Critical Role of Pharmacists in Caring for Alzheimer’s Disease Patients

Abstract

Background:

The global prevalence of Alzheimer’s disease (AD) and its treatment costs are projected to increase significantly, placing increasing pressure on health systems to create new models of care. Community pharmacists are well-positioned to provide medication management for people with AD. In Arabic-speaking countries, little is known about pharmacists’ knowledge and practices in caring for people with AD.

Objective:

To evaluate community pharmacists’ knowledge of AD and its management, counseling skills, and dispensing patterns when caring for people with AD and their caregivers in the United Arab Emirates (UAE).

Methods:

A large-scale cross-sectional survey of community pharmacists was conducted in three cities in the UAE using stratified random sampling. The questionnaire comprised of validated tools to measure knowledge and open-ended questions. A logistic regression model was conducted to predict counseling comprehensiveness.

Results:

A total of 325 community pharmacists completed the questionnaire. The mean knowledge scores about AD and its pharmacotherapy were 57.0% and 67.6%, respectively. Major shortcomings in pharmacists’ practices were identified; history-taking, adherence assessment, and counseling were provided by 2.2%, 9.3%, and 17.3%, respectively. A minority provided comprehensive counselling; the multivariate analysis yielded new insights into pharmacist characteristics associated with such counseling.

Conclusion:

Pharmacists did not provide structured patient-centered care for people with AD. Community pharmacists did not provide adequate counseling, did not assess adherence-related issues appropriately, and had deficient knowledge. To develop patient-centered pharmacy-based services for Arabic-speaking communities, a multifaceted approach is required that goes beyond improving pharmacy workforce knowledge and communication skills to address broader sociocultural, legislative, and financial factors.

Keywords

Alzheimer’s disease Arabs community pharmacy services counseling knowledge medication therapy management

INTRODUCTION

Alzheimer’s disease (AD) is the most common form of dementia [1]. It is a neurodegenerative disorder characterized by progressive memory impairment, cognitive and executive function deficits, and behavioral and psychiatric disturbances [2]. The global prevalence of AD is projected to quadruple by 2050 [3, 4]. The most recent estimate of the global annual cost of AD is one trillion US dollars and is expected to double by 2030 [3].

Similar to global trends, many Arabic-speaking countries have seen an increase in life expectancy and the proportion of older people within their populations [5, 6]. While there are no official data on the prevalence of AD and the extent of dementia in the region, the World Alzheimer Report 2015 estimated that the prevalence of dementia in people over 60 years in the Middle East and North Africa region (Arabic-speaking countries) is higher than the global average (8.7% versus 5.6–7.6%) and is set to increase by 125% by 2050 [7]. In addition, evidence has emerged that the early onset of cardiovascular diseases and stroke in the Arabic-speaking populations is associated with an earlier onset of AD [5].

Two classes of AD medications are currently approved; cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) and N-methyl-D-aspartate (NMDA) receptor blocker (memantine) [1]. While these medications produce significant reductions in disease severity scores, these reductions often do not translate into clinically meaningful improvement in symptoms [1]. Additionally, no medications are currently available that can slow or halt the progression of the disease [1].

It is estimated that one-third of people with dementia are living at home, and this varies among countries [8]. As AD progresses and patients become increasingly debilitated, family members and caregivers are required to assist intensively with daily activities including feeding, dressing, bathing, taking medicines, and managing aggressive or depressive behavior, and incontinence [7, 9]. This high dependency and burden on caregivers negatively affect their quality of life [10]. Family members of people with AD in Arabic-speaking communities are more likely to experience heavier burden because of the collective cultural view that sending the older adults to a nursing home is considered abandonment of family duty. Therefore, such patients typically reside with their younger kin who provide care and support [6].

