1 Standard of Practice in Geriatric Medicine for Pharmacy Services

2 Geriatric Medicine Standard Working Group* 3 4 Suggested citation: SHPA Geriatric Medicine Standard Working Group (2018). Standard of Practice in 5 Geriatric Medicine for Pharmacy Services. Standard of Practice series. The Society of Hospital 6 Pharmacists Australia (SHPA). 7

8 Preface

9 This Standard is for professional practice and is not prepared or endorsed by Standards Australia. It 10 is not legally binding. 11 This Standard references and relies upon the SHPA Standards of Practice for Clinical Services (1) as 12 the foremost Standard. This Standard may overlap with others and depending on the area of 13 specialty practice it may be advisable to refer to additional Standards of Practice. 14 The use of the word ‘specialisation’ in this standard is in line with the National Competency Standards 15 Framework for Pharmacists in Australia (2) where ‘specialisation’ refers to the scope of practice rather 16 than the level of performance. ‘Specialisation’ of itself does not confer additional expertise. 17

18 Introduction

19 Older People 20 In developed countries the term ‘older people’ usually refers to people aged 65 years and over. In 21 Australia this age is used to determine eligibility for some aged care services. However, 65 years is 22 an arbitrary cut-off and individual people age differently. For many people better healthcare and living 23 standards has delayed the onset of health and physical problems typically associated with ageing, so 24 they remain healthy and active into their 70s or 80s. On the other hand, some people develop 25 geriatric syndromes and frailty in their 50s. Indigenous Australians have a lower average life 26 expectancy than the general population and are eligible for aged care services from the age of 50 27 years. The term ‘older’ is preferred over ‘elderly’, ‘aged’ or ‘geriatric’ when describing a person over 28 65 years of age, as the latter terms carry negative connotations and may lead to generalisations 29 about the health and physical status of the older person. 30 31 Older people constitute a large and growing proportion of the population, making geriatric medicine 32 a rapidly growing specialty. Pharmacists who specialise in geriatric medicine pharmacy practice work 33 in a variety of settings. These include acute and subacute geriatric medicine units, other hospital

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34 units that focus on the care of older people (e.g. psychogeriatric and orthogeriatric units), residential 35 aged care facilities (RACF) and community-based programs (e.g. Transition Care, Hospital Outreach, 36 Home Care). The principles of geriatric medicine and geriatric pharmacy practice are also relevant in 37 other healthcare settings in which older people are managed, for example general medicine units, 38 oncology units and primary care. 39 A central component of geriatric medicine is ‘comprehensive geriatric assessment’ (CGA) (3). CGA 40 provides a comprehensive assessment of the older person’s health and wellbeing, with input into 41 the diagnosis and management plan from multiple disciplines (4). It includes assessment of medical, 42 cognitive, affective, functional and social issues, and development of a management plan that 43 considers the patient’s goals and preferences. Medication review and assessment of patients’ 44 medication management are important components of geriatric assessment, and core roles of the 45 geriatric pharmacist (3, 5). 46 There is a substantial body of published literature demonstrating the clinical and economic benefits 47 of clinical pharmacy services for older people in inpatient, residential care and ambulatory settings. 48 Clinical benefits include: prevention, identification and resolution of adverse drug reactions and 49 other medication-related problems, improved quality of prescribing, enhanced continuity of 50 medication management during care transitions and better medication adherence (5-20). In some 51 patient groups, pharmacist review may reduce unplanned hospitalisations (20). 52 Geriatric medicine pharmacists require specialised knowledge and expertise to contribute effectively 53 to the care of older people because medication management for older patients differs significantly 54 from that of younger adults (Table 1). Geriatric syndromes, many of which may be caused or 55 worsened by medicines or may impact on the older person’s ability to manage their medicines, 56 further complicate medication management. Syndromes that are common in older people include: 57 cognitive impairment (delirium and dementia), incontinence, immobility, falls, frailty, functional 58 impairment and iatrogenic disease. These often have multifactorial aetiologies (including medication 59 reactions) and have a major impact on older peoples’ quality of life.

60 Table 1 How medication management for older people differs from younger adults.

• Higher prevalence of multimorbidity and polypharmacy. • Altered and variable pharmacokinetics and pharmacodynamics. • Decreased physiological reserve and resilience. • Increased susceptibility to drug interactions and ADRs. • Atypical presentation of illness and ADRs.

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• Limited evidence with respect to effectiveness and safety of medications, especially in multi-morbid and frail older people (due to their exclusion from most clinical trials). • Variable goals of care, especially in frail individuals and those with limited remaining life expectancy (e.g. maintaining function and quality of life and avoiding ADRs may be prioritised over aggressive disease management and achievement of stringent treatment targets). • Higher prevalence of impaired functional capacity and cognitive decline, impacting on patients’ ability to manage complex medication regimens. • More complex care transitions as a result of polypharmacy, multiple medication changes, use of pharmacy-packed dose administration aids (DAAs), and transfer to settings in which medication charts or orders are needed to enable ongoing medication administration (e.g. residential aged care, community nursing care). 61 ADR = adverse drug reaction

62

63 Objectives of the Service

64 The objective of a geriatric medicine pharmacy service is to provide patient-centred care to optimise 65 medication-related outcomes for older people. 66 The pharmacist should work with other members of the multidisciplinary team to ensure that drug 67 therapy for the older person is rational, safe, cost-effective and acceptable to the patient. They 68 should focus on preventing and detecting ADRs, including atypical ADRs such as those that present 69 as geriatric syndromes. When appropriate, the pharmacist should recommend and assist with 70 deprescribing to reduce unnecessary or inappropriate polypharmacy. They should assess patients’ 71 capacity to safely manage and adhere to their medication regimen, and implement strategies to 72 assist patients and carers with this task. Patient and carer education and ensuring continuity of 73 medication management during care transitions are core objectives.

74

75 Scope

76 These standards describe activities consistent with best practice for the provision of clinical 77 pharmacy services for older patients receiving geriatric care or aged care in any setting, including 78 hospitals, residential care facilities, transition care services and in the community.

