Course Outline and Syllabus Name: Lawrence Jackson and Lalitha Raman-Wilms Course Number: PHM 352H1: Pharmacotherapy Selective Course Course Title: Pharmacotherapy of Older Adults Course Description: Growth in the proportion of the population over age 65 is expected to place significant demands on the health care system. Pharmacists must be prepared to manage the pharmacotherapy of older patients in order to achieve optimal individual and health system outcomes. This 26-hour selective course will prepare students for their future roles in geriatric practice through the development of specific competencies in the knowledge and application of pharmaceutical care for older adults. This course will cover demographics, biology of aging, socioeconomics, ethical issues, informed consent, elder abuse, and beliefs and barriers regarding health care and medication use in older individuals. Communication issues, unique needs of caring for seniors, and barriers to medication taking will also be addressed. Specific pharmacotherapy of conditions prevalent in the elderly, including movement disorders, dementia, urinary incontinence, and specific drug-induced illnesses will be covered. This course will rely on case-based discussions to enable students to develop skills integral to patient assessment and optimizing drug therapy in the older adult with complicated disease and medication history. Required: Selective: YES, Year 3 Winter term Elective
1. Course Learning Objectives: Upon completion of this course, students will be able to: 1. Apply knowledge and skills of age-related pharmacotherapy, as well as appropriate diseasespecific assessment instruments, to select, evaluate and monitor medications for older adults 2. Design Care Plans for selected disease states, considering patient-specific factors 3. Demonstrate sensitivity to multiple factors impacting medication use by older adults such as goals of therapy, pharmacokinetics and dynamics, safety, cognitive and physical capacity, psychosocial status, ethics and frailty 4. Describe the pharmacist’s role and contributions to care of the older adult, within an interprofessional team 5. Demonstrate the knowledge, skills and attitudes necessary to provide optimal pharmaceutical care to older individuals (this would include the application of evidence-based pharmacotherapy and ethical issues in making treatment decisions in the older individuals),and an awareness of the health care system within which care is provided (awareness of role of home care, ODB formulary, home visits, etc.). Introductory = knowledge and comprehension of concepts, definitions Intermediate = application of concepts to simple situations 1
Advanced = application of concepts to more complex situation with ability to synthesize and evaluate Knowledge Objectives Introductory: a) Describe cultural aspects of aging, such as preferences, values and needs of the geriatric patient. b) Describe major primary and secondary disease prevention strategies: a. Primary Prevention: osteoporosis, cardiovascular disease (stroke (will address risk factors for lipids, DM, hypertension, AF)) b. Secondary Prevention: acute delirium, constipation, osteoporosis (specifically steroidinduced), functional decline c) Describe key issues that arise in the care of the hospitalized elderly. d) Describe various philosophies of palliative care, and the appropriateness of maintenance medications and use of symptom control strategies for common symptoms and their assessment. Intermediate: a) Describe the physiologic changes of aging (renal and hepatic function, body composition, CNS function) and how they impact medication therapy in terms of pharmacokinetics (absorption, distribution, metabolism, and elimination) and pharmacodynamics (medication effects). (Basic sciences) b) Describe the pathophysiology of common geriatric syndromes and diseases more commonly seen in the elderly. (Clinical sciences) c) Identify and manage the social or economic issues of medication use for individual patient’s therapy Advanced: a) Select appropriate parameters to assess effectiveness and safety when monitoring therapy for selected therapeutic areas. b) Justify your choices from among the therapeutic options considered for simulated patients (paper cases). Skills Objectives Introductory: a) Design a Plan for Follow-up Evaluation for a selected therapeutic regimen including physiological and biochemistry parameters. Intermediate: Care provider (AFPC terminology) or Patient care process (Pharmaceutical Care terminology) Based on simulated patient cases (paper cases): Assessment a) Obtain and evaluate past and current medical and medication history and relevant physical assessment information from an elderly patient. b) Choose, administer, and interpret a validated and reliable tool/instrument appropriate for the elderly to assess: cognition, mood, physical function, nutrition, pain, and other screening assessments. c) Appropriately recommend and interpret laboratory results for an elderly patient. d) Distinguish between clinical presentation and management strategies for delirium, dementia and depression. Plan care 2