The majority of people with AD, including in Arabic-speaking countries, are over the age of 65 and are likely to have comorbid conditions associated with advanced age, such as cardiovascular diseases and diabetes [6 , 12]. The treatment of these conditions often requires long-term use of multiple medications that is associated with increased risk of medication-related problems, including cognitive impairment [13, 14]. Cognitive impairment in people with AD can further complicate therapy by causing difficulties in adhering to the prescribed regimen [15, 16]. Poor medication adherence has been associated with low quality of life, poor disease outcomes, and increased hospitalizations and healthcare costs in the elderly [15 –17]. In response to the growing problem of AD globally and specifically in Arabic-speaking countries new models of care are required to deliver improved health service within primary care setting.

As highly accessible healthcare providers, community pharmacists are in frequent contact with diverse groups of patients, including older people who are at increased risk for AD. Community pharmacists are well positioned to provide care for people with AD. Evidence showed that pharmacist-led medication management identified and resolved medication-related problems, educated patients and caregivers about the safe and appropriate use of medications, simplified treatment regimens, and improved patients’ quality of life [18 –21]. Additionally, community pharmacists could recognize early signs of AD in their regular clients, placing them in an ideal position to provide screening for individuals at risk of developing AD [20], and referral to physicians for further evaluation [22]. Therefore, it is essential that community pharmacists be well trained to provide this level of care and service.

In the UAE, medications are classified into one of three groups: Over-the-Counter, Pharmacist-Only, and Prescription-Only Medications (POMs). Despite the fact that legislation does not allow pharmacists to dispense POMs without prescription, the practice continues to allow public access to a wide range of medications, including AD medications [23]. Enforcement of the regulations prohibiting the sale of prescription medications without a physician’s order is needed in order to establish the appropriateness of diagnosis and, therefore, the appropriate treatment.

Little is known about the knowledge and competence of community pharmacists in providing care for patients with chronic disease such as AD in the United Arab Emirates (UAE). This study, therefore, aimed to evaluate community pharmacists’ knowledge about AD and its management and explore pharmacists’ current practices in caring for people with AD in the UAE. Such an assessment is necessary to identify knowledge and skill gaps that could be used as a starting point to develop continuing education programs to assist pharmacists in providing optimal care to people with AD and in supporting their caregivers.

MATERIALS AND METHODS

Ethical approval

Ethical approval to conduct the study was obtained from the University of Sharjah Research Ethics Committee (REC-17-09-24-02-S).

Study design and setting

A large-scale cross-sectional survey was conducted in community pharmacies in three cities in the UAE: Dubai, Sharjah, and Ajman. These three cities were selected because they are under the jurisdiction of the UAE Ministry of Health and Dubai Health Authority, which combined regulate pharmacy practice in six out of the seven emirates of the UAE. Stratified random sampling of pharmacies by district within these cities was employed to increase the representativeness of the study sample. The absence of reliable postal services and the lack of internet access in many community pharmacies in the UAE precluded the options of mail or online surveys. Therefore, to ensure adequate participation, data-collectors visited each pharmacy in person and delivered a printed copy of the questionnaire.

Questionnaire development

A scoping literature review was conducted to identify available tools to assess pharmacist knowledge about AD, the medications used in its management, and the role of community pharmacists in the care of people with AD. Key databases (PubMed and Google Scholar) were searched using relevant broad search terms and Boolean operators (community pharmacist, knowledge, practice, Alzheimer’s disease). Several studies and articles were identified [24 –31], including two validated measures of AD knowledge in healthcare professionals; the Alzheimer’s Disease Knowledge Scale (ADKS) and the Alzheimer’s Disease Pharmacotherapy Measure (ADPM). The questionnaire in this study was written in English, and comprised of 73 close- and open-ended questions in four sections (Supplementary Material). The first section covered pharmacist and pharmacy characteristics, including pharmacists’ demographic information, time in practice, and self-reported continuing education and learning resources. Section 2 was the ADKS, which consists of 30 true/false items that assess knowledge of various aspects of AD; namely, risk factors, diagnosis, symptoms, life impact, caregiving, and management [26]. Section 3 was the ADPM, which consists of 18 true/false statements on knowledge of the pharmacological management of AD, including treatment options, treatment efficacy, adverse effects, dose titration, and the role of supplementation [27]. Permission to use the ADKS and ADPM in this study was obtained from the developers of the two tools.

