What is community pharmacists’ level of comfort and interest in managing patients with or at risk of major neurocognitive disorders?

Major neurocognitive disorders (MNCDs) have been forecasted to almost triple globally to 152 million people by 2050.¹ In MNCDs, the brain is impacted so that cognitive processes, such as memory, language, organizational abilities, planning and judgment, gradually deteriorate.² With considerable damage, a person’s daily life is impaired, decreasing autonomy and further resulting in requiring assistance with everyday tasks.³

The Plan Alzheimer du Québec (PAQ) was created in 2013 based on an existing provincial health and social services framework to allow optimal care of patients with cognitive impairments.⁴ This initiative equips the Family Medicine Groups (FMGs) of the province to manage patients with cognitive disorders.⁵ FMGs are collaborative and interdisciplinary primary care clinics consisting of family physicians, nurses and, more recently, social workers and pharmacists.⁶ These professionals provide care and offer resources that aim to sustain the autonomy of patients affected by MNCDs.

In line with the PAQ, the Projet GPS is an ongoing pragmatic controlled study funded by the “Fonds de recherche du Québec-Santé.” It aims to measure the impact of pharmacists’ contributions to FMGs regarding patients who either have MNCDs or are undergoing cognitive assessment.⁷ FMG pharmacists’ interventions focus on optimizing a patient’s medications.⁸ They aim to improve quality of life by managing prescriptions and deprescribing those that are suboptimal.^9-11 Medication optimization is crucial for older persons to remove medications that may exacerbate their cognitive disorders.¹² Therefore, as a living laboratory-type intervention, the Projet GPS will enable us to explore additional elements of MNCD patients’ journeys, including connecting with community pharmacy.

One of a patient’s first contact points with the health care system is the community pharmacy. From a study in 2016, it was seen that about 25% of Canadian seniors typically take 10 or more prescription drugs per year, making community pharmacists an essential player on their health care team.¹³ It has been established that the elderly with cognitive problems are more prone to increased risk of adverse drug events.¹⁴ With the notable increase in chronic illnesses within the elderly community, pharmacists are well placed to facilitate the early detection of those who present signs of cognitive impairments and support their health system navigation.^14,15

Although community pharmacists play a distinct interactive role with patients, which could be advantageous in optimizing the pharmacotherapy of those with or at risk of MNCDs and flagging patients who require medical attention to their FMGs, little is known about their level of comfort and willingness to engage in these activities. Therefore, this project’s goal was to survey pharmacists (both licensed and final-year pharmacy students) practising or wishing to practise in community pharmacy settings about their role among the elderly with or at risk of MNCDs.

A total of 107 respondents agreed to participate and fully completed the web-based questionnaire. Among them, 66.4% were licensed pharmacists practising in community pharmacies, whereas the rest (33.6%) were fourth-year pharmacy students with the intention of continuing their practice in a community pharmacy setting. Of those who participated, 20.6% practised or planned to practise in the CIUSSS du NIM territory.

Table 1 presents respondents’ interest and comfort with patients with or at risk for MNCDs. The mean score for questions about interests (questions 1-4) was 4.06 (where a score of 5 means “extremely”), while it was 3.34 for questions about comfort level (questions 5-8).

From the survey results, it is apparent that community pharmacists feel comfortable with their knowledge of pharmacotherapy and are interested in being actively involved in the care of patients with or at risk of MNCDs. Although the respondents expressed a high interest, their lack of comfort in identifying the early signs of cognitive disorders or in intervening/referring a patient with suspected MNCDs hinders optimal pharmacological treatments and early referrals to the appropriate professionals. The participants admitted to having limited knowledge of the resources available to patients with or at risk of MNCDs. In addition, they reported that their communication skills with this population need to be improved.

Before this study, a literature review demonstrated that most studies were on pharmacists’ knowledge of pharmacotherapy to treat MNCDs instead of their level of interest in and comfort with this population.^16-18 However, as shown in a study about factors influencing pharmacists’ adoption of new practices,¹⁹ knowledge is not the sole element in the equation. The complexity associated with these cases, the type of practice setting and the relationship with the patient’ physician are all factors that can affect a pharmacist’s adoption of new activities.¹⁹ A study similar to ours done in Northern Ireland demonstrates that, even when having the interest to intervene in pharmacotherapies, pharmacists require more training to be comfortable doing so.²⁰ We also suspect they require more experience and that their practice settings need some transformation.

One of the strengths of the present study is its objective’s originality, which does not aim to measure the knowledge of participants but rather their interest and level of confidence. To our knowledge, it is one of the first studies on this question. The questionnaire was developed by 2 pharmacists and a fourth-year pharmacy student, as well as pretested by a pharmacist and 2 pharmacy students. This ensured questions were pertinent and well understood, a requisite for valid results. However, we must acknowledge some limitations and call for caution in interpreting the results. Due to its short duration, our survey sample size (N = 107) was relatively small and might not be representative of all community pharmacists of the province of Québec. Although we were interested in pharmacists’ level of comfort and interest in managing patients with or at risk of major neurocognitive disorders in community pharmacies, a third of our population were fourth-year pharmacy students with limited practice experience. Moreover, participants were not randomly selected but were instead limited to interested pharmacists and students, potentially allowing selection and information bias. Lastly, although not suspected, the inability to verify the possibility of duplicate answers is a limitation as well.

Our study supports the importance of developing and publicizing tools adapted to community pharmacists and better educating pharmacists and pharmacy students in managing patients with or at risk of MNCDs. In addition, we identified potential solutions to help improve community pharmacists’ practice when intervening with patients and optimizing pharmacotherapy. We developed tools that could aid in closing the gap that community pharmacists feel with their knowledge and comfort in intervening with patients with or at risk of MNCDs. A decision-making algorithm to help community pharmacists identify specific elements suggestive of MNCDs and refer patients to available resources was created and is available at https://www.ciusssnordmtl.ca/zone-des-professionnels/pharmaciens/. It can be accessed under the heading “Aide à la décision pour la clientèle avec ou à risque de trouble neurocognitif majeur.”²¹ Additionally, a directory of local resources (e.g., 211, social workers, Elder Abuse Helpline) adapted to the needs of the CIUSSS du NIM pharmacists was developed and is also available on their website.²² Both tools have been shared with pharmacists, and more active dissemination is being explored.

Last, our results suggest it would be beneficial to create video modules demonstrative of common scenarios and effective communication techniques pharmacists could use to ease their future interventions. An MNCD-specific self-learning module is available for FMG pharmacists participating in the Projet GPS. We plan broader dissemination after the completion of this study. Combining these measures would further educate pharmacists on early interventions concerning MNCDs.

One of the PAQ’s objectives for its phase 3 initiative (2022-2024) is to extend its outreach to community pharmacists who could help support patients with or at risk of MNCDs.^5,23,24 One such element includes early referral to the medical team when warranted. It is believed that the FMG pharmacists could serve as an intermediate between community pharmacists and family doctors. Facilitating early detection of patients at risk of MNCDs could allow for better outcomes because of earlier consultations and care.

Although community pharmacists’ interest in this field is high and relevant, there is a knowledge gap preventing them from being comfortable in intervening with patients with or at risk of MNCDs. Management of these patients is thus challenging due to the disorder’s complexity, which is only furthered by the lack of resources available for patients and pharmacists. Therefore, the development and greater accessibility of valuable tools and training would better equip community pharmacists to use their existing knowledge and improve their comfort in managing patients with or at risk of MNCDs. ■