By Victoria Goldman
NHS England is supporting people to age well as it struggles to deal with the growing health and social care needs of an ageing population. Seventy-five per cent of 75-year-olds in the UK have more than one long-term medical condition, rising to 82 per cent of 85-year-olds. This is putting increasing pressure on NHS hospitals and services.
In 2016, the over-65s (11.8 million people) made up 18 per cent of the total UK population. It is projected that by 2066 there will be a further 8.6 million UK residents aged 65 and over, making up 26 per cent of the total population. But it is the 85-plus age group that’s growing particularly rapidly. In 2016, the over-85s made up 2 per cent of the UK population. This is expected to double by mid-2041 and more than triple by 2066.
The over-65s are generally classified as ‘older people’. However, while the risk of being disabled or affected by multiple chronic conditions increases with age, everyone ages biologically at a different rate. Some 75-year-olds are in better health than people aged 60. According to the Office for National Statistics, in August 2018 the over-65s can expect to spend about half of their remaining life expectancy in good health.
It is now suggested that an individual’s frailty should be considered when assessing their specific needs, as this may have a bigger impact on their day-to-day lives. Age UK highlighted in July 2018 that more older people than ever are missing out on the vital care and support they need. Increasing numbers of frail, ill, older people are being left to manage on their own, and certain conditions, such as dementia and arthritis, are particularly associated with reduced mobility and frailty.
According to the Alzheimer’s Society, there are 850,000 people with dementia in the UK and numbers are set to rise to more than 1 million by 2025 and 2 million by 2051. Alzheimer’s disease is the most common type of dementia, affecting 62 per cent of those diagnosed. Vascular dementia affects 17 per cent of those diagnosed and mixed dementia affects 10 per cent.
Nina Barnett, Royal Pharmaceutical Society spokesperson and consultant pharmacist with a special interest in older people at London North West University Healthcare NHS Trust, says that before being able to help customers with dementia, pharmacists first need to evaluate their own knowledge of the disease and whether they feel confident enough to deal with dementia patients. “Dementia exists in a range of different forms and affects people in different ways,” she says. “Pharmacists need to make sure they are able to make the customer feel as comfortable as possible. Their purpose is to help customers get the most from their medicines and take them safely and effectively. They need to assess if the dementia is affecting a customer’s ability to think clearly and whether they will remember to take their medicines. They also need to find out what the customer is doing about their memory problems already so they don’t cause even more confusion by suggesting something else.”
Emma Bould, programme partnership project manager at the Alzheimer’s Society, says that community pharmacists can help people with dementia in several ways. “We know that seven in 10 people with dementia live with one or more co-morbidities,” she says. “This means they often have a number of medicines to manage at the same time. This can be challenging for both the person with dementia and their carer. It would be useful to provide printed out medication lists that detail type, dosage and other necessary information. This would give both patients and carers a record to show to other health and social care professionals. Community pharmacists may also find it helps to do weekly, or more frequent, prescription collections of smaller amounts, as this would prevent people accidentally taking too much and support safe medicine management. Pharmacists should also advise on daily living aids, such as medication reminders or pill boxes, where appropriate.”
Community pharmacists are encouraged to register for the Alzheimer’s Society’s Dementia Friends programme, which aims to transform the way the nation thinks, acts and talks about dementia. “Becoming a Dementia Friend fits in with the whole NHS Long Term Plan about prevention,” says Ms Barnett. “It can help pharmacies to provide a simple non-confusing environment for people with dementia, by placing a Dementia Friend sticker in the pharmacy window and educating every member of staff about the disease. From a business angle, advertising that the pharmacy is dementia friendly should help to get more people through the door.”
If a pharmacy becomes a Dementia Friend, staff may choose to wear a badge to show that they will be more patient and understanding when a customer with dementia asks for help. They will also highlight that they are able to signpost customers with dementia, or their carers, to local relevant services and the Alzheimer’s Society website and national helpline (0300 222 1122), which offers confidential advice.
Lila Thakerar, superintendent pharmacist at the Shaftesbury Pharmacy in Harrow, says she learned a lot through the Dementia Friends programme, including that dementia is not a natural part of ageing and doesn’t just involve losing memory. “Becoming a Dementia Friend has enhanced my skills and changed my approach to talking to patients with dementia,” she says. “I now handle the consultation in a different manner, repeating myself more often, checking the patient has understood and asking them questions to jog their memory the next time I see them as well.”
To become a Dementia Friend, pharmacists need to register their organisation on the Alzheimer’s Society Dementia Friends website. They will then be given access to a set of videos that are specific to customer service scenarios. “These will help staff assist customers with dementia, who may experience a variety of difficulties in store, such as handling money, finding items or forgetting to pay,” says Ms Bould. “Employees need to watch the introductory video, and at least one of the four others available, to become Dementia Friends. To achieve the Dementia Friends criterion of the Quality Payments Scheme, pharmacies must ensure 80 per cent of their staff who work in patient-facing roles become Dementia Friends. This payment can be claimed at two different review points and is worth 5 points at each review (10 points in total), potentially equating to a payment of £640.”