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79 The scope of services provided by geriatric medicine pharmacists will be dependent on the setting, 80 funding models, the priorities of the organisation and the scope of practice of the individual 81 pharmacist. 82 As well as providing clinical pharmacy services for individual patients, the geriatric medicine 83 pharmacist should be a point of contact for geriatric medicine pharmacy related enquiries from 84 other pharmacists and health professionals within the health or aged care service. The role of the 85 pharmacist in geriatric medicine should also include involvement in development of policies, 86 procedures, guidelines and resources, comment on medicine formulary issues, provision of 87 educational programs and training for pharmacy students, intern pharmacists, postgraduate 88 pharmacists, pharmacy technicians and other healthcare professionals, as well as quality 89 improvement activities and research related to geriatric medication management. 90

91 Operation

92 Access to clinical pharmacy services

93 Older patients in all healthcare settings should have access to a clinical pharmacy service. 94 In hospital inpatient settings, best practice is to provide a comprehensive geriatric medicine 95 pharmacy service in accordance with these standards 7 days a week (1). If a geriatric medicine 96 pharmacy service is not available on weekends and public holidays, the pharmacy department 97 should provide a general clinical pharmacy service on those days to ensure that newly admitted 98 patients are reviewed and discharging patients are reviewed and receive discharge medication 99 counselling and clinical handover (1). 100 For residential and community aged care, a less intensive clinical pharmacy service would be 101 appropriate.

102 Identifying patients who require clinical pharmacist review

103 If a geriatric medicine pharmacy service cannot review all patients, it should target people at 104 greatest risk of adverse medication events. The broad criteria used to determine eligibility for 105 pharmacist services such as Home Medicines Reviews (21) do not effectively identify those at 106 greatest risk (22). The SHPA has developed criteria that may identify at-risk patients more effectively 107 (23). 108 Transitions between care settings and changes to an older person’s care needs are associated with 109 increased risk of adverse medication events and indicate the need for a clinical pharmacist review 110 (Table 2).

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111 Table 2 Examples of transitions that indicate need for clinical pharmacist review of an older person

• Admission to hospital • Discharge from hospital • Discharge from a Transition Care Program • Admission to a residential aged care facility (RACF) • Referral to an Aged Care Assessment Team (ACAT) • Referral to a home nursing service for medication management • Admission to a home care package (Australian Government-funded aged care at home) • Admission to a palliative care service 112

113 Policies and Procedures

114 Geriatric medicine pharmacists must have knowledge of the following:

115 • Australian Charter of Healthcare Rights (24). 116 • Pharmacy Board of Australia Code of Conduct (25). 117 • National Competency Standards Framework for Pharmacists in Australia (2). 118 • Professional Practice Standards (26). 119 • Legislation, specifically State and Territory Acts and Regulations.

120 These documents provide a framework within which the pharmacist must practice. 121 Guidelines of relevance to geriatric medicine pharmacists are listed in Appendix 1. Resources.

122 Components of a geriatric medicine clinical pharmacy service

123 A summary of the components of a geriatric medicine pharmacy service in different practice settings 124 is provided in Table 3. 125 The range of services provided by a geriatric medicine pharmacist are generally similar to those 126 provided for other patient populations, however the focus or prioritisation of the service may differ. 127 This section of the standards does not describe all clinical pharmacy procedures that form a geriatric 128 medicine pharmacy service. Its purpose is to highlight key differences and procedures as they relate 129 to older patients.

130 Medication history and reconciliation

131 Medication reconciliation is especially important for older patients due to the high prevalence of 132 multimorbidity and polypharmacy, interaction with multiple health services and prescribers, and 133 factors that make history-taking more challenging, such as cognitive impairment and poor health

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134 literacy. Greater time and effort may be required to obtain the best possible medication history in 135 this population. 136 Medication reconciliation should be undertaken on every: 137 • presentation or admission to a health or aged care service (including hospitals, clinics, and 138 residential and community aged care services); 139 • transfer between wards and care settings within an organisation; 140 • transfer between community-based providers (1, 12, 27). 141 Medication reconciliation should also occur whenever handwritten medication charts are re-written 142 and when there are significant changes to a person’s medication regimen (e.g. following a 143 medication review, to ensure that intended medication changes are correctly implemented.

144 Medication review

145 Medication review, referred to as ‘assessment of current medication management’ in the Standard 146 of Practice for Clinical Pharmacy Services (1), is a vital component of health care for older people, 147 especially those who use multiple medications (27-31). 148 An interdisciplinary approach to medication review is recommended, involving the pharmacist, 149 medical practitioner(s) and aged care or community nurse (27, 29, 30). The patient’s views, concerns 150 and wishes should be central to the review. For patients who are unable to participate in the review, 151 for example due to severe cognitive impairment, their advance care plans should be considered, if 152 available, and their carer or substitute decision-maker (e.g. medical power of attorney) should be 153 involved. 154 For hospital inpatients, medication reviews should occur on admission, during the hospital stay and 155 prior to discharge (1, 32, 33). Medication review on admission should focus on identifying 156 medications and un-treated or under-treated medical problems that may have contributed to the 157 person’s presenting complaints. Subsequent medication reviews provide an opportunity to reassess 158 the benefits and risks of pre-admission medications, ensure appropriateness of new medications, 159 deprescribe unnecessary or inappropriate medications and simplify the discharge medication 160 regimen (34, 35). Medication review is also recommended for older surgical patients as part of pre- 161 operative and post-operative assessments (36, 37). 162 In community and residential aged care settings it is recommended that a comprehensive, 163 interdisciplinary medication review occur at least once every 12 months (27, 28, 38). People moving 164 into a RACF should have a comprehensive medication review 4 to 6 weeks after admission. This 165 timing allows the person to adjust to their new environment, with potentially improved nutrition, 166 hydration and medication adherence. It is also an ideal time to reassess the benefits and risks of

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167 long-term medications and develop and implement a deprescribing plan if necessary. Additional 168 reviews should occur when there is a significant change to the patient’s health or medication 169 regimen, and within 5-10 days of discharge from hospital (27, 29, 30, 38). 170 Referral to an aged care assessment team (ACAT) or home nursing service should trigger a 171 medication review since these events indicate a decline in functional capacity which may be related 172 to medications or may impact on the older person’s ability to manage medications (16, 39). 173 174 Whenever possible, medication reviews (in all settings) should include face-to-face discussion 175 between the pharmacist and prescriber(s) to enable efficient and effective communication and 176 decision-making and ensure that potential medication-related problems are addressed. If a face-to- 177 face discussion is not possible telehealth is an alternative. Professional practice guidelines and 178 standards for pharmacists relating to the medication review process are listed in Appendix 1.