a) Determine realistic therapeutic goals incorporating patient specific factors (quality of life, age, functionality, preference) b) Evaluate standards of practice/treatment guidelines for appropriateness in geriatric population c) Determine therapeutic options and risks/benefits to the patient (e.g. no treatment, non pharmacological management, pharmacological intervention, complementary/alternative medicine) d) Apply principles of pharmacokinetic and pharmacodynamic changes associated with aging, or renal or liver function to the design of pharmacotherapy regimen. e) Design and recommend age/patient specific regimen including medication, dose, dosage form, dosing interval, route of administration Follow up and evaluate outcomes a) Develop patient specific Plan for Follow-Up Evaluation for elderly patients b) Recommend revisions to therapeutic plans based on changes in patient status Document a) Demonstrate the ability to prepare documentation of interventions or recommendations so that other health care providers can utilize the information. Communication a) Identify barriers to communication (such as hearing and or sight impairments, speech difficulties, limited health literacy and cognitive disorders) and demonstrate ability to communicate your plan. b) Retrieve, analyze and interpret appropriate literature to provide drug information to older people or other health care providers c) Demonstrate ability to prepare written educational materials. Advanced: Medication management a. Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, cardiovascular drugs that should be avoided or used with caution in the elderly and explain the potential problems associated with each. b. Describe the purpose of criteria for assessing appropriateness of medications in the elderly (i.e. Beer’s criteria, START/STOPP criteria). c. Demonstrate an ability to manage chronic medication therapies by reviewing patient’s medications (prescription, over-the-counter, vitamins/supplements, etc) to assess for appropriate indication, effectiveness, safety, and adherence. Attitudes/Values Objectives Introductory: a) The student will undertake assessment and care plan development activities in a manner
respecting patient autonomy and the individual therapeutic goals. b) The student will use interprofessional patient centered care principles to reach decisions for
therapeutic alternatives. Intermediate:
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a) Define the purpose and components of an interdisciplinary, comprehensive geriatric assessment and the roles individual disciplines play in conducting and interpreting a comprehensive geriatric assessment b) Explain the spectrum of health care services available for older adults (home care, care givers, long term care facilities, assisting living facilities, etc.) c) Describe and advocate health care initiatives relative to wellness and health promotion (eg – diet, medication adherence, immunizations, exercise, health screenings) Advanced: a) Demonstrate an awareness of myths and age stereotypes (no ageist attitudes). b) Demonstrate an ability to view each older person as an individual, appreciating the diversity/heterogeneity in the elderly. c) Describe the importance of having compassion and understanding of the problems of older people and caregivers d) Appreciate the need to improve physical, social and cognitive function in older adults, rather than just focusing on diseases. 2. Rationale for Inclusion in the Curriculum: The geriatrics selective will prepare students for direct patient care by exposing them to specific knowledge, skills and attitudes necessary for the provision of optimal pharmaceutical care to the elderly. Information acquired in this course will be applied further during the Advanced Pharmacy Practice Experiences. In this course, students will be required to integrate knowledge learned in previous and concurrent courses including anatomy, physiology, pathobiology and pathophysiology, pharmaceutics, pharmacology, pharmacokinetics, informatics and clinical trials, the mandatory pharmacotherapy courses, and incorporate new pharmacotherapeutic information in order to identify, resolve and prevent drug therapy problems in simulated patient cases. Through pre-class preparation, group discussion and in-class discussions, students will acquire and reinforce their knowledge of therapeutics; skills in assessing