Caring for our elders

Geriatric Specialist Fernandez Seeks to Educate, Empower Patients and Caregivers in Golden Years

The complexities of aging require a specific kind of health care. Navigating through the maze of medications and balancing the care with a dignified life for elder patients requires experts like University of Houston College of Pharmacy (UHCOP) alumna and Clinical Associate Professor, Julianna M. Fernandez, Pharm.D., BCPS, BCGP.

After earning her Pharm.D. at UHCOP, Fernandez's transition into geriatric pharmacy was ignited during her early years in practice, where she encountered the unique challenges and rewards of working with older adults. According to Fernandez, the focus in geriatric pharmacy isn't just on managing diseases; it's about enhancing the quality of life for elderly patients, helping them maintain independence, and pursuing the activities that bring them joy.

There is a big difference between her practice as a geriatric pharmacist and that of general internal medicine. In general medicine, there are patients of all ages. In geriatric care, you work with people who "either have really good genetics or have done something right to take care of themselves," given that most of her patients are 80 years old or older. This gives geriatric pharmacy a different focus than other pharmacy fields.

Geriatric pharmacy focuses on improving the patient’s quality of life for the time they have left. It revolves around patient-centered care, meaning what matters the most to the patients and their families.

“Geriatric pharmacy is not about fixing diabetes on a 90-year-old; it is about helping the patients feel comfortable and able to do things that are most important to them, like going to church on Sundays or getting to see the grandchildren once a week,” said Fernandez, who is both a board-certified pharmacotherapy specialist and board-certified geriatrics practitioner.  

Patients in this age demographic, particularly those grappling with dementia, often find themselves prescribed numerous medications, a situation commonly referred to as polypharmacy.

"I would say most of our patients will have closer to 20 medications and that is very overwhelming for the patients and family members," Fernandez said.

Treatment for this type of behavior can have a lot of side effects, which can result in other drugs being prescribed. This "stacking" of medication can result in what is called a prescribing cascade. Therefore, communicating with the patients and their family members or caregivers about medications is crucial for geriatric pharmacists. According to Fernandez, the key goal of a geriatric pharmacist is to optimize medication utilization making sure that the medication is doing more good than harm.   

"A lot of times what they need is to feel empowered to ask more questions," Fernandez said. "Educating the patients so that they know what questions to ask and they're not afraid to do so, it's very fulfilling to me because then they can be their own best advocate."

Challenges in the Aging Patient

Working with the elderly also has its unique struggles.

"I would say that one of the biggest challenges are the social issues that come with older patients," Fernandez said.

Living and transportation arrangements, healthcare coverage, difficulty with day-to-day tasks and mobility, and finances are of imperative importance in providing the best care for older patients. Often, patients may also be experiencing cognitive decline, which can result in poor decision-making. Differing opinions about "what’s best" for the patient also can be a source of conflict between the patient and caregiver, which is traditionally a family member.

"A lot of what we do on our geriatric service, which I would say is more of a social service, is to talk to them and make everyone understand what is happening to pick out what is the most important to the patient and their family," Fernandez said.

Teaching the 4 M’s’

Soft skills are vital in the field of geriatric pharmacy. Fernandez uses a specific method to help students develop these skills: "Four M's: What Matters Most, Mobility, Mentation, and Medications."

By incorporating this approach, pharmacists learn to start with what matters the most to the patient and their family. Then the practitioners must reflect on how the treatment affects the patient’s ability to function, such as if they are going to be at risk of falling (mobility). This is followed by assessing the patient’s mental activity (mentation), in which pharmacists look at the mental capabilities of the patient: if the patient can think clearly or if they need help. The "Medication" focus centers on ensuring that the medicine takes the best benefit without causing serious side effects to the patient.

Students need to be more holistic in their approach when undertaking the geriatric pharmacy path, Fernandez said. This mindset includes focusing on the social determinants of the patients, which can affect the health of the patient but are not necessarily health related. Among these are access to transportation for groceries, medical appointments, or other travel needs as well as insurance coverage and out-of-pocket expenses.

Workforce, Peer Education

For several years, Fernandez has been involved with the Southeast Texas Geriatric Workforce Enhancement Program (SETxGWEP). Funded by the Health Resources & Services Administration (HRSA), the SETxGWEP aims to prepare health care professionals, and community and social service workers to provide care to older adults.

In this role, Fernandez has delivered presentations on optimizing medication management and polypharmacy (to name a few), while also conducting conferences for internists and PCPs on various aspects of older adult care.  

Fernandez said the SETxGWEP team hopes to focus on underserved populations, such as tribal organizations and rural communities if future funding is awarded for program continuation and expansion. A key component will be interprofessional education, bringing together multiple health professionals to learn how to enhance collaboration and coordination for improving patient health outcomes.

"We will try to educate folks in areas where they may not have specialists to better care for older adults," Fernandez said.

Fernandez has also been involved with the American College of Clinical Pharmacy (ACCP) and its geriatrics pharmacy practice and research network (PRN). She has been an officer for the Geriatric PRN, serving as secretary, treasurer, incoming chair, and chair. Her focus on the PRN is to offer programming on elder care to those interested, such as webinars and projects.

Stress Reduction Through Education

The most meaningful moment Fernandez experiences during her job is sitting down with patients and their family members to help them understand their medication regimen. Explaining the purpose of each medicine and potential side effects eases the stress in both patients and family members since the medication regimen can become overwhelming.

"I think is a very fulfilling area of pharmacy," Fernandez said. "You truly impact not only the patient but often their entire family. Knowing you have made a positive impact towards the end of their journey is very rewarding."