Alzheimer's Disease: Untapped Potential for Pharmacy

Many pharmacies across the country are searching for new ways to demonstrate their value as a health care partner in a way that is manageable and cost effective. One solution could be to focus on a population that’s growing rapidly: patients with Alzheimer’s disease. By employing just a few resources and tapping into pharmacists’ existing knowledge and skills, pharmacists can become the perfect partner in the battle against Alzheimer’s disease.

“Helping people with Alzheimer’s makes use of the compliance and adherence information that we’ve already learned for all of our patients. So this is a patient population that we can very easily serve with very few resources, just a little time, and we can really make a significant difference in their care and their outcomes,” says Lori Syed, PharmD, Director of Advanced Pharmacy Practice Experiences in the Department of Pharmacy Practice at Mercer University, in Atlanta, GA.

Community pharmacists can help by simplifying drug regimens, identifying medications that may be causing additional confusion, or using innovative packaging strategies. But their role doesn’t end there. Pharmacists can also aid in the identification of possible Alzheimer’s symptoms.

Across the country, a growing number of pharmacies are offering simple cognitive memory screenings as part of their regular counseling services. Community pharmacies are also reaching out to form partnerships with local chapters of the Alzheimer’s Association or developing stronger relationships with the physicians who treat these patients to better serve this population.

A Growing Problem

As the baby boomers enter their golden years, the number of patients diagnosed with Alzheimer’s is on the rise. According to the Alzheimer’s Association, approximately 5.4 million Americans were living with Alzheimer’s disease in 2016. By 2050, the number of people over age 65 who have the disease is projected to be 13.8 million--nearly three times current levels if no significant clinical breakthroughs are made.

There will be a great need in the medical community to care for these patients. Many pharmacists in both community and clinic settings are already armed with the tools and skills necessary to be a valuable member of the healthcare team.

According to Syed, pharmacists already have the ability to speak two languages: They can have a simplified conversation with a layperson and a more technical, detailed, medical discussion with physicians and other healthcare providers.

This “bilingual” ability- combined with their accessibility, extensive drug knowledge and established trust with patients-positions pharmacists to be a powerful resource to both patients and physicians.

“We have that ability to liaison between patient and physician,” Syed says. “Often times patients may tell us things or we may elicit more information about how they are taking medications than they’ve shared with other caregivers. We may know that they are only taking their medication every other day because they really can’t afford it.”

Identification of Memory Concerns

Community pharmacists may also be among the first health care practitioners to notice early symptoms of Alzheimer’s disease in their regular patients.

Everyone is occasionally confused, particularly older adults who are often managing multiple medications. However, Syed says if pharmacists have tried giving patients tools to help manage their medications and confusion still persists it may be time for concern.

Geriatric neurologist Rita A. Shapiro, DO, FACP, FAAN, says pharmacists should look for changes in adherence, confusion at the cash register, a customer wearing clothing that doesn’t match the season, or trouble communicating as possible early signs of dementia.

“Many times dementia is uncovered when a person begins to fail functionally in their own life,” Shapiro says, who serves as a Clinical Associate Professor in the Department of Neurology and Rehabilitation at the University of Illinois College of Medicine at Chicago. “Pharmacists will probably notice first that this person who used to be very reliable about refilling their meds has run out of one or is filling one and not the other.”

Next: Communicate with caregivers

Syed recommends that pharmacists who are concerned either talk with the patient’s caregiver or contact the prescribing physician to discuss any changes in behavior or habits they’ve observed.

“In Alzheimer’s we don’t have a lot of medication choices for treating. The medications don’t cure at this point; they may just slow the on-going effects of disease. Because we’ve been there to recognize changes early, we have a chance of getting a patient on a medication sooner, “she says. “That’s a benefit to the patient.”

Shapiro, who has more than three decades of affiliation with VA care, says there’s a spectrum of opinions when it comes to whether medications should be used in all patients. She recommends adhering to guidelines such as those developed by the VA or the Alzheimer’s Association to guide prescriber decisions.

Medications may not be the best choice for everyone, particularly patients who are very frail or have other issues such as cardiac or GI contraindications. In these scenarios, she usually discusses the pros and cons of medications with the patient and their family.

At Acquaviva’s Pharmacy in Palm Bay, Florida, Carl Acquaviva, RPh, says this year his pharmacy added brochures that highlighted the signs and symptoms of Alzheimer’s for patients and their caregivers. The materials were provided through the Good Neighbor Pharmacy network, in which his pharmacy participates.

Some pharmacies are going one step further by performing memory screenings in house. For instance, Kmart Pharmacy recently partnered with the Alzheimer’s Foundation of America (AFA) to offer free-confidential memory screenings at all of its pharmacy locations for the month of November.

According to Jennifer Speares, RPh, Director of Compliance and Administration for Kmart Pharmacy, the pharmacy conducted about 5,000 memory screenings across its approximately 500 locations during the month-long event. The event took place at the same time as the Medicare re-enrollment period, allowing the pharmacists to offer comprehensive patient counseling sessions that included memory screenings, assistance with re-enrollment, and immunizations. “It really became a full-on health event, but memory screenings were sort of the primary focus of what we were trying to do,” Speares says.