patient’s medical conditions and appropriateness of medications in order to identify, resolve and prevent drug therapy problems; and attitudes and values that increase sensitivity to a range of issues related to the use of medications faced by the elderly. Teaching will occur through large class, 2-hour didactic sessions. The sessions will be designed to allow approximately 50 percent of the time for in-class discussion. Students will be required to work up cases prior to some classes and complete pre-class assignments, where assigned. The cases will contain a range of geriatric issues that the student will identify and resolve through the development of a plan of care that addresses the issues. The pre-class work will include succinct documentation of the student’s intervention/plan. Selected readings will be included with each patient case; however, students are encouraged to explore additional literature in working through the “problem” case. Although students are required to develop their own learning objectives, general learning objectives for each therapeutic area will be provided. Therapeutic areas covered in this course include familiarity and utilization of laboratory values for diagnosing and managing various conditions, assessment and management of adverse drug reactions and drug allergies, principles of drug therapy in the elderly, common geriatric syndromes and diseases occurring more commonly in the elderly. 4
3. Pre-requisites:
Mandatory Pharmacotherapeutics and Medication Therapy Management courses
Foundational Year 1 Medical and Pharmaceutical Science courses (Anatomy, Physiology, Pathophysiology, Pharmacology (included components included within Pharmacotherapy courses), Pharmacy Informatics and Biostatics
4. Statement of agreement from course coordinators of courses for which this course is a prerequisite: Not applicable 5. Co-requisites: (for the current and subsequent year) None 6. Statement of agreement from coordinators of courses for which this course is a co-requisite: Not applicable. 7. Course Contact Hours and Teaching Methodologies: Didactic (lecture) Large group problem-based or case-based learning Large Group Size (eg 30, 60, 120, 240) Laboratory or Simulation Tutorial/Seminar/Workshop/Small Group Small Group Size (eg 5, 10, 15, 20, 25) Experiential On-line Optional material may be available on-line Other (please specify)* * Other specific information: Total course contact hours
16 hours 10 hours Up to 240 persons hours hours persons hours hours hours hours
8. Estimate and description of student's weekly out-of-class preparation time excluding exam preparation: Students will be expected to spend 3 to 5 hours per week working up the case, responding to the pre-class questions and completing care plan documentation requirements. In preparation for class, students will be expected to read any assigned readings, research assessment tools, and work up the cases that are given in advance of the class session. Students will be expected to have reviewed any relevant materials from pre- or co-requisite courses. There will be 1 individual assignment which will require up to 5 hours of out of class preparation. Groups will be expected to meet outside of class time and be prepared for class discussions. In addition to the discussions, each group may be asked to make a presentation of a case in class (for a component of the class participation mark). 5
This course is taught in a large class format (up to 240 students). It is essential that students attend class and are prepared to discuss the cases. Attendance and participation are required to succeed in this course. Out of class preparation is essential in order to be able to participate in the in-class discussion. 9. Course Coordinator and contact information: Lalitha Raman-Wilms
[email protected]
Tel: 416-978-0616
10. Course Instructors and contact information: Several guest lecturers. 11. Required Resources/Textbooks/Readings:
Pharmacotherapy: A Pathophysiologic Approach, 8th ed. DiPiro JT, Talbert RL, Hayes PE, et al. McGraw-Hill Co., Inc., NY, 2011
Assigned readings for each lecture as identified by instructor/course coordinator
12. Recommended Resources/Textbooks/Readings: Fundamentals of Geriatric Pharmacotherapy – An evidence-based approach Lisa C Hutchison and Rebecca B. Sleeper (editors), American Society of Health-System Pharmacists, 7272 Wisconsin Avenue, Bethesda, MD. 2010
Koda-Kimble MA and Young LY, et al (eds) Applied Therapeutics: The Clinical Use of Drugs, 10th ed. Lippincott Williams & Wilkins, Baltimore, MD, 2012
Pharmaceutical Care Practice. Cipolle, Strand and Morley. 3d ed., 2012