179 ADR detection and management

180 Iatrogenic disease and prescribing cascades (where a medication is prescribed to manage the 181 adverse effects of another medication) are common in older patients. ADRs may be difficult to 182 detect as a result of atypical presentation (3). 183 ADR should be considered as a potential cause of any new symptom in an older person. Monitoring 184 for ADRs should occur when any new medication is commenced or a dose is increased. Monitoring 185 should also occur following any change to an older person’s medication management that may lead 186 to a sudden increase in medication adherence, such as admission to hospital or a RACF, assistance 187 with medication-taking (e.g. by a home nursing service) or implementation of a DAA. 188 It is also important to monitor for adverse drug withdrawal events when long-term medications are 189 stopped or deprescribed. Adverse drug withdrawal events include recurrence of the original 190 symptom, withdrawal symptoms, or rebound phenomenon (40). 191 Monitoring for ADRs and adverse drug withdrawal events is a shared responsibility involving the 192 prescriber, pharmacist, nurse, and the patient and their carer.

193 Deprescribing

194 Deprescribing attempts to balance the potential for benefit and harm by systematically withdrawing 195 unnecessary or inappropriate medications, with the goal of managing polypharmacy and improving 196 outcomes (40). Deprescribing has become a major focus of geriatric medicine and pharmacy 197 practice, and is especially important for older people with limited remaining life expectancy (41). 198 Since people in their last year of life present to hospital on average two to four times, admission to 199 hospital may be a trigger to discuss end of life care and consider deprescribing in people who are

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200 clearly declining in health (41). Deprescribing should also be considered following admission to a 201 RACF, where the average remaining life expectancy is around two years. 202 Other triggers to consider deprescribing include ADR, high treatment burden, or a decline in 203 functional capacity (which may be indicated by referral to an ACAT, home nursing service or home 204 care package). 205 The rationale for deprescribing decisions should be documented in the patient’s medical record and 206 communicated in clinical handover, including criteria for reintroduction of the medication (40). A 207 plan for follow-up of outcomes is also important. These steps reduce the risk of ADWEs, and allows 208 for the prompt re-introduction of the medication if indicated. 209 Deprescribing decisions should occur as part of a comprehensive medication review and in 210 consultation with the patient and/or their carer or substitute decision-maker. Protocols, algorithms 211 and guidelines for deprescribing are available (42).

212 Regimen simplification

213 Simplification of medication regimens can improve adherence and reduce treatment burden for 214 patients and carers. Simplification may involve medication withdrawal or changes to dose-forms, 215 dose-times and dose-frequencies (34). Regimen simplification should form part of all comprehensive 216 medication reviews for older people. The impact on regimen complexity should also be considered 217 at the time of prescribing, reviewing or dispensing a new medication, because sometimes an 218 alternative medication, dose-form or dose-regimen may be available that will have less impact on 219 the complexity of the patient’s medication regimen.

220 Assessment of patient’s ability to manage medicines

221 Older patients are more likely to have barriers to accurate and safe medication management than 222 younger patients. Barriers include: polypharmacy, cognitive or sensory impairment, reduced manual 223 dexterity and poor health literacy. Assessment of a patient’s (or carer’s) ability to manage and 224 adhere to their medication regimen helps to determine whether a patient needs assistance or 225 medication aids such as medication reminders or a dose administration aid (DAA). 226 Examples of situations where an assessment of a patent’s ability to manage medicines should be 227 considered include: when there has been a change in the patients’ functional capacity (e.g. following 228 an acute event such as stroke or delirium), when there are changes to the patient’s medication 229 regimen (especially changes that increase regimen complexity or introduce new dose-forms), or 230 when there are concerns about the patient’s capacity to safely manage their medicines. In 231 residential care, when a resident wants to self-administer medicines an assessment of their capacity 232 must be conducted (27, 30).

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233 Various performance-based instruments exist to assess a patient’s capacity to manage their 234 medications (43, 44). Content of tools is variable, but most include ability to read and explain a 235 dispensing label, open packaging and remove a dose, orientation to time and memory recall (43). 236 Some tools use the patient’s own medication for the assessment, whereas other use a mock 237 medication regimen. The former may be best suited to settings in which the patient’s own 238 medications are available, such as in the patent’s home. The latter may be more feasible in the 239 hospital setting (44). Supervised self-administration of medicines (see next section) can also be used 240 to assess a patients’ ability to manage medicines. 241 An assessment of medication management ability should be performed before implementing a DAA 242 such as a Dosett box, blister pack (e.g. Webster Pak) or sachet system (18). DAAs are not suitable for 243 all patients (6, 18). Sometimes simpler, less costly alternatives may be suitable, such as regimen 244 simplification and use of reminder charts or alarms. Approaches to assessing patients’ suitability for 245 DAAs have been published (6, 18).

246 Self-administration of medicines programs (SAMP)

247 Self-administration of medicines programs (SAMP) are used mainly in sub-acute hospital units and 248 residential care facilities to assess patients’ ability to safely manage their medications, encourage 249 patient participation in their care, provide education and training in medication-taking and identify 250 supports required for ongoing medication management (45, 46). Patients who complete a SAMP 251 may demonstrate better drug knowledge, better adherence and fewer medication errors (47). 252 In hospitals, a SAMP should be considered for patients who plan to self-administer their medicines 253 after discharge and have had significant changes to their medication regimen and/or changes in their 254 functional capacity. In residential care, a SAMP should be conducted when a resident wants to self- 255 administer their medicines. SAMP could also be considered in other settings such as people living at 256 home with an aged care package or community nursing support. 257 A SAMP commences with an assessment to determine suitability of the patient for the program, 258 format of medicine supply and to obtain patient consent. Medicines are dispensed with full 259 directions, in the format that the patient will use (original packs or DAA). The patient then 260 administers their medicines with direct nurse supervision. If the patient demonstrates correct 261 administration over several days the program may allow for greater patient independence with 262 regular monitoring. 263 Patients suitable for SAMP are medically stable with a consistent medication profile. Geriatric 264 medicine pharmacists are involved in identifying suitable patients, patient assessment, organising 265 the supply of medicines in the required format, providing education and monitoring outcomes.