Section 4 included items to assess pharmacists’ current practices in the care of people with AD and their family members. These questions covered 1) dispensing practices of AD medications, 2) comprehensiveness of counseling, measured by frequency and topics/points covered, 3) assessment and promotion of adherence to the medications, and 4) engagement in screening activities for AD. When assessing pharmacists’ practices, open-ended questions were used instead of and as a follow-up to multiple-choice questions.

We wanted to ensure face and content validity (the degree to which the instrument fully assesses the construct of interest) of our questionnaire. Efforts have been placed on ensuring that the questions (mainly in the fourth section) fully represent the domain of pharmacist’s role in supporting people with AD and their caregivers. We included items that measure all activities involved in such a process of care, including history taking, dispensing, counseling, and support. The development of a content valid instrument was achieved through a rational analysis by experts who were familiar with the construct of interest and the research subject (five practicing community pharmacists who had experience in dispensing AD medications, two academic pharmacists who teach AD and geriatric diseases, and three academic physicians with relevant expertise). These experts reviewed the questionnaire items for readability, clarity, and comprehensiveness, and all agreed on items included in the final questionnaire. Minor refinements were made on the wording of some items and the order of choices in Section 4. No changes were made to either the ADKS or ADPM. The final questionnaire was pilot tested before dissemination.

Data collection and participants

Stratified random sampling was used to obtain a diverse and representative sample of pharmacies. All districts within each of the three cities were targeted. Lists of all registered community pharmacies in Dubai and Sharjah were obtained from governmental organizations (Dubai Health Authority and Sharjah Economic Development Authority). In Ajman, where this was not possible, the list was compiled from a recent official telephone directory. In total, there were 913 pharmacies in the three cities (501, 412, and 45 pharmacies in Sharjah, Dubai, and Ajman, respectively). At city-level, the pharmacies were stratified based on their district. The stratified list was then imported into Microsoft Excel. The RAND function was used to assign a random number between zero and one to each pharmacy within each district. All pharmacies within the district were then arranged in ascending order of their randomly assigned number, creating a list of all pharmacies within a district arranged in random order. Based on the sample size calculation (see below) and to ensure the representativeness of the study sample, one-third of all pharmacies needed to be recruited. Pharmacies within each district were approached in the order in which they appeared on the random list until a third of the pharmacies in the district were recruited.

Study objectives were explained to the pharmacist on-duty and signed informed consent was obtained. After signing the consent form, the pharmacist on-duty completed the survey. One survey was completed per pharmacy. Pharmacy assistants were excluded. When one of the preselected pharmacies declined taking part in the study, the next pharmacy on the list within the same district was approached. All questionnaires were self-administered. The pharmacists were given the option to complete the survey on the spot or at a later time. If the latter were chosen, research assistants visited these pharmacies to collect completed surveys.

Sample size

The sample size was calculated using the formula of estimating a single proportion in a cross-sectional study. For a predicted proportion of pharmacists who are knowledgeable about AD of 70%, and a confidence level of 95% and a margin of error of 5%, the minimum number of subjects needed for this study was 319.

Data analysis

The data were entered, cleaned, and analyzed using SPSS 20 (Statistical Package for Social Sciences 20). ADKS score was calculated by adding the number of questions with correct answers on all the scale items and then transforming the calculated total into a percentage. Similarly, the ADPM score was calculated for all study participants.

Univariate analysis was performed by reporting counts and percentages for categorical variables, means and standard deviations for normally distributed scale variables and medians for skewed ones. Normal distribution of continuous variables was tested using the Kolmogorov-Smirnov (KS) test. For bivariate analysis, Chi-square, independent t-test, and analysis of variance (ANOVA) tests were used. Tukey’s HSD test was used for post hoc analysis when ANOVA test results were significant. Non-parametric tests, specifically Mann-Whitney U test and Kruskal-Wallis test, were used when data did not satisfy the assumptions of the parametric tests. To predict counseling comprehensiveness, a binary logistic regression model was conducted using seven covariates (sex, age group, highest qualification (i.e., degree), years in practice, pharmacy type, ADKS score, and ADPM score). Comprehensive counseling was defined as the pharmacist-reported covering of at least three counseling points (from a list of nine points) at a frequency of “mostly” or “always” during encounters with patients and/or caregivers. The odds ratio was reported to indicate the strength of association, and a p-value less than or equal to 0.05 was considered statistically significant.

