermore, in an emergency situation where
time is of the essence, if the patient is emotion-
ally distraught, or if medical terms are not clearly
described, misunderstanding may occur. When
all of the elements of informed consent are met,
the patient has the right to make an autonomous
decision, and the decision should be respected
by healthcare professionals. Finally, authori-
zation for any procedure must occur though a
signature on a legally valid document.
11
Informed consent is most frequently asso-
ciated with participation in clinical research;
however, written informed consent for nursing
home residents with dementia treated with
psychoactive agents is mandated in some
states and may become commonplace.
12
Nearly
one-third of elderly nursing home residents with
dementia are receiving an antipsychotic medi-
cation, and those with impaired decision-making
ability are 50% more likely to receive these medi-
cations. The combination of high utilization and
patients with dementia makes the process of
informed consent in this situation precarious.
13
Privacy and Condentiality
The Health Information Portability and Account-
ability Act of 1996, also known as the Privacy
Rule or HIPAA, provides federal protections for
personal health information (PHI) held by covered
entities (healthcare providers and healthcare
institutions) and gives patients certain rights
regarding the information.
14
A patient’s under-
standing of his or her personal health record and
how PHI is used allows the patient to assume
responsibility for the accuracy and authorization
of use of PHI. The basic rights under HIPAA are:
• Request a restriction on certain uses and
disclosures of PHI
•
On request, obtain a paper copy of the
notice of information practices
• Inspect and/or receive a copy of personal
health record
• Request an amendment or correction to
personal health record
•
Obtain an accounting of disclosure of PHI
•
Request for communication of PHI by alter-
native means or at alternative locations
• Revoke authorization to use or disclose PHI
except to the extent that action has been
taken
Application of HIPAA policies in the health-
care setting ensures that geriatric patients have
the right to receive care in privacy. This means
that in the community pharmacy setting, medica-
tion counseling should be provided in a private
area, away from other patients; in the nursing
home, patients should receive their care, such as
the administration of medications, in their room
and not in the public areas of the facility. Phar-
macy examples of HIPAA violations include the
selling of prescription information to companies
tracking prescribing patterns of physicians or
the unauthorized speaking with family members
regarding a geriatric patient’s medications.
KEY POINT: Pharmacists have
the obligation to ensure that PHI is
only disclosed as patients permit.
Ethnogeriatrics: Cultural
Considerations
It is the professional responsibility of healthcare
providers to become knowledgeable regarding
the cultures of the patients they serve and to
understand the implications of these cultural
beliefs on individual health behaviors. There are
data to show that lack of cultural competence on
the part of the healthcare provider can lead to
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2 - Ethical and Socioeconomic Considerations |
35
disparities in healthcare access and provision.
15
Information is available for pharmacists to deter-
mine and further develop their personal cultural
competence.
16
Cultural considerations are
important in understanding the health beliefs of
patients from various generations, backgrounds,
religions, and traditions. Cultural competence on
the part of healthcare providers ensures that the
effects of factors such as socioeconomic status,
education, race/racism, ethnicity, culture, sex,
disability, and sexual orientation are considered
when providing care related to the health and
functioning of the older population.
17
The term ethnogeriatrics was first estab-
lished by the Stanford Geriatric Education Center
in 1987 and serves to recognize the challenges
of caring for a growing, ethnically diverse, aging
population.
18
The ETHNIC(S) mnemonic is a
tool for clinicians to use for cultural evaluation
during a patient encounter.
17
Each letter in the
mnemonic stands for a cultural aspect of care
involved in a patient encounter and should
allow the healthcare provider to appreciate the
centrality of culture in illness: Explanation, Treat-
ment, Healers, Negotiate, Intervention, Collabo-
ration, and Spirituality. Table 2-2 provides ques-
tions to be asked during the patient encounter.
Pharmacists are encouraged to incorporate
this model into their patient encounters when
providing pharmaceutical care such as coun-
seling on medications, medication therapy
management, and medication reconciliation for
geriatric patients. The use of assessments such
as the ETHNIC(S) tool should help healthcare
professionals recognize the heterogeneity of
older minority patients, avoid stereotyping and
generalizations, and help to provide culturally
competent pharmaceutical care.
Medication adherence in the elderly is
affected by one’s attitude toward self-efficacy
(the belief that one can perform a specific
behavior under differing conditions), medication-
efficacy, confidence in the prescribers’ knowl-
edge, perceptions about natural products and
home remedies, beliefs of control (over one’s
health), and illness perceptions.
