Abstract
• Emphasizes the opportunity for community pharmacists to contribute to CGA, especially given their frequent interactions with older adults. • Highlights challenges in using geriatric assessment tools, such as limited referral resources and difficulty in acting on results in primary care settings.
• Community pharmacists could be integrated into geriatric assessment by using simple screening tools, when appropriate • Highlights the importance of tailoring geriatric assessment tools to prioritize both physical and social aspects of aging, and suggests involving patients and caregivers in the process through self-administered screenings to enhance engagement and personalization.What this paper adds
Applications of study findings
Introduction
Comprehensive Geriatric Assessment (CGA)
Community-dwelling older adults, who make up the overwhelming majority of the senior population (65 years plus) in Canada, may not access established teams (Statistics Canada, 2024). Instead, they visit different individual providers for specific issues, concerns, and services. These medical and social care professionals are not typically 1) physically co-located; 2) sharing electronic health record platforms; or 3) necessarily considering themselves members of broader interprofessional team/s. Community CGA is therefore subject to the well-known barriers to effective interprofessional health care in other patient populations, including time constraints, poor communication and role clarity (Wei et al., 2022).
Pharmacists identify, resolve, and prevent drug therapy problems in older adults and inform safe, effective medication prescribing. As such, they have established roles providing inpatient and outpatient geriatric care independently and on teams (Lee et al., 2015). Primary care pharmacists encounter patients in outpatient clinic settings or community pharmacies. Community pharmacists in particular regularly meet older adults in their care due to their high accessibility as a trusted resource for information and drug therapy services (Collier et al., 2023). They also process prescriptions from multiple prescribers caring for the older adult, forming a fuller picture of overall medical needs. Primary care pharmacists are well-positioned to contribute to CGA of community-dwelling older adults, but data on their assessment roles beyond medication management, especially when practicing and seeing the patient independently, is lacking.
This study explored what non-medication aspects of CGA could be performed by primary care pharmacists. Specifically, what assessment tools could primary care pharmacists use to screen older adults and whose findings would then signal the need to consult or refer the older adult to other health professional/s.
Methods
We adopted a modified Delphi panel approach (Chalmers & Armour, 2019) to identify recommended CGA tools. We considered geriatric assessment domains of functional status, mobility, nutrition, cognition, mood, social support, substance use and a miscellaneous category. The relevant assessment tools were selected following a literature review and previous Delphi panel studies for CGA (Puts et al., 2022; Voorend et al., 2021). We excluded tools related to medication assessment as these already fall within pharmacist scope of practice evaluating polypharmacy in older adults. An online survey including full versions of the tools was devised to conduct the consensus process.
Eleven multidisciplinary members with expertise and clinical practice caring for older adults in British Columbia representing dietetics (1), nursing (1), geriatric medicine (2), occupational therapy (1), pharmacy (3), physiotherapy (1), psychology (1), and social work (1), joined three patient partners to form the Delphi expert panel. Using a seven-point linear scale anchored at 1 (“very important”) with decreasing level of importance to 7 (“not important at all”), panel members rated how important they believed each tool was in the care of an older adult. After voting on the tools for each geriatric assessment domain, a text box was embedded where panel members could provide any additional feedback.
The consensus threshold was set a priori to be 75% of panel members voting at any level of positive agreement about the importance of the tool (rating choices 1–3). Mean and standard deviation values were also calculated to augment decision validity (Franc et al., 2023). Tools were discarded between each round (2–3 voting rounds intended) based on consensus scores less than 50% or feedback by the expert panel.
Results
Consensus Levels for Delphi-Rated Items Among Expert Panelists
SD = standard deviation.
The consensus threshold is 75% of panel members voting at any level of positive agreement about the importance of the tool (rating choices 1 very strongly agree, 2 strongly agree, or 3 agree).
aindicates consensus agreement reached.
