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CHAPTER AIMS
The aims of this chapter are to:
Discuss the roles of a systematic patient care process, clinical reasoning, and critical thinking in assessing and resolving medication-related problems as part of a collaborative effort to provide patient-centered care in hypertension management in an older adult.
Illustrate common medication-related problems encountered in older adults using clinical reasoning and critical thinking techniques through utilization of the Pharmacists’ Patient Care Process.
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KEY WORDS
• Older adults • hypertension • polypharmacy • prescribing cascade • clinical reasoning • clinical problem solving • medication-related problems
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Pharmacy practice in cardiology provides opportunity for managing chronic disease states such as hypertension, hyperlipidemia, anticoagulation, and heart failure (HF). Pharmacists working in a clinic to manage cardiovascular disease states often focus on patient education, appropriate medication selection, and patient safety.
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Cardiovascular disease is the leading cause of death in the United States.1 The American Heart Association reports that between 2015 and 2018, over 75% of adults, 60 to 79 years, had cardiovascular disease (defined as presence of hypertension, coronary heart disease, HF, or stroke).2 Hypertension is common among older adults, afflicting more than half of US adults.3 The incidence of hypertension increases with age, with a large percentage of older people having uncontrolled blood pressure.4 With recent clinical guidelines on the management of high blood pressure recommending more stringent goals for older adults, healthcare providers are frequently faced with patients who have blood pressure readings that remain above goal despite being on multiple antihypertensive agents.5 Older adults often pose a challenge to treat, with several potential barriers to care, including multiple comorbidities, heterogeneity in function, medication intolerances, polypharmacy, and lack of understanding regarding the importance of blood pressure-lowering.6 The pharmacist can serve as part of an interprofessional team to help address these barriers to improve treatment of cardiovascular disease states in older adults.
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KEY POINT
Managing the pharmacotherapy of older adults is challenging as these patients often suffer from several comorbidities, which lead to use of multiple medications and increase the risk of side effects, drug interactions, and nonadherence.
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OUR PRACTICE—AN OUTPATIENT PHARMACIST-RUN CARDIOVASCULAR RISK REDUCTION CLINIC
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Our practice is an outpatient pharmacist-run clinic working under a collaborative practice agreement with a private cardiology practice, where pharmacists provide medication management services for blood pressure (hypertension and hypotension), HF, hyperlipidemia, smoking cessation, and polypharmacy (medication review). Pharmacists receive referrals from cardiologists and are asked to manage specific disease states through patient education, medication therapy management, monitoring, and follow-up. The pharmacists have prescribing authority, which can include medication initiation, discontinuation, and/or dose titration. Two of our three clinic locations are in retirement communities in the Phoenix Metropolitan area; therefore, most patients are over 65 years of age. This practice is staffed ...