Community pharmacists can also signpost customers to the Admiral Nurse Dementia Helpline (0800 888 6678 or email@example.com), the only specialist-led dementia helpline in the country. Admiral Nurses are specially trained to provide the one-to-one support, expert guidance and practical solutions that dementia patients, and their carers, need. They also work with other healthcare professionals to ensure best practice in dementia care. “This is available to anyone who has any questions or queries around dementia, including community pharmacists themselves, and is staffed entirely by Dementia UK’s Admiral Nurses,” says Paulette Winchester-Joseph, clinical lead for the Admiral Nurse Dementia Helpline. “The helpline can also let people know if there is a local Admiral Nurse service in the area and how people can access it.”
Joint pain and arthritis are often overlooked in older people because they are seen as a natural part of ageing or because it is assumed that nothing can be done. However, any older customers who are experiencing severe or persistent joint pain or stiffness should be referred to their GP.
“It’s worth asking if people have more than an hour or two of morning stiffness in their affected joints that gets better as the day goes on,” says Professor Philip Conaghan, Versus Arthritis spokesperson and professor of musculoskeletal medicine at the University of Leeds. “This is suspicious for an inflammatory arthritis and needs a chat with a GP for potential referral to a rheumatologist. Also ask if there is a previous history of gout, as this is commonly undertreated. Most joint pain is mechanical in nature, which means it is better after resting, with little morning stiffness, and worse after prolonged usage and at the end of day. Pharmacists will be aware that many people, especially the elderly, shouldn’t be taking non-steroidal anti-inflammatories. Topical NSAIDs are much safer and are probably under-utilised. Tips to keep people strong are key. Weak people shouldn’t be told to go for long walks. The mantra is first get strong, then get active.”
Joint pain in older people can be difficult to treat, especially persistent pain. Muscle strengthening is the first line of care for many mechanical joint problems, so local physiotherapy, group exercise classes or Pilates, especially for back pain, may help. Pharmacists can also offer a range of evidence-based alternatives to conventional painkillers.
“Pharmacists can play a pivotal role in steering older people with joint pain away from medications and towards a prevention programme, which promotes lifestyle and diet changes, including recommendation of clinically proven joint-specific supplements,” says consultant rheumatologist Dr Rod Hughes. “Supplements such as Gopo have been shown to help protect and repair joints and should certainly be considered for patients at the early onset of even mild joint pain. Exercise and weight reduction are also very valuable in reducing the effects of arthritis in the elderly.”
Ms Barnett suggests that when pharmacists discuss non-pharmacological methods of dealing with chronic pain, they should also consider the psychological element, such as stress, anxiety and mood, and the practical day-to-day effects. “Look at the ‘Live Well Without Pain’ website,” she says. “Physical pain has a psychological element and isn’t just treatable with medicines. This doesn’t mean it doesn’t exist, but it can be influenced by other factors. Pharmacists can help customers manage their pain in their day-to-day lives and support self-care. If they have arthritis, find out how it affects them and whether they take their medicines, whether they can open packaging.”
When considering older customers and those with a disability (not just arthritis), Ms Thakerar suggests looking at the physical layout and accessibility of the pharmacy. “Some people may need easy access to the premises, or pharmacy counter, if they use a wheelchair or frame,” she says. “Pharmacy staff may need to provide physical assistance in the pharmacy, reaching shelves or finding the right products, if customers are unable to reach these themselves. Providing chairs for customers who are waiting for a prescription may also be helpful.”
Mobility aids can help older customers, or anyone with a physical disability, to remain as independent as possible, and this is an area in which community pharmacists can become involved. Wicker Pharmacy in Sheffield first began stocking mobility aids in 1977. “We initially stocked a small range of equipment, displaying it and then gradually expanded as people asked for other items,” says Martin Bennett, superintendent pharmacist at Associated Chemists (Wicker). “We now hold about £90,000 worth of stock and had to expand into adjoining premises to house it all.”
Ms Thakerar’s pharmacy can also supply mobility aids if customers require them. “Obviously, not all pharmacies are able to display products due to a lack of space, but some companies can deliver products within a few hours for customers to try out or buy,” she says. “Some companies also offer a service where patients can hire a wheelchair rather than buy one if they only need it for a short period of time. There is so much out there to make lives easier, especially for people who live on their own, and pharmacies are well-placed to help customers buy suitable cutlery, crockery, bath accessories, walking aids and feeding aids, etc.”
Mr Bennett suggests that, in the present climate, pharmacists should look for a mobility aids supplier that offers a wide range of stock with good margins and extended credit terms. “To market the service, a display in the pharmacy is the simplest, cheapest and best approach to take, as well as a catalogue/fliers that can be given out with prescriptions. If pharmacy space is limited, either rely on a catalogue and obtain items to order or decide to devote, say, one metre of display shelving and opt for the most popular items.”
Shilpa Shah, pharmacist for Lloydspharmacy, says that when the pharmacy team is advising customers about mobility aids, it’s important to find out exactly what is needed by that individual customer and to make sure the product will work for them. “Stocking smaller items on a small module or carousel may help to open up a wider conversation to discuss their specific needs,” she says. “There’s a move towards online catalogues, as well as those available instore. By having access to these websites in the pharmacy, pharmacists may be able to show customers a 3D image of the product and someone using it.”