Pedoman Konseling pada Pasien

GERIATRI
By
Hari Ronaldo Tanjung
 Pasien geriatri merupakan tantangan
tersendiri bagi konseling farmasis-regimen
pengobatan yg kompleks, keterbatasan fisik,
penurunan fungsi kognitif, isu2 ekonomi,
kepatuhan, dan sikap thd penyakit dan
pengobatan membutuhkan proses konseling
dng peran serta aktif pasien/ keluarga pasien.
 Definitions
Counseling: Konseling pasien melibatkan
interaksi one-to-one antara farmasi dan
pasien/caregiver.
Berinteraksi secara alami.
Semestinya jg termasuk penilaian apakah
informasi yg dimaksud telah diterima pasien
dng baik dan pasien mengerti bagaiamana
menggunakan informasi tsb utk meningkatkan
kemungkinan hasil terapi yg positif.
 Knowledge and skills
Farmasis harus memiliki pengetahuan dan
keterampilan berikut untuk dapat melaksankan
konseling dng efektif kpd pasien geriatri:
A. Pengetahuan terkini ttg geriatric
pharmacotherapy dan aging.
B. Pengetahuan terkait budaya pasien dan sikap
pasien thd kesehatan dan penyakit.
C. Kesadaran thd penurunan fungsi sensory/kognitif
pasien.
 Pharmacist and patient roles
Jelaskan pada pasien bhw farmasis memiliki
fungsi yg sesuai dan penting dlam
memberikan edukasi dan konseling. Pasien
harus dirangsang agar menjadi pasien yg aktif.
 Pharmacist's role:
A. Verifikasi bhw pasien memiliki pemahaman,
pengetahuan dan keterampilan dalam mengikuti
regimen farmakoterapi dan rencana monitoring.
Termasuk juga informasi penyakit.
B. Carilah jalan utk memotivasi pasien agar pasien belajar
ttg pengobatannya dan menjadi rekan aktif dlm
perawatan.
C. Berkolaborasi dengan tenaga kesehatan lain untuk
menentukan informasi spesifik dan konseling yg
dibutuhkan bagi tiap individu pasien.
 Patient's/Caregiver's role:
A. Patuh thd regimen farmakoterapi.
B. Monitor efek medikasi.
C. Melaporkan hal yg dialami kpd farmasis atau
tenaga kesehatan lain.
D. Mencari informasi dan memberi perhatian
thd hal2 yg dpt mempengaruhi kepatuhan.
 Tahapan Konseling
A. Tahapan dlm edukasi pasien dan proses
konseling dapat bervariasi tgt kebutuhan
individual, lingkungan dan kondisi praktis.
B. Bangunlan sebuah hubungan yg memaksimalkan
komunikasi efektif dengan cara menunjukkan
ketertarikan thd pasien.
C. Panggilan pasien dengan nama yg diinginkannya.
D. Perkenalkan diri anda sbg farmasis, jelaskan
tujuan dan perkiraan waktu yg dibutuhkan, dan
peroleh persetujuan pasien utk berpartisipasi.
D. Kenali penghalang bagi pasien utk
berkomunikasi.
F. Nilai pengetahuan pasien ttg masalah
kesehatan dan medikasi, kapabilitas fisik n
mental utk menggunakan obat secara sesuai,
serta sikap thd masalah kesehatan dan
meedikasi.
 F cont..
1. Tanyakan open-ended questions ttg setiap tujuan
pengobatan dan apa yg pasien harapkan.
2. Minta pasien utk menjelaskan bgmn dia telah
menggunakan pengobatan mereka. Tanyakan apakah
ada masalah, perhatian atau ketakpedulian yg mereka
alami dng pengobatan mereka. Evaluasi scr rutin.
3. Jika pasien mengalami masalah, dapatkan data dan
nilaialh masalahnya. Kmdn sesuaikan regimen
farmakoterapetik sesuai protokol atau hub dokter.