Geriatric resources including web sites ADLs: Katz scale: www.soapnote.org/elder-care/katz-adl/ IADLs- Lawton scale: http://www.soapnote.org/elder-care/lawton-iadl/ o Palliative Care- Fraser Health, http://fraserhealth.ca/EN/hospice_palliative_care_symptom_guidelines/ o EPERC- http://www.eperc.mcw.edu/EPERC o www.agingwithdignity.org/five-wishes.php o www.ohsu.edu/polst/ Geriatric assessmento Elsawy B. The geriatric assessment. Am Fam Physician. 2011;83(1):48-56 o Rosen L. Geriatric assessment tools. Mt Sinai J Med. 2011;78:489-97 Polypharmacy- Updated Beers Criteria, www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf Balance and Falls-http://www.hospitalmedicine.org/geriresource/toolbox/mini_cog.htm
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Painhttp://nationalpaincentre.mcmaster.ca/opioid/cgop_a05_canadian_guideline_inception.ht ml Cognition- www.mocatest.org/, minicog: http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clock_drawing_test.pdf http://www.hospitalmedicine.org/geriresource/toolbox/mini_cog.htm http://www.med.nyu.edu/med_clerkship/course_materials/learning_objectives.html
Readings from pharmacokinetics course as relevant
CSHP, Documentation of Pharmacists’ Activities in the Health Record: Guidelines
13. Topic Outline/Schedule Detailed Course Outline Weeks Content Week 1 Introduction Week 2 Pharmacotherapy Issues in the Elderly Week 3 Dementia Week 4 Genitourinary Conditions Week 5 Population-specific Activities Wound Care Week 6 Osteoporosis, Falls and Fractures Week 7 Cardiovascular Conditions Week 8 Respiratory Issues Endocrine Disorders Week 9 Parkinson Disease and Movement Disorders Week 10 Acute Care Problems in the Elderly Gastrointestinal Issues/Nutrition Week 11 Pain Syndromes Psychiatric Disorders Week 12 Palliative Care and End-of-life Issues Week 13 Integrated Case Discussions Course and Exam Review
14. Assessment Methodologies Used: MCQ question, Questions requiring Short answer responses, Case-based questions Learning Objectives Addressed Assessment 1: TBD Assessment 2: TBD Assessment 3: TBD 7
Assessment 4: TBD Assessment Method Used Assessment 1: Assessment 2: Assessment 3: Assessment 4:
Assignment Mid-term: MCQs and SA questions Final exam: MCQs and SA questions Class Participation; groups may also be asked to make a presentation
When Administered Assessment 1: Assessment 2: Assessment 3: Assessment 4:
To be assessed and returned before course drop date Mid-term sometime between weeks 6 to 8 Final exam period (after week 13) Throughout the course
Percentage of Course Grade Assessment 1: Assessment 2: Assessment 3: Assessment 4:
10% 40% 45% 5%
For Group Work (maximum 10% of course grade) indicate how marks within groups are allocated: Individualized or Same for all Group Members Assessment 1: Assessment 2: Assessment 3: Assessment 4: 5% - same for all group members Remediation Opportunities? Students having difficulty in the course will be encouraged to meet with the course coordinator to get individual guidance on how to improve their performance in the course. Assessment 1: Assessment 2: Assessment 3: Assessment 4: Expectation for pass grades for all Pharmacy courses is 60%. 15. Policy and procedure regarding make-up assignments/examinations/laboratories: Missed Exam/Test Policy Students who miss an examination or a test and who have a valid petition filed with the Registrar’s office will be eligible to complete a make-up examination or test. The format of this examination or test will be at the discretion of the course coordinator, and may include, for example, an oral examination. 8
NOTE: The student will be provided with one opportunity to write a make-up exam. Missed Assignment Policy: Students who fail to submit an assignment by the specified due date, and who have a valid petition filed with the Registrar’s office will be eligible to submit the completed assignment, or an alternative assignment based on course requirements, with no academic penalty. For each calendar day’s delay in submitting the assignment, 5% of the assignment mark will be deducted to a maximum of 35%. The assignment will not be accepted 7 calendar days past the due date. 16. Policy and procedure regarding supplemental assignments/examinations/laboratories: As per Faculty policy. 1. Please estimate resource implications associated with teaching methodologies to be used. a. Guest Lecturers 2. Please estimate resources implications associated with assessment methodologies to be used. a. Assistance with Exam marking. 3. Which of the five curricular themes will be covered in this course? How will integration of these themes be achieved through teaching and assessment methods used? All 5 curricular themes will be relevant at some level within this course. For this selective course, the course coordinator will meet with the theme coordinators to discuss the integration of the theme within the course. a. b. c. d. e.
