The optimal management of cardiovascular disease (CVD) and CVD risk factors in older adults can be challenging for health care professionals. Older adults often present to cardiology clinics with numerous comorbid conditions, including cognitive decline that needs further management. A multidisciplinary, team-based approach that offers a broad range of clinical services to better address older adults with multiple chronic conditions can aid the busy cardiovascular practitioner. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) trial studied the effectiveness of a multifaceted intervention to maintain cognitive function in at-risk older adults. Study participants in the intensive multidomain intervention group received nutritional guidance, physical exercise training program, cognitive training with social activity, and intensive monitoring and management of metabolic and vascular risk factors. The results of this large-scale, randomized, controlled trial supports the use of a multidomain prevention approach to delay and prevent cognitive decline in at-risk elderly patients.¹

Pharmacists are becoming integral members of multidisciplinary health care teams. They offer extensive clinical services from identification and prevention of drug therapy-related problems to designing patient-specific, evidence-based medication regimens while promoting medication adherence. Traditionally, the pharmacist's role has been known for medication dispensing. Although this role remains an important activity of pharmacists, several studies support transformation in the pharmacist role towards a more patient-centered and collaborative care approach.² Pharmacists' delivery of high-quality, patient-centered care in a multifaceted approach has been associated with an overall improvement in the care of patients in critical settings, such as those in intensive care units.³ Also, pharmacist-provided care has shown to reduce the number of unidentified drug-related problems, decrease hospital readmission rates, and decrease overall hospital length of stay.^4-8 There is a growing body of evidence supporting the role of pharmacists in the identification and management of modifiable CVD risk factors. A systematic review of 30 randomized controlled trials involving 11,765 patients assessed the outcome of pharmacist-provided care in the overall management of major CVD risk factors among outpatients. The findings demonstrated that interventions made by pharmacists either exclusively or in collaboration with physicians or nurses led to an overall improvement in CVD risk management as evidenced by a greater reduction in systolic and diastolic blood pressure and lipid levels (total cholesterol and low-density lipoprotein cholesterol).⁹

Pharmacist integration into a multidisciplinary team has been shown to have a positive impact in the management of a variety of different disease states. A comprehensive medication review by pharmacists has been shown to improve overall patient health and alleviate health care burdens.¹⁰ The Asheville Project is one such example in which pharmacist-physician collaboration led to improved patient and health care outcomes. This was a community-based, pharmacy-directed, medication therapy management program in which pharmacists provided care in the management of chronic disease states, such as diabetes, hypertension, hyperlipidemia, and asthma. This service, provided for employers of Asheville, North Carolina, led to an approximately three-fold increase in appropriate cardiovascular medication use with a 46.5% decrease in medical expenses mostly related from decrease in emergency department visits and hospitalization.¹¹ The program matches health plan beneficiaries with pharmacists and physicians who collaborate to provide on-going evaluation and monitoring of medication regimens, education, and hands-on training in the management of modifiable risk factors to improve health and reduce associated risks. The success of this model has led pharmacists to develop patient care services in other community practices and disease states. Pharmacists are also assuming significant roles in the management of critical care non-cardiac issues that affect the geriatric cardiovascular patient, such as decreasing the incidence of agitation while improving the time spent at goal sedation level.²

Geriatric cardiology is an emerging cardiology subspecialty that integrates adult cardiology and geriatric medicine. The nature of this complex field enables it to inherently embrace a multidisciplinary, team-based approach. Bell and colleagues have elegantly described geriatric-specific features, such as multimorbidity, frailty, polypharmacy, cognitive decline, functional disability, and shared decision making, that can affect even routine cardiovascular care.¹² As the incidence of older adults with multiple chronic conditions increases, novel strategies will need to be implemented to address this important issue in a multidimensional manner. Pharmacists, as part of a health care team, bring a unique skill set to the table. Regardless of the setting, they are critical members of the team and can undertake clinical, educational, scholarly, and administrative duties³ that are aimed toward decreasing the burden of CVD and improving the health of older adults.

References

1. Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet 2015;385:2255-2263.
2. Preslaski CR, Lat I, MacLaren R, Poston J. Pharmacist contributions as members of the multidisciplinary ICU team. Chest 2013;144:1687-95.
3. Preslaski CR, Lat I, MacLaren R, Poston J. Pharmacist contributions as members of the multidisciplinary ICU team. Chest 2013;144:1687-95.
4. Bondesson A, Eriksson T, Kragh A, Holmdahl L, Midlöv P, Höglund P. In-hospital medication reviews reduce unidentified drug-related problems. Eur J Clin Pharmacol 2013;69:647-55.
5. Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003;163:2014-8.
6. Pasquale TR, Trienski TL, Olexia DE, et al. Impact of an antimicrobial stewardship program on patients with acute bacterial skin and skin structure infections. Am J Health Syst Pharm 2014;71:1136-9.
7. Jackevicius CA, de Leon NK, Lu L, Chang DS, Warner AL, Mody FV. Impact of a multidisciplinary heart failure post-hospitalization program on heart failure readmission rates. Ann Pharmacother 2015 Aug 10. [Epub ahead of print]
8. Howard-Thompson A, Farland MZ, Byrd DC, et al. Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes. Ann Pharmacother 2013;47:1471-7.
9. Santschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G. Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Arch Intern Med 2011;171:1441-53.
10. Howard-Thompson A, Farland MZ, Byrd DC, et al. Pharmacist-physician collaboration for diabetes care: cardiovascular outcomes. Ann Pharmacother 2013;47:1471-7.
11. Smith BH. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc 2008;48:23-31.
12. Bell SP, Orr NM, Dodson JA, et al. What to expect from the evolving field of geriatric cardiology. J Am Coll Cardiol 2015;66:1286-99.

Keywords: Adult, Aged, Asthma, Blood Pressure, Cardiovascular Diseases, Cholesterol, Cholesterol, LDL, Chronic Disease, Cognition, Cooperative Behavior, Critical Care, Diabetes Mellitus, Disease Management, Hyperlipidemias, Hypertension, Intensive Care Units, Lipoproteins, LDL, Medication Adherence, Medication Therapy Management, Outpatients, Patient Care, Patient Care Team, Patient Readmission, Patient-Centered Care, Pharmacists, Physicians, Polypharmacy, Risk Factors, Risk Management

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