Pharmacists May Be First to Recognize Deterioration

Mrs jones has been coming to the pharmacy for decades, but lately, she has not been her typical organized, perky self.

Pharmacy staff members making calls to confirm routine medications have noted weeks of unused medications. Her weekly stops to the pharmacy have been replaced by more frequent requests for delivery. Since the death of her husband last year, her usual diligence in managing her affairs has shifted to increased confusion about her checkbook and medications. The pharmacy’s delivery driver has mentioned that Mrs. Jones takes much longer to answer the phone or come to the door.

Precious to each of us is our ability to think. A wonderful life is often a function of memories accumulated over time. Childhood, children, education, family, friends, neighbors, parents, and profession weave a miraculous and unique human experience. Memory, the ability to form and retain memories, is critical to the human experience, and nothing frightens us more than losing this critical part of being human.¹

Dementia is the deterioration in cognitive function beyond what might be expected from normal aging. The total number of individuals globally with dementia is projected to reach 82 million in 2030 and 152 million in 2050. Dementia is 1 of the major causes of dependency and disability among older people worldwide. It can be terrifying and tragically overwhelming, not only for the people who have it, but also for their caregivers and families.²

ASSESS AND ASSIST

Pharmacists are perfectly positioned to assess and assist patients with functional health and, thus, cognitive health. Frequent and long-established therapeutic relationships are common in community pharmacies. It is reported that pharmacists see patients between 1.5 to 10 times more frequently than primary care physicians do.³ It is during these seemingly benign interactions that pharmacists observe patients’ “normal.” Pharmacists routinely make note of emotional states, family and social history, health conditions and challenges, and personality—really getting to know patients. These dynamics and relationships allow pharmacists to often be the first health care profes- sionals to observe changes in patients’ cognition and health, such as the ones Mrs Jones is experiencing.

Formal assessments of cognitive function are strikingly low. Adults are often reluctant to discuss cognitive changes with health care professionals, which can lead to poorer prognosis at the time of diagnosis.⁴ Early detection and intervention are greatly improved with the addition and support of pharmacist-led cognitive evaluations. Cognitive assessments⁵ may range from a series of question-based interactions (such as Abbreviated Mental Test scores, Mini-Cog, and Mini-Mental State Examination) and sensory testing for hearing and smell, to a newer laptop-like device that uses FDA-cleared technology to assess cognitive function (Cognivue Thrive) and is sensitive enough to objectively detect cognitive decline before dementia.^6,7 The community pharmacy setting may prove optimal for this computer-assisted technology, resulting in increases in screening, early detection, and intervention.

Cognitive health is the ability to clearly learn, remember, and think. Executive function, memory, and visuospatial orientation make up 3 cognitive domains under the broader category of cognitive health. The course of dementia should be viewed as a continuum across life that begins with healthy cognitive functioning. Cognitive health is an important correlate to brain health and is representative of brain organ function. The function of the brain is directly related to foundational physical health and function of the body.

We live in a culture that reliably produces disease. Six of 10 Americans live with 1 chronic disease, 4 of 10 live with 2 or more chronic diseases, with the beginnings of these conditions occurring decades before diagnosis.^8,9 These pathologies, which are functional challenges, do not bode well for brain health. As physiologic changes occur in the body and subsequently the brain, functional changes occur that are presymptomatic but can eventually result in mild cognitive impairment. This is when changes in function or memory may become noticeable to friends, loved ones, or even pharmacy staff members.⁴

As is often the case with many chronic health conditions, cognitive decline is frequently affected by many contributing factors. Imagine a roof with 36 holes. This is how groundbreaking researcher Dale Bredesen, MD, speaks of the contributing factors to decreasing cognitive health. Bredesen searched for 20 years for a single contributor to cure Alzheimer disease, and his discoveries successfully led to a multifactorial, integrative lifestyle approach addressing many of these “holes.”¹⁰ Bredesen’s research is part of a growing body of evidence regarding modifiable risk factors contributing to cognitive decline and dementia.¹¹

WHY PATIENTS NEED A CHEMISTRY EXPERT

Pharmacists are uniquely trained in understanding the chemistry of the human body. It is with this functional, mechanistic approach that they are optimally suited to assist patients with affecting these modifiable risk factors (see table). Critical to cognitive health is optimal body chemistry.¹² Food is the chemistry of life. Nutrients (such as curcumin), flavonoids, iron, omega-3 fats, selenium, zinc, and vitamins, B, C, D, and E have been shown to influence cognition by acting on cellular processes that are vital for cognitive function. Optimizing dietary nutrient intake is a critical strategy for enhancing cognitive abilities, protecting the brain from damage, and promoting repair.¹³ Deficiencies in these chemistries from either a nutrient-poor or toxic diet—the standard American diet—or secondary to drug-induced nutrient deficiencies contribute to the progression of chronic health conditions as well as cognitive decline.⁸