Pharmaceutical Care Critical Appraisal Critical Reasoning Patient Safety Professionalism and Ethics
Approval from Theme Coordinator (name of theme coordinator): insertion of theme coordinator’s name occurs after your course has been reviewed and approved 5. Which of the following course evaluation measures will you incorporate in your course to facilitate review and iterative refinement? Dixon’s Levels (1-4 increasing validity)
Quantitative Measures
1
Evaluations Forms (‘Happiness’ Index) Course evaluation forms will be used
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Qualitative Measures
Focus groups / Interviews
2
Pre-testing versus Post-testing
Participant Surveys / Questionnaires Standard Course evaluation forms will be used
3
Change daily practice or learning habits
Structured Interviews
4
Improve Outcomes
Receiver Questionnaires
AFPC Educational Outcomes Introductory = knowledge and comprehension of concepts, definitions, Intermediate = application of concepts to simple situations Advanced = application of concepts to more complex situations with ability to synthesize and evaluate As Care Providers, pharmacy graduates: Please note that this course will contribute to the checked outcomes by preparing students to provide care to simulated patients presented as paper patient cases A. Assess patients 1.1 Develop and maintain professional, collaborative relationships required for patient care. 1.1.1 establish and maintain a professional, caring practice environment; 1.1.2 demonstrate that the patient's goals are the priority; 1.1.3 determine when it is ethically and professionally appropriate to involve caregivers; 1.1.4 acknowledge and respect the roles and responsibilities of the pharmacist, the patient and/or caregivers, and the patient's other health care professionals (9). 1.2 Elicit and complete an assessment of required information to determine the patient's medication related and other relevant health needs. 1.2.2 obtain and evaluate relevant history from the patient, his/her chart, caregivers and other health care professionals; 1.2.3 order, retrieve and assess relevant lab tests and diagnostic assessments; 1.2.4 perform and interpret findings of relevant physical assessments that are required to determine appropriate medication therapy, and; 1.2.5 complete an assessment of the patient's ability to take / use / administer his/her medications. 1.3 Assess if a patient's medication-related needs are being met; 1.3.1 evaluate the safety and effectiveness of a patient's medications with consideration of the patient's values and preferences, characteristics, conditions, functional capabilities, other medications and access to health care / monitoring; 10
1.3.3 determine whether a patient's medications are achieving the desired goals including consideration of efficacy and adverse effects; 1.3.5 where appropriate, identify a patient's medication-related needs as specific medication therapy problems, and: 1.3.6 determine if a patient requires additional care or services consistent with established collaborative practice agreements (see glossary). 1.4 Determine if a patient has relevant, priority health and wellness needs. 1.4.1 recognize signs, symptoms and risk factors that relate to medical or health problems that fall into the scope of practice of other health care professionals.(Including, for example, signs and symptoms of diabetes mellitus, hypertension, arthritis, stroke, cardiac disease.) 1.4.2 recognize signs and symptoms associated with medical emergencies; 1.4.3 recognize problems with activities of daily living important to the patient's well-being, and: 1.4.4 identify opportunities for advocacy, health promotion and disease prevention with individuals to whom they provide care. B. Plan Care 1.5 Refer patients for management of priority health and wellness needs that fall beyond the scope of practice of pharmacists 1.6 Develop a care plan that addresses a patient's medication-therapy problems and priority health and wellness needs. 1.6.1 prioritize a patient's medication-related needs; 1.6.2 establish goals of medication therapy with the patient (desired endpoints, target values and timeframes for medication therapies) ; 1.6.4 integrate the recommended therapeutic options for a patient's medication-related needs into a co-ordinated plan; 1.6.5 determine monitoring parameters for desired therapeutic endpoints and potential adverse effect, specifying target values and start, frequency and end time-points for monitoring, and: 1.6.7 determine if a patient requires information or other support to facilitate his/her management of needs related to activities of daily living, health promotion or well-being, and: 1.7.4 convey information on maintaining and promoting health, and: 1.7.5 convey information about available social support services to assist with daily living.