G. Berikan informasi scr oral dan gunakan alat
bantu utk mengisi gap dlm pengetahuan dan
pemahaman pasien. Tunjukkan pd pasien ttg
warna, ukuran, bentuk, dan tanda2 pd sediaan
tablet. Utk sediaan cairan dan injeksi,
tunjukkan pasien tanda2 batas dosis yg tertera
pada alat.
 Demonstrasikan cara merakit dan
menggunakan alat2 bantu spt alat semprot
hidung/mulut. Sebagai tambahan, sertakan
handouts/ brosur supaya membantu pasien
dlm mengingat kembali informasi.
 Gunakan active listening skills, good eye
contact, and gestures yg sesuai. Tunjukkan
gejala nonverbal spt bahasa tubuh, ekspresi
wajah, sbg reaksi. Berikan dukungan,
semangat dan umpan balik.
 Special considerations in
communicating with the elderly
1. Focus on abilities, rather than disabilities.
2. Assess individually and reassess often.
3. Use family or caregiver as a resource when
the person is unable to give information.
 Consider environment.
Education and counseling are most effective when
conducted in a room or space that ensures privacy and
opportunity to engage in confidential communication.
Patients, including those who are disabled, should have
easy access and seating. Space and seating should be
adequate for family members or caregivers.
The design and placement of desks and counters or
beds and wheelchairs should minimize barriers to
communication.
 Distractions and interruptions should be few, so
that patients and pharmacists can have each
other's undivided attention.
For example, in the home or institutional setting
a loud radio or television may interfere with the
counseling process.
The environment should be equipped with
appropriate learning aids, e.g., graphics,
anatomical models, medication administration
devices, memory aids, written material, and
audiovisual resources.
4. Be aware of the potential for interference in
communication abilities due to emotion, anxiety,
anticipation, fatigue or pain.
5. Adjust the pace, and allow adequate time for response.
6. Employ a variety of communication media, as appropriate
(e.g., signs, pictures or other aids).
7. Assess comprehension. Restate the patient's statements to
ensure comprehension.
8. Adapt goals to what the patient can comprehend. Be
simple, but respectful, and reinforce with non-verbal cues.
9. Return when the patient is more receptive if there is a lack
of response or co-operation,.
10. Give simple, relevant information.
 Consider "alternative" approaches
based on special needs.
Aphasic
Facilitate communication with the aphasic
patient by using writing pads, signs, signals,
pictures, and gestures.
Hearing Impaired:
Eliminate as much background noise as possible.
Determine if the patient wears a hearing aid and that it is present
and functioning.
Augment oral communication with other methods, e.g., writing,
pictures, signs, and gestures.
Face the person directly to achieve eye contact and enable lip
reading.
Do not cover your mouth or turn away when speaking.
Speak slowly and clearly without exaggeration or shouting.
Evaluate understanding frequently and rephrase if necessary.
Focus on the main subject without unnecessary detail
Visually Impaired:
Determine if patient wears glasses, contacts or other visual
correction device.
Position what needs attention so that it is in the center of the visual
field.
For printed communi cation, use black printing on white or off-
white paper and larger font sizes.
Be creative about methods of communicating, including talking
books, radio and tapes.
Speak as you approach the person so that he/she knows you are
there. Introduce yourself and use touch, if the person does not
object.
Sit at the same level, and face them during the conversation. Give
clues to relevant aspects that they may not be able to see.
Cognitive impairment:
Gain the patient's attention.
Address one topic at a time.
Give simple, relevant information.
Allow the patient to feel in control. Manner, tone of
voice, and body language can convey power and
authority.
Use a calm matter of fact approach, with clear and
distinct verbal communication.
Adapt to disease related language and memory
deficits.
 Content
The pharmacist's responsibility is to ensure
that the patient understands the intended use
of their medications, the goals of therapy, and
safety concerns and convenience of use.
The following points are applicable to both
prescription and nonprescription medications.
Pharmacists should counsel patients in the
proper selection of nonprescription
medications.