RESULTS

Pharmacists’ characteristics

A total of 325 community pharmacists completed the questionnaire; 140 in the city of Dubai, 170 in Sharjah, and 15 in Ajman. There were slightly more male than female pharmacists, and 54.8% of pharmacists were aged over 30 years (Table 1). About half of the pharmacists (52%) were Indian nationals. Most pharmacists (86.8%) had a bachelor’s degree only, 41.8% had more than five years of experience in community pharmacy practice, and almost all pharmacists (94.5%) worked on a full-time basis. Slightly more pharmacists (55.7%) worked in chain community pharmacies than in independently owned pharmacies.

Table 1

Pharmacists’ characteristics (N = 325)

Pharmacists’ characteristics		% (n)
Sex	Male	54.8 (178)
Age group (y)	23–29	45.2 (147)
	≥30	54.8 (178)
Nationality^*	India	52.0 (169)
	Arab country	19.3 (63)
	Pakistan	10.5 (34)
	Others	6.4 (21)
	Missing	11.7 (38)
Educational level	Bachelor degree	86.8 (282)
	Masters/PharmD	13.2 (43)
Time in practice	1–3 y	31.1 (101)
	4–5 y	27.1 (88)
	>5 y	41.8 (136)
Employment	Full-time	94.5 (307)
	Part-time	5.5 (18)
Pharmacy type	Chain	55.7 (181)
	Independent	44.3 (144)
Time spent on professional development per week (h)	0–2	41.2 (134)
	3–4	34.8 (113)
	5–6	12.6 (41)
	>7	11.4 (37)
Resources for professional development	Internet websites	88.9 (289)
	Online courses	29.5 (96)
	Conferences, workshops, or seminars	23.1 (75)
	Textbooks	23.1 (75)
	Peer-reviewed journals	8.6 (28)
	Other	2.5 (8)

^*Pharmacists self-identified their nationalities.

When asked about time spent on continuing professional development, 41.2% of pharmacists spent two or fewer hours per week. The most commonly cited learning resources for professional development were internet websites (88.9%), online courses (29.5%), and textbooks and conferences or workshops (23.1% each) (Table 1).

Pharmacists’ knowledge about AD and its pharmacotherapy

The mean ADKS score was 57%, with pharmacists scoring highest on the life impact domain (71.7%), followed by assessment and diagnosis (70.2%). Mean scores ranged between 62.1% and 63.8% in the course of the disease, treatment and management, and symptoms subscales. Pharmacists scored lowest in the risk factors and caregiving domains (45.1% and 40.6%, respectively). In the pharmacotherapy knowledge assessment tool (ADPM), the mean score was 68%.

Female pharmacists had significantly higher knowledge scores about AD than male pharmacists (58.7% and 55.7%, respectively, p = 0.032). Pharmacists who worked in independently owned community pharmacies had higher knowledge score (59.0%) about AD than their counterparts in chain pharmacies (55.3%, p = 0.005) (Table 2). Pharmacists over the age of 30 had a significantly higher pharmacotherapy knowledge score than younger pharmacists (68.9% versus 65.6%, p = 0.001). Pharmacists with over five years in practice had a significantly higher pharmacotherapy knowledge score (70.6%) than both pharmacists with 1–3 years and 4–5 years (66.1% and 64.4%, respectively) (Table 2).