C. Follow-up and Evaluate 1.8 Elicit clinical and / or lab evidence of patient outcomes. 1.8.1 determine the clinical status of the patient, including completing physical assessments required for monitoring of medication therapy; 1.8.2 evaluate the efficacy of the care plan relative to the desired goals; 11
1.8.3 evaluate the safety of the care plan including the presence of adverse drug reactions or effects; 1.8.4 identify any medication errors or close calls (see glossary)(9), and: 1.8.5 determine changes in pharmacotherapy that are required. 1.9 Assess and manage patients’ new medication-related needs.(Go back to assessing patients section.) D. Document 1.10 Support the continuity of patient care by documenting their patient care activities 1.10.2 fulfill professional responsibilities for documentation.
As Communicators, pharmacy graduates: 2.1. Communicate non-verbally and verbally with others. 2.1.2. exhibit empathy, tact and respect in their dealings with others; 2.1.3. demonstrate sensitivity, respect and empathy in intercultural and inter-professional situations; 2.1.4. when speaking, use organized processes and appropriate, precise expressions and vocabulary; 2.1.5. tailor the content of their communication to specific contexts and audiences, and: 2.2. Communicate in writing. 2.2.1. write clearly, using organized processes and appropriate vocabulary, and: 2.3. Present information.
As Collaborators, pharmacy graduates: 3.1. Function as members of teams. 3.1.3 clarify roles, responsibilities and expertise of team members, identifying overlaps and gaps; 3.1.4 recognize and respect the roles, responsibilities and competence of other professionals, and: 3.1.6 contribute to planning, organizing and performing of work to be done, and integrating evidence while evaluating the results. 3.2 Support team-based care in a community setting with geographically distinct centres of care. 3.2.2 clarify pharmacist’s roles and responsibilities that are acceptable / appropriate. 3.3 Work collaboratively with the patient and his/her health care professionals to provide care and 12
services that facilitate management of the patient's health needs. 3.3.1 negotiate the care and services that the pharmacist and other members of the health care team will provide as consistent with laws / regulations relevant to collaborative care, and: 3.3.4 plan the provision of care in a coordinated fashion. As Managers, pharmacy graduates:
As Advocates, pharmacy graduates: 5.1 Interpret the advocacy role of pharmacists / profession of pharmacy. 5.1.1 describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity and idealism, and: 5.1.2 explain the role of the profession in advocating collectively for health and patient safety. 5.2 Promote the health of individual patients, communities, and populations 5.2.1 facilitate patient's interaction with the health care system through advice, education and/or guidance; 5.2.5 undertake relevant public health screening processes for early disease detection, and; As Scholars, pharmacy graduates: 6.1 Demonstrate a thorough understanding of the fundamental knowledge required of pharmacists and apply this knowledge in daily practice. 6.1.1 rationalize their recommendations and decisions with appropriate, accurate explanations and best evidence; 6.2.3 critically analyze information including primary research articles; 6.2.4 determine plausible solutions and select the most appropriate recommendation; 6.2.5 communicate information / recommendations; 6.4 Apply principles of scientific inquiry and critical thinking while participating in practice-based research. 6.4.2 recognize relevant practice or medication use problems; 6.4.3 define the parameters of relevant problems; As Professionals, pharmacy graduates: 7.1 Demonstrate professionalism throughout patient encounters. 7.1.2 accept responsibility for recognizing and meeting patients’ medication therapy needs; 13
7.1.3 maintain patient confidentiality. 7.2 Practice in an ethical manner which assures primary accountability to the patient. 7.2.1 involve the patient in decision-making, respecting their right to make their own choices; 7.2.2 fulfill requirements for obtaining patient consent; 7.2.3 integrate patient preferences related to culture, beliefs and practices, and: 7.2.7 recognize and manage situations presenting ethical dilemmas including conflicts of interest.
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