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266 Facilitating continuity of medication management on transition between care settings

267 Geriatric medicine pharmacists should provide medicines information to patients, carers and health 268 professionals during transitions of care, ensure ongoing access to medicines, and ensure that 269 medications are able to be safely and accurately administered after a transition of care (1, 32). 270 All older patients who use multiple medicines should be provided with a patient-held medication list 271 (in addition to verbal instructions) (29, 48). At transitions of care the medication list should also 272 include information about medicines that have been recently discontinued. As noted above, 273 patients’ ability to manage their medicines should be assessed, and appropriate medication 274 management strategies and supports implemented. 275 If RACF staff or community nurses will be supporting the patient, they usually require medication 276 administration orders. It is recommended that hospitals provide an interim medication 277 administration chart for all patients discharged to RACFs to avoid medication administration delays 278 and errors upon arrival at the RACF (30). These can be prepared by a pharmacist or hospital medical 279 officer (30). A copy of the interim chart should be provided to the patient’s community pharmacy. 280 When a community pharmacy-packed DAA is used upon discharge from hospital, the packing 281 pharmacy must be provided with information to enable timely and accurate DAA preparation. 282 Provision of discharge medication information to community pharmacists is also important for non- 283 DAA users who have had significant changes to their medication regimen in hospital.

284 Patient and carer education

285 Medication information and education should be provided to all older patients, including those using 286 a DAA and patients living in residential care facilities, even if they are not self-administering their 287 medicines. It should include both verbal and written information. For some patients with cognitive 288 impairment or poor literacy, Consumer Medicines Information may be too complex and simpler 289 written materials should be offered. Pharmacists should ensure language used is simple and clear 290 and avoids unnecessary medical terminology. Physical impairments including visual and auditory 291 changes may impair an older person’s ability to receive the message being delivered. Use of 292 appropriate light, colour, font and a lower pitch voice and checking for hearing aids are important 293 when delivering medication information. Speaking slowly, breaking downs tasks and demonstration 294 is necessary in those with cognitive impairment (49). For patients on multiple medications a 295 medication list should be provided, and the patient should be encouraged to keep this up to date. 296 It is recommended that education for inpatients is provided throughout the admission, because 297 delivering a large volume of information at the point of discharge may be overwhelming and 298 ineffective.

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299 Older persons may have third parties managing their medicines (e.g. carer or nurse). Whilst these 300 parties may require medication education, it is important to still involve the patient unless they are 301 unable or have indicated that they do not want to receive education.

302 Interdisciplinary teamwork

303 Interdisciplinary teamwork is at the core of evidence-based models of geriatric medicine. 304 Participation in interdisciplinary activities is an effective avenue for pharmacists to build rapport 305 with other clinicians (e.g. medical practitioners, nurses and allied health including occupational 306 therapists, speech pathologists and dieticians) and contribute to patient care. 307 Geriatric medicine pharmacists should routinely participate in interdisciplinary ward rounds and 308 other forums at which decisions about medication management are made, such as team meetings 309 and case conferences. The geriatric medicine pharmacist’s contributions to team discussions should 310 include providing information about current and recent medication use and medication changes, 311 ADR identification, advice about appropriate medication selection, deprescribing and discharge 312 planning. 313 Geriatric medicine pharmacists must be proactive participants in discussions about hospital 314 discharge planning, to ensure that medication management issues are considered and addressed 315 before decisions are made about the discharge destination and support services.

316 Quality use of medicines activities

317 Geriatric medicine pharmacists should lead or contribute to quality use of medicines (QUM) 318 activities, to optimise medication management and patients’ health outcomes in all health and aged 319 care settings. 320 QUM activities can take many forms including (21): 321 • educational activities for health professionals, carers and patients/residents; 322 • continuous quality improvement activities such drug use evaluations; 323 • participation in Medication Advisory Committees; 324 • development of medicine-related policies and procedures; 325 • assisting the organisation to meet and maintain medication management accreditation 326 standards.

327 Recommended Staffing

328 The level of geriatric medicine pharmacy service should be agreed with the health or aged care 329 service provider and the healthcare team, and resourced appropriately to enable delivery of the 330 agreed service. The ideal geriatric medicine clinical pharmacy service and associated pharmacist

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331 staffing ratios for different aged care settings are described in Table 3. These recommendations are 332 based on published evidence (50, 51) consensus guidelines (1, 27-30, 32, 52, 53), and consultation 333 experienced geriatric medicine pharmacists and geriatricians. They assume the pharmacist will be 334 primarily providing clinical services and will have limited or no direct involvement in medication 335 supply functions.

336 Many factors influence the ability of geriatric medicine pharmacists to deliver the clinical services 337 recommended in these standards, such as funding, staffing levels, extent of integration of 338 pharmacists into the multidisciplinary team, education and training of the pharmacist and availability 339 of support staff (e.g. pharmacy technicians, dispensary pharmacists, quality use of medicines 340 pharmacists). In residential and community aged care settings, the size of the service, travel 341 distances required to provide the service and the number and location of medical practitioners will 342 impact on efficiency of the clinical pharmacy service and staffing levels required. 343 Where possible, pharmacy technicians should be employed to support the geriatric medicine clinical 344 pharmacist, because this has been shown to increase the number of patients able to be reviewed by 345 the pharmacist and improve timeliness of review (51). Tasks that can be undertaken by pharmacy 346 technicians are described elsewhere (1).

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347 Table 3 Recommended clinical pharmacy services and pharmacist:bed ratios for aged care services

Type of care Acute aged care* Subacute inpatient aged Residential aged care Community aged care^ care Average LOS 7-10 days 14-28 days 24 months (8 weeks for Variable residential Transition Care Program [TCP] clients) Optimal pharmacist:bed ratio 1:20 1:30 1:200 (1:40 for residential See footnote% TCP)&& Optimal clinical pharmacy service

• Medication history and Yes, within 24 hours Yes, within 24 Yes, within 72 hours** Yes, within 72 hours** reconciliation on admission

• Medication chart review and Yes, daily Yes, at least 2nd-daily Yes, at least monthly. Yes, at least monthly clinical review • Reconciliation of new dose DAAs not routinely used Yes, if patient is Yes$ Yes$ administration aid (DAA) packs in acute aged care participating in a self- with medication orders/charts administration of when packs are supplied. medications program using DAAs