Table 2

Differences in knowledge about Alzheimer’s disease and its pharmacotherapy by pharmacist subgroup

Pharmacist characteristics	Total ADKS score (%)		Total ADPM score (%)
	Mean±SD	p	Mean±SD	p
Sex^*
Male	55.7±11.7	0.032	67.2±12.2	0.812
Female	58.7±12.3		67.8±12.2
Age group^*
23–29 years	56.0±13.0	0.231	65.6±11.7	0.001
≥30 years	57.7±11.3		68.9±12.2
Degree^*
Bachelor	57.0±12.0	0.296	67.8±12.2	0.281
Masters/PharmD	56.7±13.0		66.1±13.3
Time in practice^**
1–3 y	55.3±13.0	0.160	66.1±12.2	<0.001^‡
4–5 y	57.0±12.3		64.4±12.2
>5 y	58.0±11.3		70.6±11.1
Pharmacy type^**
Chain	55.3±11.7	0.005	66.7±13.3	0.174
Independent	59.0±12.3		68.9±10.0

^*Mann-Whitney U-test. ^**Kruskal-Wallis test. ^‡Tukey’s HSD was used for pair-wise comparisons of mean ADPM scores among the subgroups.

Products used in AD management in daily practice

Around one-third of pharmacies (32.6%) maintained a stock of products used in the management of AD. Of the surveyed pharmacists, most reported that they infrequently dispensed AD medication (one to ten times in the past six months). When asked about how they usually received requests for AD medications, 45% of pharmacists reported that AD medications were most commonly requested without a prescription, 28% with a prescription, and 27% reported that requests came directly from physicians.

Community pharmacists’ practices in the care for people with AD

When AD medications were requested, 24% of pharmacists reported that they asked the caregiver about the history of the disease. When pharmacists were asked to specify questions that they ask caregivers, most (92%) did not respond. A few indicated that they asked about the duration of AD (3.1%), about any improvement in symptoms (2.8%), or the patient’s medical history (2.2%). Most pharmacists (87%) did not describe their routine practice when they dispensed AD medications and infrequently provided counseling; 11.1% and 18.5% reported never and occasionally counseling patients or caregivers, respectively (Table 3).

Table 3

Pharmacist practices in care of patients with Alzheimer’s disease

Pharmacist practices		% (n)
History taking
Ask caregiver about AD history	Yes	24.0 (78)
	No	42.5 (138)
	Missing	33.5 (109)
Types of history questions	Duration of the disease	3.1 (10)
	Improvements in behavior and date of next physician appointment	2.8 (9)
	Patient’s medical history	2.2 (7)
	Missing	92.0 (299)
Frequency of counseling	Never	11.1 (36)
	Occasionally	18.5 (60)
	Sometimes	20.0 (65)
	Most of the time/always	17.3 (56)
	Missing	33.2 (108)
Counseling points	Use instructions	48.0 (156)
	Indication	32.9 (107)
	Adverse-effects	30.8 (100)
	Lifestyle advice	29.2 (95)
	Storage instructions	24.3 (79)
	Missed dose instructions	22.5 (73)
	Drug interactions	21.5 (70)
	What to do if disease worsens	13.5 (44)
	Missing	33.5 (109)
Method of communication	Verbally	35.7 (116)
	In writing	1.2 (4)
	Verbally and in writing	29.5 (96)
	Missing	33.5 (109)
Availability of written material for patients with AD	Yes	8.3 (27)
	No	56.3 (183)
	Missing	35.4 (115)
Whether adherence aids are given	No	53.8 (175)
	Yes	12.3 (40)
	Missing	33.8 (110)
Frequency of assessing adherence to medication	Never	15.7 (51)
	Occasionally	21.2 (69)
	Sometimes	18.5 (60)
	Most of the time/always	9.3 (30)
	Missing	35.4 (115)
How adherence is assessed	Asking caregivers	9.5 (31)
	Missing	90.5 (294)
Response to nonadherence	Consult physician	7.1 (23)
	Informing caregiver	5.8 (19)
	Giving written instructions	0.3 (1)
	Missing	86.7 (282)
Pharmacists’ knowledge of support groups in the UAE	Yes	22.5 (73)
	No	43.4 (141)
	Missing	34.2 (111)
Pharmacist knowledge of AD screening	Yes	2.2 (7)
	No	63.1 (205)
	Missing	34.8 (113)
Names of AD screening tests	Dementia Screening Interview	0.3 (1)
	Memory test	0.3 (1)
	Genetic test	0.3 (1)
	MRI	0.6 (2)
	Missing	98.5 (320)