 The medications trade name, generic name,
common synonym, or other descriptive name(s)
and, when appropriate, its therapeutic class and
efficacy.
The medications use and expected benefits and
action. This may include whether the medication
is intended to cure a disease, eliminate or reduce
symptoms, arrest or slow the disease process, or
prevent the disease or a symptom.
The medication's expected onset of action and
what to do if the action does not occur.
 The medication's route, dosage form, dosage,
and administration schedule (including
duration of therapy).
Directions for preparing and using or
administering the medication. This may
include adaptations to fit patients' lifestyles or
work environments.
Action to be taken in case of a missed dose.
 Precautions to be observed during the
medication's use or administration and the
medication's potential risks in relation to
benefits. For injectable medications and
administration devices, concerns about latex
allergy may be discussed.
Potential common and severe adverse effects
that may occur, actions to prevent or minimize
their occurrence, and actions to take if they
occur, including notifying the prescriber,
pharmacist, or other health care provider.
 Techniques for self-monitoring of pharmacotherapy.
Potential medication-medication (including
nonprescription), medication-food, and medication-
disease interactions or contraindications.
The medication's relationships to radiologic and
laboratory procedures (e.g., timing of doses and
potential interferences with interpretation of results).
Prescription refill authorizations and the process for
obtaining refills.
 Instructions for 24-hour access to a
pharmacist.
Proper storage of the medication.
Proper disposal of contaminated or
discontinued medications and used
administration devices.
Any other information unique to an individual
patient or medication.
 Additional content may be appropriate when
pharmacists have authorized responsibilities
in collaborative disease management for
specified categories of patients. Depending on
the patient's disease management or clinical
care plan, the following may be covered:
 The disease: whether it is acute or chronic and
its prevention, transmission, progression, and
recurrence.
Expected effects of the disease on the
patient's normal daily living.
Recognition and monitoring of disease
complications.
 Documentation
Pharmacists should document education and
counseling in patients' permanent medical
records as consistent with the patients' care
plans and applicable policies and procedures,
and state and federal laws.
 Biggest errors made in prescribing
for elderly people
Polypharmacy - a drug for every complaint and elderly
people have lots of aches and pains, circulation and
breathing difficulties etc
Side effects are missed because they are misinterpreted as
part of getting old - particularly senility - hearing loss etc
Elderly people often see a different doctor every time and
the next doctor does not realize that the patient was
clever and active a week ago.
Physicians often assume that the patient is ill because
they are not taking their medications when in fact they are
taking them and the amount prescribed for them too
much.
 Reasons why elderly have compliance
problems for taking medications

opening pill containers(weak/arthritis pain/tremors/spills)

fear of choking while swallowing large pills
reading the labels and information
depression - sleepy - poor concept of time for doses
cognitive impairment - cant recall a few moments ago
cost of medications are prohibitive -- food vs. medications
adverse drug reactions limit benefit of medications
Bottom line - youre never sure whether they are taking too
much or too little.

Elderly are more likely to tell their PT than their doctor whether they are taking their
medications or not because they are too polite to tell a doctor that his pills make
them feel sicker. You are in a position to make a difference!!
 Medication problems that affect the
physical therapists work
Deafness - problem communicating
visual acuity - problem seeing demonstration
drowsiness &/or mental status - remembering instructions
balance, fainting, strength, Beta2 agonist
relax bronchioles
cardiovascular strength albuterol

respiratory ability-oxygenation -ability to use inhalers?

abdominal discomfort
joint pain, range of motion
bruising
skin rashes - skin thinning, cracking, bleeding
 Dizziness, Fainting and Weakness
Inner ear disturbances, nauseants, low blood pressure, anemia and
hypoxia, electrolyte imbalances like hypokalemia, dehydration.
Antihypertensive medications - beta blockers, Ca channel blockers,
diuretics, ACE inhibitors, nitrates, clonidine, alpha blockers -
orthostatic hypotension - side effect is an extension of the desired
blood pressure lowering.