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Type of care Acute aged care* Subacute inpatient aged Residential aged care Community aged care^ care • Comprehensive interdisciplinary Yes, within 3 days of Yes, within 7 days of Yes, within 4-6 weeks of Yes, within 4-6 weeks of medication review admission admission admission and repeated at admission and repeated at intervals determined by intervals determined by clinical need (not less than clinical need (not less than yearly, and within 5-10 yearly, and within 5-10 days of returning from an days of returning from an unplanned hospital unplanned hospital admission) admission)

• Monitoring and review of Yes, at least weekly (with Yes, at least weekly (with Yes, at least 4 weekly Yes, at least 4 weekly deprescribing plan and plan for ongoing plan for ongoing outcomes, following a monitoring provided in monitoring provided in comprehensive medication discharge summary) discharge summary) review. • Multidisciplinary ward round Yes, at least twice-weekly Yes, at least once-weekly Yes (if available) Yes (if available) participation

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Type of care Acute aged care* Subacute inpatient aged Residential aged care Community aged care^ care • Multidisciplinary team meeting / Yes, weekly Yes, weekly Yes (if available) Yes (if available) case conference participation

• Provision of information and Yes Yes Yes Yes advice to prescribers, nurses and carers • Provision of information to Yes Yes Yes$ Yes$ patients and/or carers about medication changes • Assessment of patients’ ability to Yes, if discharge plan is for Yes, if discharge plan is for Yes, if patient wishes to Yes, if patient wishes to self-administer medications patient to manage own patient to manage own self-administer medicines self-administer medicines. medicines medicines • Self-administration of medicines Not routinely used in Yes, if plan is to manage Yes, if patient wishes to Yes, if patient wishes to program^^ acute aged care own medicines after self-administer medicines self-administer medicines discharge • Development of a plan for Yes Yes Yes (residential TCP) Yes medication management after discharge

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Type of care Acute aged care* Subacute inpatient aged Residential aged care Community aged care^ care • Discharge prescription review Yes Yes Yes NA and reconciliation

• Preparation and delivery of Yes Yes Yes NA discharge medication information for patient/carer# • Preparation and delivery of Yes Yes Yes Yes medication information for clinical handover (to community pharmacy, GP, community nurse, RACF and/or hospital as applicable)@ • Referral to post-discharge Yes Yes Yes Yes medication review service if patient meets eligibility and risk criteria& • Medication reconciliation after Yes Yes Yes$ Yes$ any care transition (e.g. transfer

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Type of care Acute aged care* Subacute inpatient aged Residential aged care Community aged care^ care between units, after hospital discharge)

• Participation in medication Yes Yes Yes Yes management committees

• Quality Use of Medicines Yes Yes Yes Yes activities (e.g. audits, staff education) • Contributing to Medication Yes Yes Yes Yes policy and procedure development 348 * Acute aged care: Acute medical units for the aged and other acute units with a focus on older people (e.g. orthogeriatric units)

349 ^ Community aged care: Formal care provided to the older person in their own home, such as Home Care Packages, community-based Transition Care Programme and 350 home nursing services. 351 && Pharmacist to bed ratio in RACFs assumes the clinical pharmacist is not involved in reconciliation of new DAA packs with RACF medication administration charts or 352 provision of counselling/education to the patient or substitute decision-maker each time a new medication is dispensed (because these services are the responsibility of 353 the dispensing pharmacy service). If these roles are included, increased pharmacist resource would be needed. The pharmacist resource required will also be affected by 354 the size of the facility, number of medical practitioners, and the model of care (e.g. fewer medical practitioners who attend regularly for ‘ward rounds’ would increase 355 efficiency of the clinical pharmacy service)

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356 % The ratio of pharmacists to patients is variable as a result of variable length of stay within community aged care services and variable travel distances (e.g. metropolitan 357 versus rural). On average, a community-based clinical pharmacist can perform a comprehensive medication review for 2 to 3 patients/day depending on patient complexity 358 and travel distance 359 ** If possible, the medication history should be obtained prior to admission (at the patient’s home) as this results in a more accurate history and will reduce the risk of 360 medication charting errors on admission. Reconciliation of the medication chart with the medication history should then occur as soon as possible after admission. 361 $ May be provided by the supplying pharmacy 362 ^^ It is usually not feasible for all patients to participate in self-administration of medications program. Patients at highest risk of medication errors should be identified and 363 targeted. 364 # Verbal information, patient medication list (including all current medicines and medicines ceased in hospital) and consumer medicines information if applicable 365 @ Includes contributing medication information to the medical discharge summary, communicating medication changes to the patient’s community pharmacy and/or 366 preparation of an interim residential care medication administration chart. 367 & For example, hospital outreach medication review, HMR or RMMR service, to review medication management and outcomes of medication changes in consultation with 368 GP within 5-10 days of discharge 369

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370 Training and Education (for the service, and of the individual)

371 Training for geriatric medicine pharmacists should be provided by the organisation to improve the 372 pharmacists’ ability to care for older people, and pharmacists should also seek relevant external 373 professional development opportunities. 374 Education, training and professional development can be sourced from professional bodies such as:

375 • SHPA 376 • American Society of Consultant Pharmacy 377 • American Society of Health-System Pharmacists 378 • Universities, e.g. Monash University Geriatric pharmacy practice and Geriatric disease state 379 management postgraduate units

380 Educational material and resource and links to professional development opportunities are provided 381 on the SHPA Specialty Practice Geriatric Medicine stream page on the SHPA eCPD website. For 382 geriatric medicine pharmacists, joining and actively participating in the Geriatric Medicine Stream at 383 the Practice Group level is strongly recommended.

384 Attendance at specialist conferences and educational meetings is encouraged to maintain and 385 update specialist knowledge in geriatric medicine. Relevant domestic conferences include those 386 organised by SHPA, The Australian and New Zealand Society for Geriatric Medicine and The 387 Australasian Association of Gerontology. International conferences in geriatric medicine include 388 those organised by the International Association of Gerontology and Geriatrics, the British Geriatrics 389 Society and the American Geriatrics Society.

