Geriatric pharmacy expert makes house calls

By Becky Phillips (see video)

“Americans tend to neglect the elderly population,” offers the dark-haired young woman behind the wheel. “I think it’s a cultural thing.”

As a first generation Hmong-American, Dr. Mays Vue grew up respecting the elderly as wise and responsible individuals within her extended family and community.

“They are the roots that hold and support the young so they can grow,” she says. “Sending them off to nursing homes is seen as an insult and abandonment.”

“On the other hand,” she continues, peering through the rainy windshield, “American society generally views old age as something to be feared and despised. The elderly in this country simply become invisible.”

Tsunami warning

That sweep-it-under-the-rug mentality may soon be called on the carpet. By the year 2030, the Centers for Disease Control predicts that the U.S. population aged 65 years or older will swell to nearly 72 million, threatening to overwhelm existing programs, services, and facilities currently in place for supporting the elderly.

Add to that the crumbling of community and social connection in America—with ensuing isolation and loneliness—and it doesn’t take much to foresee a disaster in the making: seventy-two million older adults struggling to get by in single family homes; adapting to declining physical and cognitive abilities while juggling masses of medications.

How do the children, relatives, and friends of the elderly cope? What decisions should be made when one’s parents can no longer effectively care for themselves?

While Americans begin to rethink the idea of multi-generational family housing, the move to keep elders in their own homes for as long as possible has steadily gained momentum.

With the advent of smart home technology, it will soon be possible to compensate for human frailty and memory lapses via automated appliances and environmental controls, as well as sensors that monitor an elder’s activity level—sending alerts to caregivers when abnormal patterns are detected.

Reaching out to the vulnerable

At the opposite end of the spectrum is the interpersonal, hands-on approach directed by Dr. Steve Setter and the Washington State University College of Pharmacy Geriatric Team. As a geriatric pharmacist and associate professor, Dr. Setter consults with community social workers to help home-based elders successfully use their medications and attend to medical and social needs in order to remain in their homes for longer periods of time.

Established in 1994, the interdisciplinary partnership between the College of Pharmacy and Elder Services of Spokane has provided thousands of older people an alternative to routine reliance on nursing homes or other care facilities.

Elder Services is an arm of the non-profit organization Spokane Mental Health and provides clinical case management for at-risk older adults. Among other things, the center offers help and intervention, for example, if a neighbor is concerned about an older person who no longer takes care of himself, doesn’t collect the mail, and wishes he wouldn’t wake up in the morning.

At the fragile intersection when Elder Services first admits a client into the program, Dr. Setter is there to consult with the case manager and study the person’s history in detail—soliciting input from other pharmacists, nurses, physical therapists, as well as a staff neurologist, psychiatrist, endocrinologist, and primary care physician.

Often overmedicated and under-advised, these clients may suffer from a range of medical conditions causing disorientation, depression, and suicide attempts. For others, having just returned from the hospital, the transition to sorting 15 – 30 medications, herbals, and over-the-counter remedies on their own can be overwhelming. Conflicting prescriptions ordered by multiple doctors and filled at various pharmacies can lead to adverse drug reactions. Confused, alone, or in pain, some clients simply stop taking their medicines altogether.

The human touch

Knocking at the door of this dark, sometimes disheveled scenario, Dr. Setter enters the client’s home with a friendly smile and gentle demeanor, patiently answering questions, explaining how each drug works and why it is necessary. To caregivers he describes the dangers of drug interactions and the tell-tale signs of cognitive impairment. In collaboration with the client’s doctors, he may reduce or eliminate certain meds.

Tall and animated, Dr. Setter also devotes time to research on Parkinson’s disease, Alzheimer’s, type 2 diabetes, osteoporosis, and rheumatoid arthritis—and acts as a pharmacy consultant to the Parkinson’s Resource Center of Spokane and the NW Inland Alzheimer’s Association.

“Our average home visit is an hour or more,” says Dr. Setter as our car pulls to a stop by the curb. “We get to know clients on a personal level, so they are more willing to share the problems they are having with their medicines, whether that be the cost of the medicines or a complicated drug regimen that we need to simplify.”