19
Intergenera-
tional relationships and the importance of tradi-
tional familial hierarchies influence health-related
behaviors and decision making in the Southeast
Asian, Japanese, and Hispanic cultures. Elders
from Southeast Asian cultures base their beliefs
on healthcare and medicine in the ancient prac-
tice of Chinese medicine. They characterize
Western medicine as stronger, faster, and cura-
tive compared to their folk medicines as weaker,
slower, yet preventive. This belief system may
explain why patients from Southeastern Asian
cultures may choose to be noncompliant with
medications by taking lower doses.
Members of Native American cultures
believe in the interconnectedness of healing,
spiritual beliefs, and community and look to
modern medicine to alleviate modern ills such
as hypertension and diabetes. They look to tradi-
tional Native American remedies to cure common
problems such as pain or a “sick spirit” (defined
as mental illness and/or alcoholism). Older Japa-
nese Americans respect healthcare practitioners
as authoritarian figures, place a high level of
trust in them, and tend to allow healthcare prac-
titioners to make treatment-related decisions
for them.
20
Members of the African American
culture are more likely to express negative and
suspicious beliefs about physicians’ advice on
medical treatments, including the prescribing
of drugs, and report spiritual beliefs that God is
ultimately responsible for health.
21
Patients with
a faith-based lifestyle can perceive use of medi-
cations as a sign of disbelief or weakness. It is
important for pharmacists to understand their
patients’ cultural beliefs so that medication coun-
seling can be tailored, taking these beliefs into
consideration.
What one thinks of illness and how it
develops (i.e., the result of unhealthy habits,
random occurrence, accidents, or punishment)
and one’s views on care (i.e., professional, self-
care, do nothing) and treatments (i.e., holistic,
scientific based, “natural” remedies) can all affect
medication adherence. The Greatest Genera-
tion or traditionalists may be noncompliant with
pain medications as a result of stoicism. They
may delay getting refills or may not complete
a course of antibiotics as a result of hoarding
https://t.me/medicina_free
36
| Fundamentals of Geriatric Pharmacotherapy
(saving for a rainy day) or may be more depen-
dent on home remedies as a result of self-reliance.
The Baby Boomer generation is composed of a
post–World War II cohort who expect a prescrip-
tion to be written at every patient encounter. At the
other end of the spectrum, a younger group, the
Woodstock Generation, rely on natural products
for cures. Baby Boomers are interested in infor-
mation related to their medications and generally
accept patient counseling. The use of alternative
medicine, including dietary supplements and
herbal remedies, is increasing in all age groups
and has doubled among geriatric patients since
the year 2000.
22
Pharmacists should enquire
about the use of alternative therapies when taking
a medication history and when providing patient
counseling regarding prescription medications. In
counseling geriatric patients, pharmacists should
be prepared to discuss alternative therapies and
make recommendations when asked.
KEY POINT: Patients often
have cultural beliefs that symptoms or
side eects are just part of growing older
and cannot be relieved. ese beliefs
may inuence medication adherence.
Table 2-2.
ETHNIC(S): A Framework for Culturally Appropriate Geriatric Care
17
Cultural Aspect
Direct Question or Statement
to Be Asked or Stated
(Use the Patient’s Phraseology)
Probe Questions to Be Asked or Actions to
Be Taken
Explanation
Why do you think you have this
symptom/illness/condition?
What do friends, family, and others say about these
symptoms? Do you know anyone else who has had
or who has this kind of problem? Have you heard
about/read/seen it on television/radio/newspaper/
Internet? (If the patient cannot offer an explanation,
ask what concerns him or her about the problems.)
Treatment
What have you tried for this
symptom/illness/condition?
What kind of medicines, home remedies, or other
treatments have you tried for this illness? Is there
anything you eat, drink, or do (or avoid) on a regular
basis to stay healthy? Tell me about it. What kind of
treatments are you seeking from me?
Healers
Who else have you sought help from
for this symptom/illness/
condition?
Have you sought help from alternative or folk healers,
friends, or other people who are not doctors for
help with your problems?
Negotiation
How best do you think I can help you? Try to find options that will be mutually acceptable
to you and your patient and that incorporates your
patient’s beliefs rather than contradicting them.
Intervention
This is what I think needs to be done
now.
Determine an intervention (e.g., diagnostic,
pharmacological, psychosocial, educational) with
your patient that may also incorporate alternative
treatments, spirituality, healers, and other cultural
practices (e.g., foods eaten or avoided in general
and when sick).
Collaboration
How can we work together on this,
and with whom else?
Collaborate with the family, family members, healers,
and community resources.
Spirituality
What role does faith/religion/spiritu-
ality play in helping you with this
symptom/illness/condition?
Tell me about your spiritual life. How can your
spiritual beliefs help you with this?
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