390 Credentialing

391 Pharmacists can obtain credentialing in geriatric medicine pharmacy practice by passing the Board of 392 Pharmacy Specialities Geriatric Pharmacy examination. This credential also enables pharmacists to 393 gain accreditation by the SHPA as a provider of Home Medicines Reviews (HMR) and Residential 394 Medication Management Reviews (RMMR). The Australian Association of Consultant Pharmacy 395 (AACP) can also accredit pharmacists to provide HMRs and RMMRs. 396

397 Quality Improvement

398 In addition to quality measures outlined in Chapter 14 of the SHPA Standards of Practice for Clinical 399 Pharmacy Services (1), a geriatric medicine pharmacy quality improvement program should 400 demonstrate that the service is targeting and delivering high quality care for patient groups at

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401 greatest risk for medicine misadventure. The geriatric medicine pharmacist should ensure that the 402 focus is not only on the timeliness of care, but also on the quality of care in line with national or 403 state based indicators. Many of the indicators under discussion nationally and internationally have a 404 medication-related element.

405 Indicators relevant to geriatric medicine pharmacy services include: 406 Australian National QUM indicators e.g.

407 • 3.1 Percentage of patients whose current medicines are documented and reconciled at 408 admission 409 • 5.5 Percentage of patients with a new adverse drug reaction (ADR) that are given written 410 ADR information at discharge AND a copy is communicated to the primary care clinician 411 • 5.9 Percentage of patients who receive a current, accurate and comprehensive medication 412 list at the time of hospital discharge 413 • 6.2 Percentage of patients that are reviewed by a clinical pharmacist within one day of 414 admission (to hospital)

415 ACOVE 3 quality indicators (Assessing the care of vulnerable elders, RAND Corp, USA) e.g.

416 • ALL vulnerable elders should have an annual drug regimen review

417 • IF a vulnerable elder is prescribed a drug, THEN the prescribed drug should have a clearly 418 defined indication

419 • IF a vulnerable elder is prescribed an ongoing medication for a chronic medical condition, 420 THEN there should be documentation of response to therapy

421 Standard 14 (Medication Review) of the Pharmaceutical Society of Australia’s Professional Practice 422 Standards may be used to assess the quality of pharmacist medication review services.(26) 423 There are also numerous sets of indicators of appropriate prescribing for older people that could 424 potentially be used as a measure of the quality of care provided to geriatric medicine patients 425 (Appendix 1).

426

427 Research

428 Further information on research can be found in Chapter 11 of the SHPA Standards of Practice for 429 Clinical Pharmacy Services (1). 430 Geriatric pharmacists should contribute to the generation of new knowledge and evidence related to 431 medication management for older people. This may include investigating problems with medication

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432 use and evidence-practice gaps, developing and testing new approaches to improve medication use 433 or delivery of pharmacy services, and evaluating novel treatments. Research Ethics Committee 434 approval should be sought where applicable. It is advisable to establish an interdisciplinary research 435 team, including consumer representation, to ensure the research is relevant to key stakeholders. 436 Where applicable, core outcome sets for trials aimed at improving medication use in older people 437 should be used (54-57). 438 Presentation and publication of research is important to support the development of geriatric 439 medicine pharmacy practice and drive improvements in medication use and safety. Studies should 440 be designed and conducted with this in mind, to ensure the findings are publishable. 441 External funding enables larger and more complex studies to be conducted. The SHPA National 442 Translational Research Collaborative (NTRC) funds research grants, practitioner grants and 443 educational grants. Grants may also be available from other organisations such as the Australian 444 Association of Gerontology and various charitable trusts with an interest in aged care.

445 Acknowledgements

446 This Standard of Practice has been produced with expert consensus from the Geriatric Medicine 447 Practice Standards Working Group: Rohan Elliott (Chair), Alex (Ho Yin) Chan, Gauri Godbole, Ivanka 448 Hendrix, Lisa Pont, Dana Sfetcopoulos, John Woodward, with support from Courtney Munro, Lead 449 Pharmacist Specialty Practice, SHPA. 450 The SHPA additionally wish to acknowledge the substantive work of Rohan Elliott, Mary Etty-Leal 451 and John Woodward of the former SHPA Committee of Specialty Practice in Geriatric Medicine on a 452 previous draft of this Standard. 453

454 References

455 1. SHPA Committee of Specialty Practice in Clinical Pharmacy. SHPA Standards of Practice for 456 Clinical Pharmacy Services. Journal of Pharmacy Practice and Research. 2013;43(No. 2 457 Supplement):S1-69. 458 2. Pharmaceutical Society of Australia. National Competency Standards Framework for 459 Pharmacists in Australia. Deakin West ACT 26002016 2016. 460 3. Elliott RA. Geriatric medicine and pharmacy practice: a historical perspective. Journal of 461 Pharmacy Practice and Research. 2016;46(2):169-77. 462 4. Gladman JRF, Conroy SP, Ranhoff AH, Gordon AL. New horizons in the implementation and 463 research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap. Age 464 Ageing. 2016;45(2):194-200. 465 5. Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, et al. Effects of geriatric 466 evaluation and management on adverse drug reactions and suboptimal prescribing in the frail 467 elderly. Am J Med. 2004;116(6):394-401.

