Care of the elderly - how pharmaceutical care has developed
Geriatrics was first used by Nascher in 1909 as a term to describe the medical specialty care of older people, when European research into ageing began. In the UK, it was Marjorie Warren in 1935 who encouraged the development of this area. She was practicing as a doctor at Isleworth Infirmary in London and was given responsibility for large workhouse wards, caring for hundreds of patients. It was in these wards from 1936, that she began reviewing patients, many of whom were older people, and she initiated a programme of rehabilitation. She encouraged the use of appropriate equipment to promote patient independence and improved the ward environment, for the benefit of patients and staff. She published her work, suggesting that geriatrics should become a medical specialty with specialist units in general hospitals and that medical students should be taught about the care of older people. The British Geriatrics Society was founded in 1947 and the first consultant geriatricians were appointed soon after the inception of the NHS in 1948.
However, the speciality did not develop within the NHS in the way that the government had hoped. Geriatricians were appointed to workhouses and municipal hospitals and this was seen as undesirable by the medical establishment. Doctors at that time assumed that, as before the NHS, their main income would be from private patients, of whom there were none in these hospitals. The government tackled this issue by investing heavily in geriatrics in the 1970s, with good results.1
Developments for older people within pharmacy did not parallel the emergence of geriatrics as a speciality. Pharmacists were recognised for their key role in a hospital team as early as 1771, when the New York Hospital Charter included an apothecary as one of the four salaried essential positions. However, pharmacy involvement with patients subsided in the early twentieth century. There were attempts in the USA to improve formal clinical training for pharmacists in the 1930s but universities did not begin to adapt their courses until the 1960s.2 In the UK, the Linstead report (1955) was written to address the issues of poor recruitment and retention of hospital pharmacy staff, who were badly paid and demotivated at the time. Linstead recommended that pharmacy should be its own speciality, pharmacists should advise on pharmaceutical matters and the service should be unified. However, these recommendations were mostly ignored and the situation remained unchanged until the development of ward pharmacy in the late 1960s. This coincided with the Noel Hall report, which, in 1970, provided a grading structure for pharmacists. The report was published with a white paper, ensuring that the recommended improvements to the hospital pharmacy service were implemented.3
In 1967 Baker published a paper on the development of a pharmaceutical service at Westminster Hospital, London.4 It was clear that pharmacists had lost ward-based with patients. This paper outlined the dangers of supply of medicines from handwritten prescriptions and nursing lists of patient medication requirements. The introduction of the medicine chart as a result of this work was a great improvement for the safety of patients. Technicians were recruited to prepare and distribute drugs while pharmacist effort was redirected to the wards. With the rapidly increasing number of drugs available through the 1960s Baker recognised that prescribing was becoming increasingly complex, increasing the risk of interactions and drug administration errors. Pharmacists were required to check all new treatments, including therapeutic incompatibilities and to provide information to nursing and medical staff regarding drug treatment. This marked a change in the way hospital pharmacists worked and laid the foundation for today’s clinical pharmacy and medication management services, including those for older people, by promoting greater care and better supervision of prescribing. Pharmacists were increasingly to be found on the wards during the 1970s and involvement with medicine related care of patients became standard practice. Pharmacy services for older people began to develop in the early 1980s once clinical pharmacy services had become established.
Progress in the speciality of geriatrics accelerated in the 1970s. Marjorie Warren’s model of care, known as the traditional model, centred around improving conditions for patients and rehabilitation. Patients requiring long-stay care were referred to geriatric wards by other doctors, rather than being accepted as direct admissions. In Sunderland, another model of care was developed where services for patients were provided on the basis of age in parallel units (age-defined model). In Newcastle upon Tyne, physicians treated both general medical and geriatric patients on the same wards for acute treatment, and rehabilitation facilities were retained separately (integrated model). The key development affecting pharmacy was the emergence of the multidisciplinary work setting, as well as setting functional goals for patients to aid rehabilitation. This work developed alongside the establishment of an academic base for geriatrics, which appeared in most medical schools around the same time. Research from the US supported the type of practical work occurring in the UK, however multidisciplinary units did not fit in with the US funding systems in hospitals.1
In the US, drug information centres were established as early as the 1960s but other specialities took longer to develop. By 1976, psychiatry, pharmacokinetics, paediatrics, parenteral nutrition, adverse drug reactions and cardiopulmonary resuscitation pharmacists were established in various hospitals in the US.2
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Citation: Hospital Pharmacist URI: 10977332
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