Pharmacists doing more to support patients with dementia, their families and caregivers
March 16, 2016 (Ottawa): When Marc Riachi’s mother, Sonia, was diagnosed with frontotemporal dementia, Riachi discovered that she still had much to teach him. As a pharmacist, Riachi became part of her caregiving team. “When you actually have a loved one going through this disease, you learn so much more about its intricacies and develop a better appreciation of the severely limited medical treatments available. It’s a humbling and very challenging experience,” he says. Riachi, who is also a clinical editor at the Canadian Pharmacists Association, turned his research skills to his mother’s care, reading up on treatment guidelines, systematic reviews, and experimental therapies.
But experience taught him more than literature alone. “You helplessly observe how a lifetime of your loved one’s carefully crafted mental checks and balances gradually wear away. It’s like looking at a ‘naked brain,’ if you will.”
From his experience, Riachi has become a strong proponent of the role pharmacists can play in the care of patients with various forms of dementia such as Alzheimer’s disease, frontotemporal dementia, vascular dementia, Lewy body dementia, and others.
In an article in the Canadian Pharmacists Journal (CPJ), Riachi discusses many of the ways that pharmacists can help their patients with dementia. Riachi refers to an article published in an earlier issue of CPJ, in which pharmacists Dr. Feng Chang and Dr. Tejal Patel, with Mary Schulz, Director of Education at the Alzheimer Society of Canada, outline the many roles for pharmacists in dementia care as Canada faces a “rising tide” of dementia over the coming decades.
As primary care professionals who see patients regularly, pharmacists may be among the first to recognize signs of dementia, or patients may ask them about memory problems or for products that improve memory, say Chang and Patel. Pharmacists can screen patients for cognitive impairment and refer them to their physician for further testing and diagnosis.
Once a patient has received a dementia diagnosis, pharmacists can help patients and their caregivers with medication issues, as well as with guidance to other helpful products and therapies, say Riachi, Chang and Patel (see Medication management for patients with dementia).
Riachi says his mother’s symptoms were not only cognitive but also physical and behavioural, as is often the case in dementia. Symptoms also change often, sometimes monthly, making it very challenging for the caregiver to adapt, says Riachi. As patients experience new and varying symptoms, pharmacists can help by:
- recognizing problems that may be caused by medication side effects
- “de-prescribing” (stopping) medications that are no longer contributing to quality of life or are worsening cognitive symptoms
- changing dosages or switching medications if needed
- finding medication formulations (such as suppositories, injections, and nasal sprays) that the patient can take, and ensuring the packaging can be easily read and opened
- recognizing health problems that may be unrelated to dementia
- making suggestions to improve quality of life
- acting as a “one-stop shop” for information on other health services such as physiotherapy and support services such as the local Alzheimer Society
Primary care (community) pharmacists as well as pharmacists in long-term care homes can meet with patients and their families to review and discuss medications.
“A lot of people don't realize that the pharmacist can be a tremendous ally in managing a person’s dementia,” says Mary Schulz. Chang adds, “Pharmacists are in a unique proactive position to really listen to the caregivers, to treat the patient as a person who deserves respect, and to foster a good relationship with the family.”
See “Background: Pharmacists as part of the dementia care team” for details on how pharmacists can help patients with dementia and their family and caregivers.
About the Canadian Pharmacists Journal
Established in 1868, the Canadian Pharmacists Journal is the oldest continuously published periodical in Canada. CPJ’s mission is to support pharmacists in optimizing patient care by linking knowledge to practice. CPJ is an official publication of the Canadian Pharmacists Association. CPhA advocates for pharmacists and supports its members to advance the profession and enhance patient outcomes.
To arrange an interview with Marc Riachi, contact him at marc.riachi@gmail.com
or (613) 371-6400
To arrange an interview with Dr. Feng Chang, contact her at feng.chang@uwaterloo.ca
or (519) 888-4567 ext 21321
To arrange an interview with Dr. Tejal Patel, contact her at t5patel@uwaterloo.ca
or (519) 888-4567 ext 21337
To arrange an interview with Mary Schulz, contact Rosanne Meandro, Director of Communications, Alzheimer Society of Canada, at rmeandro@alzheimer.ca or 416-847-8920
For more information, please contact:
Mark McCondach
Director of Communications
Canadian Pharmacists Association
mmccondach@pharmacists.ca
(613) 523-7877 Ext. 285
Background
Pharmacists as part of the dementia care team
Identifying signs of dementia
Pharmacists may be among the first health professionals to recognize the signs of dementia in a patient, says Dr. Tejal Patel. “Pharmacists see patients routinely, and may discover a patient is having problems or confusion.” She says difficulties managing medications, such as getting refills late, failing to renew prescriptions, blister packs not punched out or punched out on the wrong dates, may alert a pharmacist that the patient may have a cognitive impairment.