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468 6. Elliott RA. Appropriate use of dose administration aids. Australian Prescriber. 2014;37(2):46- 469 50. 470 7. Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A 471 comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a 472 randomized controlled trial. Arch Intern Med. 2009;169(9):894-900. 473 8. Crotty M. Does the Addition of a Pharmacist Transition Coordinator Improve Evidence-Based 474 Medication Management and Health Outcomes in Older Adults Moving from the Hospital to a 475 LongTenn Care Facility? Results of a Randomized, Controlled Trial. The American Journal of 476 Geriatric Pharmacotherapy. 2004;2(4):257. 477 9. Deliens C, Deliens G, Filleul O, Pepersack T, Awada A, Piccart M, et al. Drugs prescribed for 478 patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and 479 impact of a clinical pharmacist. J Geriatr Oncol. 2016;7(6):463-70. 480 10. Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a 481 collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, 482 controlled trial. J Am Geriatr Soc. 2007;55(5):658-65. 483 11. Zermansky A, Petty DR, Raynor DK, Freemantle N, Vail A, CJ. L. Randomised controlled trial of 484 clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in 485 general practice. British Medical Journal. 2001;323(7325):1340-3. 486 12. Hanlon JT, Weinberger M, Samsa GP, Schmader KE, Uttech KM, Lewis IK, et al. A Randomized, 487 Controlled Trial of a Clinical Pharmacist Intervention to Improve Inappropriate Prescribing in 488 Elderly Outpatients With Polypharamcy. The American Journal of Medicine. 1996;100:428-38. 489 13. Lipton HL, Bird JA. The Impact of Clinical Pharmacists' Consultations on Geriatric Patients' 490 Compliance and Medical Care Use: A Randomized Controlled Trial. The Gerontologist. 491 1994;34(3):307-15. 492 14. Roberts M. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 493 52 nursing homes. Br J Clin Pharmacol. 2000;51:257-65. 494 15. Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric 495 medication advisory service in residential aged care: a randomised controlled trial of case 496 conferencing. Age Ageing. 2004;33(6):612-7. 497 16. Elliott RA, Martinac G, Campbell S, Thorn J, Woodward MC. Pharmacist-led medication review 498 to identify medication-related problems in older people referred to an Aged Care Assessment 499 Team: a randomized comparative study. Drugs Aging. 2012;29(7):593-605. 500 17. O'Sullivan D, O'Mahony D, O'Connor MN, Gallagher P, Gallagher J, Cullinan S, et al. Prevention 501 of Adverse Drug Reactions in Hospitalised Older Patients Using a Software-Supported 502 Structured Pharmacist Intervention: A Cluster Randomised Controlled Trial. Drugs Aging. 503 2016;33(1):63-73. 504 18. Etty-Leal MG. The role of dose administration aids in medication management for older 505 people. Journal of Pharmacy Practice and Research. 2017;47(3):241-7. 506 19. Elliott RA, Tran T, Taylor SE, Harvey PA, Belfrage MK, Jennings RJ, et al. Impact of a pharmacist- 507 prepared interim residential care medication administration chart on gaps in continuity of 508 medication management after discharge from hospital to residential care: a prospective pre- 509 and post-intervention study (MedGap Study). BMJ Open. 2012;2(3):8. 510 20. Jokanovic N, Tan EC, van den Bosch D, Kirkpatrick CM, Dooley MJ, Bell JS. Clinical medication 511 review in Australia: A systematic review. Res Social Adm Pharm. 2016;12(3):384-418. 512 21. Pharmaceutical Society of Australia. Guidelines for pharmacists providing Residential 513 Medication Management Review (RMMR) and Quality Use of Medicines (QUM) services. 514 Pharmaceutical Society of Australia Ltd.; 2011. 515 22. Elliott RA, Lee CY. Poor uptake of interdisciplinary medicine reviews for older people is a 516 barrier to deprescribing. BMJ. 2016;353:i3496.

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517 23. The Society of Hospital Pharmacists Australia (SHPA). SHPA Fact Sheet: Risk factors for 518 medication-related problems Fact sheets & position statements: SHPA; 2015 [Available from: 519 https://www.shpa.org.au/fact-sheets-position-statements. 520 24. Australian Charter of Healthcare Rights [press release]. 2008. 521 25. Pharmacy Board of Australia. For Pharmacists Code of Conduct. March 2014 ed2014. 522 26. Pharmaceutical Society of Australia. Professional Practice Standards Version 5. Deakin West 523 ACT 2600.2017. p. 116. 524 27. National Institute for Health and Care Excellence (NICE). Managing medicines in care homes. 525 2015. 526 28. Shrank WH, Polinski JM, Avorn J. Quality indicators for medication use in vulnerable elders. J 527 Am Geriatr Soc. 2007;55 Suppl 2:S373-82. 528 29. Australian Pharmaceutical Advisory Council. Guiding principles for medication management in 529 the community. Canberra: Commonwealth of Australia; 2006. 530 30. Department of Health and Ageing. Guiding principles for medication management in 531 residential aged care facilities. Canberra: Commonwealth of Australia; 2012. 532 31. Hilmer SN, editor Outcome Statement: National Stakeholders’ Meeting on Quality Use of 533 Medicines to Optimise Ageing in Older Australians. National Stakeholders’ Meeting: Quality 534 Use of Medicines to Optimise Ageing in Older Australians; 2015 03/08/2015. 535 32. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in 536 medication management. Canberra: Commonwealth of Australia; 2005. 537 33. Australian Commission on Safety and Quality in Health Care, NSW Therapeutic Advisory Group 538 Inc. National Quality Use of Medicines Indicators for Australian Hospitals. Sydney; 2014. 539 34. Elliott RA. Reducing medication regimen complexity for older patients prior to discharge from 540 hospital: feasibility and barriers. J Clin Pharm Ther. 2012;37(6):637-42. 541 35. McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised 542 older patients receiving multiple medications. Intern Med J. 2016;46(1):35-42. 543 36. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), 544 American Geriatrics Society (AGS). ACS NSQIP® /AGS BEST PRACTICE GUIDELINES: Optimal 545 Preoperative Assessment of the Geriatric Surgical Patient. 2012. 546 37. American College of Surgeons National Surgical Quality Improvement Program (NSQIP), 547 American Geriatrics Society (AGS). Optimal Preoperative Assessment of the Geriatric Surgical 548 Patient.Best Practices Guideline from ACS NSQIP® /American Geriatrics Society. 2016. 549 38. Royal Pharmaceutical Society (RPS). The Right Medicine: Improving Care in Care Homes. 2016. 550 39. Elliott RA, Lee CY, Beanland C, Vakil K, Goeman D. Medicines Management, Medication Errors 551 and Adverse Medication Events in Older People Referred to a Community Nursing Service: A 552 Retrospective Observational Study. Drugs Real World Outcomes. 2016;3(1):13-24. 553 40. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 554 2016;91:115-34. 555 41. Hardy JE, Hilmer SN. Deprescribing in the Last Year of Life. Journal of Pharmacy Practice and 556 Research. 2015;41(2):146-51. 557 42. Page AT, Potter K, Clifford R, Etherton-Beer C. Deprescribing in older people. Maturitas. 558 2016;91:115-34. 559 43. Elliott RA, Marriott JL. Review of Instruments used in Clinical Practice to Assess Patients’ 560 Ability to Manage Medications. Journal of Pharmacy Practice and Research. 2010;40(1):36-41. 561 44. Elliott RA, Marriott JL. Standardised assessment of patients' capacity to manage medications: 562 a systematic review of published instruments. BMC Geriatr. 2009;9:27. 563 45. Tran T, Elliott RA, Taylor SE, Woodward MC. A Self-Administration of Medications Program to 564 Identify and Address Potential Barriers to Adherence in Elderly Patients. The Annals of 565 pharmacotherapy. 2011;45(2):201-6. 566 46. SHPA Committee of Specialty Practice in Rehabilitation and Aged Care. SHPA Guidelines for 567 Self-Administration of Medication in Hospitals and Residential Care Facilities. 2002;32(4).