Antianginal therapy - nitrates, beta blockers, Ca channel blockers
Certain antiarrythmic drugs - bretylium, amiodarone
Drugs that cause anemia - NSAIDs can cause bleeding of the GI tract
which can lead to severe anemia
Cytotoxic agents used to treat cancers or arthritis or autoimmune
diseases like lupus erythematosis, and to prevent transplant rejection
also inhibit the bone marrow from making red blood cells
methotrexate
cyclophosphamide
azathioprine
cyclosporine
Drugs that cause drowsiness and
loss of mental accuity
antihistamines (some are used as sleep
aids)
Pain medications
muscle relaxants
antinauseants
some beta blockers - like propranolol
drugs that cause insomnia - prevent a good night sleep
(caffeine, aminophylline, albuterol) - eventually cause
daytime drowsiness. Low concentration of antidepressant
are sleep aids, amitryptiline in patients with Parkinsons
while higher concentrations for depression can cause
insomnia.
 Abdominal discomfort
Constipation, inability to void the bladder
completely, stomach and gastric ulcers, inflamed
bowel disease.
drugs that cause these problems are:
pain medications containing narcotics - inhibit GI motility
antimuscarinic agents - inhibit motility - slow transit through GI tract.
antihistamines have antimuscarinic side effects
NSAIDs - inhibit prostaglandin synthesis in the gut leads to ulcers
cytotoxic agents for chemotherapy - epithelial cells lining the GI
tract slough off
antibiotics disturb the normal flora and allow pathogenic bacteria
to grow - causes diarrhea and flatulence - solved by taking antibiotics with
 Drug induced muscle wasting
catabolism, anorexia, cachexia
Glucocorticoid steroids used as antiinflammatory agents - body burns glucose and
protein (in muscle) but not fat - causes muscle wasting - fat body & thin limbs
Beta2 agonists - increase blood flow to muscles but high doses cause tremor and low K.
beta blockers - intermittent claudication - pain in muscles causing limping - 4 to 7 % of
patients have this effect
digoxin - hypokalemia = low K - causes muscle and cardiac weakness
diuretics - low K - should receive K supplement or change to K sparing diuretics -
spironolactone - old people call these water pills.
Angiotensin Converting Enzyme inhibitors = ACE inhibitors (captopril, enalopril) lower
blood pressure but can also cause rhabdomyolosis
Bromocriptine - Parkinsons patients - dopamine stimulates the chemoreceptor trigger
zone in the brain - anorexia
Methylphenidate - stimulant to treat narcolepsy or attention deficit disorder -
amphetamine like - similar to agents used in diet pills to suppress appetite.
Chemotherapy - cytotoxic agents cause extreme nausea
Cachexia - increased tumor necrosis factor alpha causes the body to become insensitive
to insulin - starvation in the midst of plenty.
Muscle wasting is more likely due to disease rather than drug induced lack of appetite.
 Joint pain, range of motion
30 drugs are listed to cause this - but most are low incidence
injections of microcrystalline steroids into joints = relieves pain,
lasts for a month, shorter relief each time because more rapid
destruction of the joint - greater pain after effect wears off.
Beta blockers betaxolol pindolol - 7 to 10% experience myalgia
Cholesterol lowering agents - fenofibrate -rhabdomyolosis
clozapine - used for abnormal movement disorders and
aggressive behaviors - neuroleptic
danazol - androgenic steroid
droloxifene - nonsteroidal antiestrogen
rifampin - used to treat tuberculosis - first week of therapy
losartan valsartan- to lower blood pressure, uncommon side effect.