Screening for dementia
When a pharmacist spots warning signs of dementia, or a patient expresses concerns about his or her memory and ability to function on a day-to-day basis, pharmacists can conduct brief cognitive assessments in a private place in the pharmacy. Patel says assessment results “add objective credibility and urgency when patients call their physician.” Pharmacists can tell patients when it might be a good time to seek medical help, says Dr. Feng Chang.
It may be a family member who asks the pharmacist about a patient’s changes in abilities. Pharmacists can empower family members by pointing them to evidence-based checklists for Alzheimer’s disease available on the Alzheimer Society of Canada website (alzheimer.ca), says Mary Schulz.
Talking about dementia care
Pharmacists may start a dialogue with patients and family if they suspect dementia or learn of a patient’s diagnosis. “Patients and family may not ask for help because they feel overwhelmed or embarrassed,” explains Chang. Riachi has seen similar reactions: “At the beginning the patient and family may be flustered.” Pharmacists can help them navigate the journey of dementia, particularly medication issues, to optimize the patient’s quality of life.
Medication management for patients with dementia
There are several medication issues for dementia patients. Many patients with dementia have other health problems as well. “The pharmacist may be useful in understanding the big picture, and pharmacists are very accessible,” says Schulz. Reviewing all medications — those for dementia and those for other health problems — is crucial.
“Some medications can worsen the symptoms patients may be experiencing,” says Chang. For example, pain and sleep medications can impair cognitive functions. Even over-the-counter drugs can cause problems. For example, Patel discovered that a patient with dementia was taking three different antihistamines for allergies, unaware that these can affect cognition. Riachi says sudden behavioural changes may be caused by medications and should be discussed with the pharmacist, who can help figure out whether cognitive changes are due to the disease or to medication side effects or interactions.
Weight loss is common as dementia progresses. This means that health problems linked to weight, such as high blood sugar (diabetes) and high blood pressure, may resolve. Riachi’s mother was on insulin for diabetes before she was diagnosed with dementia. She lost 60 pounds due to the dementia, and Riachi says her insulin dose was cut by a factor of 10. “If she had stayed on the higher dose, the insulin could have killed her.”
Riachi emphasizes that pharmacists can “de-prescribe,” taking patients off medications they no longer need and that may cause side effects. “In the later stages of dementia, the goal of care shifts from prolonging life to improving the quality of life left,” says Riachi. Pharmacists can advise on stopping medications that are no longer contributing to quality of life.
Helping make drugs easier to obtain and take
Pharmacists can help make it easier for patients with dementia to obtain and take needed medications. They can make recommendations to change the dosage or switch to another medication to manage side effects, says Riachi. If cost or drug plan coverage is an issue, they can find lower-cost alternatives or a drug that is covered under the patient’s plan. Patel noted that pharmacists can package medications so that they are easy to read and open for patients with cognitive or mobility difficulties. Many patients with dementia develop difficulty eating and swallowing, and Riachi says even crushed medications may pose a danger because poor swallowing reflex can lead to the drug going into the lungs. At this point, pharmacists can provide alternative formulations such as suppositories, injections, nasal sprays, and others.
Helping with other health problems
Dementia is a disease with physical as well as cognitive aspects, and pharmacists can help patients and their caregivers understand this. But it may be difficult to sort out whether health problems are due to dementia.“There may be a tendency to blame everything on dementia, and other physical or mental health problems may be overlooked,” says Patel. “Pharmacists can guide patients and families to follow up these health problems.”
Support for health beyond medication
There are only a few drugs available for dementia, and these drugs are only approved for Alzheimer’s disease. But Patel says pharmacists can help improve patients’ quality of life in ways above and beyond drug therapy. For example, decreased appetite is a common issue in dementia, and pharmacists can guide caregivers to products such as nutritional supplements.
Riachi says pharmacists can recommend other types of therapy and health services to help patients and their caregivers cope. “Pharmacists are knowledgeable about other health professions and can support patients by directing them to other healthcare professionals as needed,” he says. For example, many dementia patients experience painful contractures in their joints, which can be helped with physiotherapy. For patients with mobility problems, pharmacists may know of specialists to help fit wheelchairs for patients.
Chang says pharmacists can help “build a safety net around the patient.” Because the network of health professionals can be difficult for patients and caregivers to navigate, the pharmacy can be a “centre for referrals, letting people know whom they can talk to.”