Education in appropiate pharmacotherapy in older patients

Abstract

Appropriate pharmacotherapy in older patients is of increasing importance. Advances in medicine and pharmacotherapy mean that people with health problems live longer. The longer life expectancy means that health professionals, but particularly physicians, pharmacists, and nurses, will have to meet the challenge of providing pharmaceutical care to older vulnerable patients. Older patients often have more than one medical problem. This makes appropriate prescribing for curative, preventive and symptomatic treatment goals essential, with polypharmacy as a result. However, there is currently concern about the large number of drug-related problems reported, which appear to especially affect older patients. These problems are thought to be because health professionals lack sufficient knowledge and skills in pharmacology and pharmacotherapy, possibly because of shortcomings in their education and training. Indeed, it has been suggested that improving education in geriatric pharmacotherapy might improve the knowledge and skills of health professionals in complex pharmacotherapy, thereby preventing or reducing the number of drug-related problems.<!--[if supportFields]>ADDIN RW.CITE{{328 Topinkova,E. 2012; 316 Members of EMERGE, Erice Medication Errors Research Group 2009; 14 Krahenbuhl-Melcher,A. 2007; 40 van den Bemt,P.M. 2000; 97 Aronson,J.K. 2006; 317 Aronson,J.K. 2009; 321 Cherubini,A. 2012}}

This thesis presents a series of studies on education in general and geriatric pharmacotherapy, knowledge and skills of health professionals, and educational intervention studies. No high-level evidence-based geriatric pharmacotherapy education was found in the literature. The WHO-6-step is proven to be effective for prescribing in general. The general and geriatric pharmacology and pharmacotherapy education at Dutch medical schools is already constructed quite well. However medical schools need to pay attention to assessment procedures – prescribing without a ‘prescribing examination’ is like driving without a driver’s license, given that it is a high risk task with potentially negative patient outcomes. For prescribing in general, the WHO-6-step should be adopted by medical schools worldwide, given the robust evidence supporting its effectiveness. This thesis shows that the effectiveness remains after implementation in a real medical curriculum by a longitudinal learning programme. The STRIP, a medication review method, could be adopted for polypharmacy skills, given the positive results on medical students’ polypharmacy skills and the lack of other evidence-based strategies. It might be worth considering using other clinical methods to achieve educational goals. A start was made to studying interdisciplinary learning between pharmacists and physicians, by identifying the actual knowledge of both professions. Several factors contribute to differences in knowledge and skills of health professionals. Undergraduate training results in more basic pharmacology knowledge for pharmacy students compared to medical students. Medical students had better pharmacotherapy skills and on applying knowledge on patients both groups of students performed equally. In the graduated health professionals, the pharmacists and the physicians, the difference increase with more years of work experience, with the highest scores for pharmacists on all domains of pharmacology and pharmacotherpy knowledge and skills.

It is important to realize that the absence of evidence is not evidence for the absence of effect.<!--[if supportFields]>ADDIN RW.CITE{{372 Altman,D.G. 1995}} In the field of geriatric pharmacotherapy education, there is a major absence of evidence, which means that teachers and curriculum designers should use the best evidence available. The studies of this thesis provide pieces of evidence that can be used to optimize education in appropriate pharmacotherapy in older patients.