Ca channel blockers - uncommon
 Analgesics - nonsteroidal
antiinflammatory drugs = NSAIDs
Old arthritic people take more of these but they are also
prone to stomach/intestinal ulceration due to cycloxygenase
inhibition of the synthesis of protective prostaglandins in the
gastric mucosa.
chronic slow blood loss causes anemia
look for very pale weak patient
can be sudden onset - severe hemorrhage
platelet activity is slowed by NSAIDS
patients taking these meds should be asked if they have
abdominal discomfort before starting activity
activity increases blood pressure - may precipitate a bleed
longer term use of high dose NSAIDs can cause kidney
damage and loss of erythropoeitin made by the kidney which
is a hormone that stimulates red cell production and without
it there is anemia.
 Bruising - hematomas
Vit K is important for making clotting factors - malnutrition causes
bruising -lack of green leafy vegetables in diet containing Vit K
Anticoagulant dose too high (warfarin-coumadin competes with Vit K)
NSAIDs - inhibit platelets - causes longer bleeding times
antibiotics killed bacteria in the gut that make Vit K
Steroid use - Cushing syndrome - weakens blood vessels
drugs causing dizziness - orthostatic hypotension cause falls
diuretics (dehydration)
blood pressure lowering medications
Ineffective Parkinsons treatment - excessive falling
cancer chemotherapy - reduces platelets for clotting and makes a
person weak enough to fall more frequently.
Intramuscular injections - for people on anticoagulants
Elder abuse
*Muscle Relaxants - many mechanisms - not well understood - all of them cause drowsiness as
a side effect
GABAB agonist = BACLOFEN, less drowsiness than benzodiazepines!
GABAA agonists = Benzodiazepines DIAZEPAM -CLOTIAZEPAM - PINAZEPAM
QUAZEPAM TETRAZEPAM
GABA and glycinergic receptors agonist THIOCOLCHICOSIDE
Spinal reflex blockers, MEPROBAMATE CARISOPRODOL - CHLORPHENESIN -
METHOCARBAMOL, CHLORZOXAZONE,-CYCLOBENZAPRINE TOLPERISONE
METAXALONE -

Imidazo receptor blocker and alpha2 receptor blocker CLONIDINE, TIZANIDINE

- also used to lower blood pressure, ease drug addiction withdrawal - for
smoking and alcohol cessation.
Blocker of Ca release from Sarcoplasmic Reticulum in muscles DANTROLENE
Neuromuscular Cholinergic receptor blockade = Curoniums ALCURONIUM ATRACURIUM
- CISATRACURIUM - DOXACURIUM, ETIZOLAM, KETAZOLAM MIVACURIUM,- PANCURONIUM, PIPECURONIUM,
RAPACURONIUM, ROCURONIUM - TUBOCURARINE VECURONIUM - used mainly to produce muscle
paralysis in surgery
Acetylcholine agonist depolarizing blockers SUCCINYLCHOLINE used in surgery
 Drug induced ototoxicity (deafness)
at plasma levels above therapeutic level
Aminoglycoside antibiotics cause
irreversible deafness - like gentamicin,
tobramycin, amikacin
antidepressants
loop diuretics - furosemide (lasix)
erythromycin azithromycin
NSAIDs and salicylates [aspirin causes
tinnutis - ringing of the ears but
acetominophen does not] - this type of
hearing loss is reversible
quinine - tinnutis
vancomycin
 Drug Induced oculotoxicity (vision impairment)
Allopurinol - used to treat gout - can cause cataracts
amatadine - antiparkinsons antiviral - corneal opacities
amiodarone - antiarrythmic corneal microdeposits -reversible
- 10% of patients - high incidence of hypothyroidism too!
anticholinergics - ipratropium atrovent blurred vision and glaucoma
antidepressants - anticholinergic side effects
antihistamines - anticholinergic side effects
anticonvulsants - diplopia (double vision), nystagmus
-adenergic blocker - reduced tears
bromocriptine - myopia blurred vision
corticosteroids - glaucoma cataracts
digoxin - colored halos - sign of toxicity
methotrexate 25% conjunctivitis
- reduced tears & photophobia
phenothiazines - deposits in lens
tamoxifen - antiestrogens, fine retinal opacities