“We can be the eyes and ears at home and report what we find to their health care team,” he explains. “Walking through their home allows us to see how they use their medicines and what their challenges are. We get a better idea of other things that may be occurring—lack of sleep, nutrition, things like cords, throw rugs, and clutter that are contributing to falls.”

Unique in the nation

Dr. Vue, a recent PharmD graduate, is a resident in this one-of-a-kind program. On this gray wet day in late April, I am shadowing Drs. Setter and Vue on their home visit rounds in Spokane. Our first stop is on the South Hill.

Walking up to the door, Dr. Setter continues, “We’ve had people throughout the world come to study our model at Elder Services to see how these case managers work in the community to give folks another option for home-based care.”

Today we are visiting Fred, a retired lawyer in his late 70s who has Parkinson’s and dementia.

As we sit down in the living room, Dr. Setter asks Fred and his wife, Judy, about their children and how each one is doing. He keeps it light, joking and reminiscing with Fred.

Judy sits quietly—casual in khaki pants and olive green fleece jacket. A bowl of brownies, neatly wrapped in plastic, waits on the table near a colorful stack of Easter napkins.

Fred is engaged and interactive. He was a successful businessman and although suffering dementia, he still thinks like an executive. Today he is worried about his driver’s license and talks about his deep brain stimulation implants. But his facts are confused and it is hard to follow what he is saying. While we talk, Dr. Setter and Judy go to the kitchen to discuss his medications.

The neatly typed paper lists 14 prescriptions including levodopa and Stalevo, antidepressants, potassium, magnesium, anti-anxiety drugs, stool softeners, vitamins, behavior modification drugs, aspirin, and others. Dr. Setter looks at the list and notes that they will need to revisit the use of aspirin as Fred had recently suffered a bleeding episode.

As we pick up our coats to leave, Judy unwraps the brownies and I ask Fred how he likes this program.

“Steve has been like a brother with a pharmacy degree and that’s a hard one to find,” he laughs.

Neighborly advocates

“The thing about home visits is you never know what to expect,” says Dr. Vue as we drive north to visit the Elder Services office located in the Hillyard neighborhood. “Basically I am an advocate for the clients—to help them understand their drugs so they can talk to their doctors about them and ask the right questions. We try to keep people in their homes longer,” she says, “but sometimes being in a nursing home or assisted living facility can provide more social interaction and better care.”

Falls are a problem for John, the next client we visit, who was recently moved from his home to an assisted living facility in north Spokane. We meet him in the lobby with his walker. He is 69, muscular, and wearing a gray WSU tee shirt. He, too, is suffering from Parkinson’s and dementia.

In 1962 he was a middle linebacker on the WSU football team and later played semi-pro ball.

The clubs used helmets with little padding back then, and John took many blows to the head.

“They rattled us,” he says slowly, with a twinkle in his eyes.

“His condition could be related to the concussions or from chemicals,” says Dr. Setter, “we don’t know for sure.”

John, and Sally, his daughter and guardian, hand out Girl Scout cookies and take us on a mini-tour of the premises—heading for the gym to point out the weight machines he uses. The drugs John takes for Parkinson’s don’t help much with his balance, so he works on improving his stability with exercise and occasional work with a physical therapist.

Sally is worried about her father falling and breaking a hip. “He says he’d just give up if he had to go to a nursing home,” she sighs.

She explains that John’s dementia has accelerated recently and he is not able to remember his grandchildren well anymore. She and Dr. Setter discuss the eight medications he is currently taking. Previously, John had been experiencing adverse drug reactions but with adjustments, had been doing better.

Dr. Setter is not sure if the problems are related to the drugs or if John’s increased exercise and appetite at the facility are interfering with the meds. He wants to talk with John’s neurologist.

It’s the little things

Out in the parking lot, Dr. Setter confesses that some days he wonders if his efforts make any impact at all in the lives of his clients.

“But,” he concedes, “It is very satisfying when you find that someone’s depression is relieved or that they are no longer in constant pain. Sometimes, it’s just these simple real-life things that improve someone’s quality of life.”

As they did for Bernie, whom we met during our stop at the Elder Services office earlier in the day. Leaving a caregiver’s support group, he went out of his way to come over and introduce himself.

“It was an extremely good experience working with Steve,” he wanted people to know. “The group came out (to our house) and went through all of my wife’s 16 medications and explained them all. It meant a lot to us.”