Panel members offered input explaining their ratings of geriatric assessment tools. The Medical Outcomes Study Social Support Survey (MOS) was the most supported among the expert panel (11, 93%); the variety of personal and specific questions was commended. Other traits of preferred tools included short length with practical questions and nuanced response options. Health professional panel members offered cautionary remarks related to how individuals administering the tool would enact next steps, as the appropriate referrals are not always feasible.
Geriatric assessment tool ratings by patient partners were largely aligned with those of the other expert panel members with few exceptions (Table 2). Narrative feedback highlighted further points by patient partner expert panel members, including use of challenging language and overwhelming formats of certain tools. Patient partners advocated for design allowing for more personalized response options and emphasis on older adults’ desires and preferences.
Discussion
An expert member panel reached consensus on the suitability of certain geriatric assessment tools for primary care pharmacist administration. However, members additionally raised pragmatic issues with their use, notably, how the pharmacist would act on its results. In a given community setting, resources available to the older adult and family/care givers for geriatric support referral may be limited.
These findings underscore the challenges of contributing to CGA as an individual health professional in outpatient practice. Factors undermining CGA include required time and labor, communication barriers between health professionals, poor acceptance of preventative work, and lack of local specialty geriatric support (Sum et al., 2022). Such drawbacks have been principally outlined for physicians in general family practice, yet community-dwelling adults meet a host of other individual health professionals supporting their wellbeing and care (Ganguli et al., 2024). Ongoing family practice and geriatric physician shortages, compounded by the aging population, necessitate purposeful exploration of how different health professionals can contribute to CGA in primary care settings (Garrard et al., 2020).
Pharmacists serve vital roles in the care of older adults. Medication management is a prominent aspect of geriatric assessment given recent estimates of outpatient specialized geriatric service referral for drug therapy modification as high as 30% (Aggarwal et al., 2023). Medications are implicated in findings of many other geriatric assessment domains. Inappropriate prescribing in older adults is associated with risks of falls, decreased physical functioning, impaired cognition, and malnutrition (Maher et al., 2014; Zanetti et al., 2023). Community pharmacists have multiple touch points with older adults and families from which screening opportunities can be capitalized upon.
Fortunately, certain recommendations made for CGA in office-based family physician practice are applicable to primary care pharmacists (Tatum et al., 2018). Their longitudinal relationship with patients facilitates introducing portions of an overall geriatric assessment over time. Similarly, non-medication assessment may be reserved for certain populations according to age (e.g., >80), living status (e.g., alone), and specific drugs or number of drugs. Opportunities exist to incorporate simple, intentional screening questions before moving to use of a geriatric assessment tool. For example, “Are you afraid of falling?” and “If yes, have you restricted any activities because of this fear?” (Belloni et al., 2020). Finally, primary care pharmacists must become acquainted with community resources and the means and feasibility of patient access if a signal for referral is detected.
The input from patient partner in our expert panel offered valuable insights. Members prioritized short, straightforward tools but lamented question stems and response options emphasizing older adult function over spirit. Study of community-dwelling older adults’ and caregivers’ experience with CGA echo these perspectives as they appreciated attention beyond physical health to include social quality of life and the opportunity to personalize their goals (Bandini et al., 2022; Hayes et al., 2023). Although tool administration may be part of a greater patient-centered encounter, these considerations are especially important given another means to build CGA capacity is for patients or family/caregivers to complete certain screening themselves, and supporting data demonstrates they can do so effectively (Beauchet et al., 2014).
Our Delphi process could have benefited from a larger panel or more tools. However, the diversity of expert perspectives likely limited consensus across multiple rounds. Future research on CGA by independent health professionals could involve professional dyads, where expertise and familiarity with specific geriatric assessment tools are concentrated within one discipline. For example, a dietetics-only panel could evaluate nutrition screening tools suitable for primary care pharmacists.
Conclusion
Our study highlights potential tools community pharmacists might choose to contribute to CGA in primary care settings. While panelists reached consensus on suitable tools, concerns remained about patient access follow up when the results signaled need for referral. We consider how primary care pharmacists might contribute to cga using selected tools, while acknowledging the need for available multidisciplinary services.
Footnotes
ORCID iD