Syed says clinic or retail pharmacies anywhere can very easily add a quick mental status assessment into their regular counseling process. She recommends visiting the Alzheimer’s Association’s website, alz.org, to see their free assessment tools. “You can download those tools and use them as part of your practice,” she says.

While the Kmart initiative was initially a one-month event, Speares says the pharmacy quickly realized it wanted to form a long-standing partnership with the AFA and continue the memory screenings. Kmart is also exploring other ways to expand their services geared toward Alzheimer’s patients.

“As a pharmacist who is responsible for training thousands of other pharmacists, I would love to see this become a part of normal training, like an immunization,” she says.

Pharmacists may be poised to aid in early identification, but their efforts shouldn’t end there. Pharmacists can be important allies in the care and management of Alzheimer’s disease.

As a drug expert, pharmacists can conduct a thorough drug utilization review of a patient’s medication list to identify other medications, such as antihistamines or muscle relaxants, that are known to cause or amplify existing memory issues.

“We want to at least take a look and make sure that none of the offending agents are involved in their care,” Syed says.

Shapiro recommends pharmacists familiarize themselves with the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults guidelines, produced by the American Geriatrics Society. She says these guidelines can help pharmacists identify medications that could be problematic for those with dementia.

There are also several strategies pharmacies can use to try to improve medication adherence.

For instance, Syed says pharmacists may be able to help patients and their caregivers simplify drug regimens by creating a schedule that limits the number of times a day a patient needs to take medication by aligning medicines to morning or evening doses.

Acquaviva’s Pharmacy offers free compliance packaging for its patients. Although the service is open to everyone, Acquaviva says the pharmacists try to highlight the services to Alzheimer’s patients and their caregivers.

On Hawaii’s Big Island, KTA Super Store pharmacy isn’t able to offer compliance packaging, but they do fill some of their patient’s pill boxes each month to ensure their patients are getting the correct medications at the right times.

Kerri Okamura, RPh, the store’s Director of Pharmacy, says they also offer a medication synchronization program for patients and their families.

“We try to synchronize so they can get everything at once, so trips to the pharmacy are less frequent,” she says. Creating visual cues for patients, such as making a colored chart or incorporating pictures of the medications into a drug schedule, can also be useful.

In addition to adopting medication adherence strategies or policies, pharmacists can also serve as a liaison between physicians and their patients. Experts agree that patients may be more likely to want to please their physicians and may not provide accurate accounts of their adherence or medication habits.

Next: Communicate with Physicians

Patients may be more candid with pharmacists, giving them a more realistic picture of their habits. Syed says communicating with physicians is important so that all members of the care team can have an accurate sense of the patient’s actual dose, particularly if a patient is trying to stretch his or her medication by taking it less often than prescribed. “If the physician thinks that he’s not getting the full effect of the medication that he wants, he may be increasing the dose and this would not be good,” she says.

As a physician, Shapiro also advocates for open communication between the physician and pharmacist.

“When pharmacists call physicians I think one thing that might be helpful for both, is to give an alternative, like this comes in a long-acting form, a generic form, may I substitute this?” Shapiro says, who also serves as an Attending Physician at the Jesse Brown VA Medical center. Suggesting alternate delivery methods of medications, such as patches or sprinkle forms, once a patient begins having difficulty eating or swallowing is another way pharmacists can offer value.

Shapiro says pharmacists should also review prescription labels to make sure the information is accurate and in the patient’s native language. Dosing for all approved medications for Alzheimer’s disease should start low and go high, so refill directions may be different than the initial fill. Shapiro says it’s important to make sure any refills aren’t still left with the original directions.

Providing Caregiver Support Alzheimer’s strips patients of their independence and basic functioning, creating a greater reliance on caregivers.

Community pharmacists can serve caregivers too, by providing those caring for Alzheimer’s patients with information about local resources, adult day care centers, or a list of support groups and services in the community.

Okamura says the pharmacy in Hawaii has even partnered with its local Alzheimer’s Association chapter to try to increase awareness about the services that exist in the community. For example, the Alzheimer’s Association chapter is always included in the pharmacy’s wellness fairs.

“We try to support each other when we can,” she says.

Acquaviva’s Pharmacy held a fundraiser this summer to raise money for its local Alzheimer’s Association chapter. The event raised about $1,300 and increased awareness about the disease and the resources that exist in the community.

“You spark interest and conversation and it makes people aware and maybe it’s enough to get people over the hump to pursue it with their doctor,” Acquaviva says.

A Team Approach

Shapiro believes that when a pharmacist is part of the healthcare team it can result in better patient and family satisfaction, reduced emergency room visits, reduced adverse effects, and fewer hospitalizations.

“Ideally, the number of medicines go down, there’s de-prescribing, and there’s more appropriate dosing,” she says.

Phase 3 trial of the anti-amyloid antibody aducanumab (Biogen)
-- http://bit.ly/2bKvMht

Autosomal Dominant Alzheimer’s Disease (ADAD) Treatment Trial  
-- http://bit.ly/2jGitR

The API Generation Study
  -- http://bit.ly/2ixAm7U

The Dominantly Inherited Alzheimer’s Network Trials Unit (DIAN-TU) and DIAN-TU Next Generation (NexGen) studies
-- http://bit.ly/2jkj7UF

Jill Sederstrom is a Contributing Editor.