In addition to lifestyle and nutritional optimization, the pharmacist’s role in drug therapy optimization is essential. Business trends in health care, such as business- and profit-driven health care, mail order, and understaffing, have patients consuming more “chemistry” than ever, often without the therapeutic counsel and support of a chemistry expert: a pharmacist. Critical to optimal patient outcomes is the integration of the pharmacist expertise in the pro-vision and management of patient care. In the D-PRESCRIBE trial, pharmacists’ education of patients and physicians about the harms of 4 drug classes resulted in a significant reduction of inappropriate medications. Minimizing the negative impact of pharmaceuticals and polypharmacy is greatly enhanced when pharmacists are fully empowered and used to doing so, and this is critical to optimal cognitive function.¹⁴

COMMUNITY PHARMACY: WHERE CARE IS STANDARD

To provide a future of health for the next generations and reverse negative health trends, the delay and prevention of disease is imper- ative. The community pharmacist of the future must lead patients in disease prevention. This will require a paradigm shift, from assisting patients with the management of their disease to assisting them with the management and preservation of their health. In addition to clinical assessments, such as blood glucose, body composition, cognitive, and nutrient, pharmacy-based initiatives may include health coaching and strategy, cooking, nutrition education, prenatal health, and stress and weight management. These represent just a few of the lifestyle areas needed to support patients’ health and represent new revenue opportunities for the profession. The community pharmacy is perfectly positioned to implement much-needed clinical lifestyle support and to be where people go to stay healthy.

Often unrecognized and undervalued by modern medicine is the functional impact of human connection and care on health. The hug, the overt expression of human concern, and the smile are “uncodable” actions that have a profound positive effect on well-being. Social isolation significantly increases a persons’ risk of premature death from all causes and was associated with a remarkable 50% increased risk of dementia.⁸ The routine dispens- ing of care by a pharmacist and pharmacy team often may be a patient’s only human connection. For Mrs Jones, the death of her husband likely precipitated changes in her diet and sleep routine, as well as feelings of extreme sadness and, thus, profound challenges to her physiology.

Providing patients with support in optimizing modifiable risk factors, such as activity, drug therapy, nutrition, and stress—as well as dispensing consistent and large doses of care and love—greatly affects the progression of chronic disease and cognitive decline. The availability and impact of pharmacist care on patient outcomes must not be marginalized but should be celebrated, incentivized, and supported.®

References

• Weizhou T, Kanneley K, Friedman DB, et al. Concern about developing Alzheimer’s disease or dementia and intention to be screened: an analysis of national survey data. Arch Gerontol Geriatr. 2017;71:43‐49. doi:10.1016/j.archger.2017.02.013
• World Health Organization. Dementia. September 18, 2019. Accessed August 31, 2020. https://www.who.int/news-room/fact-sheets/detail/dementia
• Tsuyuki RT, Beahm NP, Okada H, Al Hamarneh YN. Pharmacists as accessible primary health care providers: review of the evidence. Can Pharm J (Ott). 2018;151(1):4‐5. doi:10.1177/1715163517745517
• Healthy Brain Initiative. CDC. Updated May 1, 2020. Accessed August 31, 2020. https://www.cdc.gov/aging/healthybrain/index.htm
• Sheehan B. Assessment scales in dementia. Ther Adv Neurol Disord. 2012;5(6):349‐358. doi:10.1177/1756285612455733
• Cahn-Hidalgo D, Estes PW, Benabou R. Validity, reliability, and psychometric properties of a computerized, cognitive assessment test (Cognivue ^®). World J Psychiatry. 2020;10(1):1‐11. doi:10.5498/wjp.v10.i1.1
• Cognivue. Cognivue. Accessed August 31, 2020. https://www.cognivue.com
• What is dementia? CDC. Updated April 5, 2019. Accessed August 31, 2020. https://www.cdc.gov/aging/dementia/index.html
• Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet. 2012;379(9833):2279-2290. doi:10.1016/S0140-6736(12)602830-9
• Bredesen DE. Reversal of cognitive decline: a novel therapeutic program. Aging (Albany NY).2014;6(9):707‐717. doi:10.18632/aging.100690
• Baumgart M, Snyder HM, Carrillo MC, Fazio S, Kim H, Johns H. Summary of the evidence on modifiable risk factors for cognitive decline and dementia: a population-based perspective. Alzheimers Dement. 2015;11(6):718-726. doi:10.1016/j.jalz.2015.05.016
• Risk factors for dementia. Alzheimer’s Society. April 2016. Accessed August 31, 2020. https://www.alzheimers.org.uk/sites/default/files/pdf/factsheet_risk_factors_for_dementia.pdf
• Gómez-Pinilla F. Brain foods: the effect of nutrients on brain function. Nat Rev Neurosci. 2008;9(7):568‐578. doi:10.1038/nrn2421
• Martin P. Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial. JAMA. 2018;320(18):1889-1898. doi:10.1001/jama.2018.16131