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568 47. Richardson SJ, Brooks HL, Bramley G, Coleman JJ. Evaluating the effectiveness of self- 569 administration of medication (SAM) schemes in the hospital setting: a systematic review of 570 the literature. PLoS One. 2014;9(12):e113912. 571 48. Pharmaceutical Society of Australia. Guidelines and standards for pharmacists Medication 572 Profiling Service. Pharmaceutical Society of Australia; 2007. 573 49. Cappuzzo KA. Communicating with Seniors and Their Caregivers. The Consultant Pharmacist. 574 2008;23(9):695-709. 575 50. Elliott R, Perera D, Woodward M, Garrett K, Szysz A, Marriott J. Improving medication safety 576 for subacute aged care patients through innovative, expanded pharmacy assistant (technician) 577 support for clinical pharmacy services. Final report for the Workforce Innovation and Reform: 578 Caring or Older People Program.: Health Workforce Australia; 2011. 579 51. Elliott RA, Perera D, Mouchaileh N, Antoni R, Woodward M, Tran T, et al. Impact of an 580 expanded ward pharmacy technician role on service-delivery and workforce outcomes in a 581 subacute aged care service. Journal of Pharmacy Practice and Research. 2014;44(3):95-104. 582 52. National Institute for Health and Care Excellence (NICE). Medicines management in care 583 homes. 2015. 584 53. Position Statement No. 15 Discharge Planning 2008 [press release]. 2008. 585 54. Beuscart JB, Dalleur O, Boland B, Thevelin S, Knol W, Cullinan S, et al. Development of a core 586 outcome set for medication review in older patients with multimorbidity and polypharmacy: a 587 study protocol. Clin Interv Aging. 2017;12:1379-89. 588 55. Beuscart JB, Pont LG, Thevelin S, Boland B, Dalleur O, Rutjes AWS, et al. A systematic review of 589 the outcomes reported in trials of medication review in older patients: the need for a core 590 outcome set. Br J Clin Pharmacol. 2017;83(5):942-52. 591 56. Millar AN, Daffu-O'Reilly A, Hughes CM, Alldred DP, Barton G, Bond CM, et al. Development of 592 a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in 593 care homes. Trials. 2017;18(1):175. 594 57. Rankin A, Cadogan CA, In Ryan C, Clyne B, Smith SM, Hughes CM. Core Outcome Set for Trials 595 Aimed at Improving the Appropriateness of Polypharmacy in Older People in Primary Care. J 596 Am Geriatr Soc. 2018;66(6):1206-12. 597

598

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Appendices

Appendix 1. Resources for geriatric medicine pharmacy practice

Recommended texts • Australian Medicines Handbook Aged Care Companion

Discretionary texts • ABC of Geriatric Medicine. Cooper N, Mulley G, Forrest K, eds. BMJ Books, Blackwell Publishing Ltd 2009 (basic introductory text) • Essentials of clinical geriatrics. 7th ed. Kane RL, Ouslander JG, Abrass IB, Resnick B. McGraw- Hill, 2013 (intermediate text) • Current diagnosis and treatment: geriatrics. 2nd ed. Williams BA, Chang A, Ahalt C, et al, eds. McGraw-Hill Lange, 2014 (intermediate text) • Brocklehurst's textbook of geriatric medicine and gerontology. 8th ed. Fillit HM, Rockwood K, Young JB, eds. Elsevier Science; ScienceDirect 2016 (comprehensive text)

Guidelines and standards • Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in medication management. Canberra: Commonwealth of Australia; 2005 • Australian Pharmaceutical Advisory Council. Guiding principles for medication management in the community. Canberra: Commonwealth of Australia; 2006 • Department of Health and Ageing. Guiding principles for medication management in residential aged care facilities. Canberra: Commonwealth of Australia; 2012 • Guidelines for pharmacists providing Residential Medication Management Review (RMMR) and Quality Use of Medicines (QUM) services. Pharmaceutical Society of Australia 2011. • Guidelines for pharmacists providing Home Medicines Review (HMR) services. Pharmaceutical Society of Australia 2011 • Guidelines for pharmacists providing dose administration aids (DAA) services. Pharmaceutical Society of Australia 2017 • Quality standards and practice principles for senior care pharmacists. American Society of Consultant Pharmacists 2016

Indicator sets for identifying potentially appropriate prescribing for older people • Beers criteria 2015

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• STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria • STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation • Polypharmacy Guidance, Realistic Prescribing. Scottish Government Polypharmacy Model of Care Group. https://www.therapeutics.scot.nhs.uk/wp- content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf

Geriatric medicine journals • Age and Ageing • Australasian Journal on Ageing • Drugs and Aging • JAGS: Journal of the American Geriatrics Society • Geriatric Therapeutics Review section in JPPR

Useful websites American Geriatrics Society (AGS) http://www.americangeriatrics.org

• Guidelines and recommendations

Australian and New Zealand Society for http://www.anzsgeriatric medicine.org/ Geriatric Medicine (ANZSGM)

• Position statements

British Geriatrics Society (BGS) http://www.bgs.org.uk

• Good practice guides, clinical guidelines

Coalition for Quality in Geriatric https://www.facs.org/quality-programs/geriatric-coalition Surgery

• Guidelines for pre- and peri- operative care

American Society of Consultant https://www.ascp.com/articles/geriatric- Pharmacy (ASCP) pharmacotherapy

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• Key geriatric pharmacy references and Geriatric curriculum guide

The ultimate guide for pharmacists https://www.rpharms.com/resources/ultimate-guides- working in care homes. Royal and-hubs/ultimate-guide-to-working-in-care-homes Pharmaceutical Society (UK) 2016 Polypharmacy Guidance (NHS http://www.polypharmacy.scot.nhs.uk/ Scotland) Deprescribing.org https://deprescribing.org/

• Guidelines and algorithms for deprescribing

Geriatric medicine podcasts MDTea GeriPal

SHPA Contact Details

Address for Correspondence The Society of Hospital Pharmacists of Australia PO Box 1774 Collingwood, Victoria 3066, Australia. Email: [email protected]

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