The most commonly reported counseling points by pharmacists were instructions on medication use (48%), the indication of the medication (32.9%), and possible adverse effects (30.8%). Around 36% of pharmacists reported communicating information to caregivers or patients only verbally, 30% reported using both written and verbal communication, and 33.5% did not respond to this item. More than half (53.5%) of pharmacists reported not giving adherence aids to people with AD or their caregivers. Assessing adherence to prescribed medications in people with AD was not routine practice; only 9% reported carrying it out “always” or “most of the time”. Most pharmacists failed to describe how they assessed adherence. When an adherence problem was discovered, 7.1% of pharmacists reported informing the caregivers and 7.1% reported consulting with the physician. Most pharmacists (63.1%) did not know about screening tests for AD. Around 22% of pharmacists knew about support groups for people with AD or their caregivers in the UAE. However, almost all pharmacists failed to name one such group (Table 3).

Bivariate associations

More years in pharmacy practice was associated with a decreased reported frequency of counseling, whereas there were no associations with pharmacist sex, age, degree, or pharmacy type (Table 4a). Pharmacists who held a masters or doctor of pharmacy (PharmD) degree reported counseling significantly more frequently about possible adverse effects (p = 0.03) and storage instructions (p = 0.02) than pharmacists who had a bachelor degree only. Pharmacists aged 23–29 years reported providing lifestyle advice significantly more frequently than older pharmacists did (p = 0.034). Pharmacists with fewer years of practice provided instructions on taking the medications significantly more frequently than those with more years in practice (p = 0.032). Finally, pharmacists who worked in independently-owned community pharmacies advised about what to do if the disease worsened significantly more frequently than their counterparts who worked in chain pharmacies (p = 0.002) (Table 4b).

Table 4a

Associations between pharmacists’ characteristics and frequency of counseling patients/caregivers about AD medications

Pharmacist/pharmacy characteristics	Frequency of counseling % (n)
	Never/occasionally	Sometimes	Mostly/always	χ ²	p
Sex
Male	47.7 (51)	28.0 (30)	24.3 (26)	1.004	0.605
Female	40.9 (45)	31.8 (35)	27.3 (30)
Age group
23-29 y	43.8 (49)	26.8 (30)	29.5 (33)	1.988	0.370
≥30 y	44.8 (47)	33.3 (35)	21.9 (23)
Degree
Bachelor	46.7 (86)	29.3 (54)	23.9 (44)	3.538	0.171
Master/PharmD	30.3 (10)	33.3 (11)	36.4 (12)
Time in practice
1-3 y	48.6 (35)	23.6 (17)	27.8 (20)	14.240	0.007
4-5 y	25.4 (15)	45.8 (27)	28.8 (17)
>5 y	53.5 (46)	24.4 (21)	22.1 (19)
Pharmacy type
Chain	46.9 (68)	28.3 (41)	24.8 (36)	1.270	0.530
Independent	38.9 (28)	33.3 (24)	27.8 (20)

Table 4b

Associations among pharmacist and pharmacy characteristics and points covered during counseling

Pharmacist/pharmacy characteristics	Points covered with patients/caregivers during counseling
	Instructions on taking medicines		Storage instructions		Advice if disease worsens		Lifestyle advice		Adverse effects
	% (n)	p	% (n)	p-value	% (n)	p	% (n)	p	% (n)	p
Sex
Male	70.8 (75)	0.636	39.6 (42)	0.361	22.6 (24)	0.416	43.4 (46)	0.865	43.4 (46)	0.401
Female	73.6 (81)		33.6 (37)		18.2 (20)		44.5 (49)		49.1 (54)
Age group
23–29 y	76.8 (86)	0.120	37.5 (42)	0.769	18.8 (21)	0.539	50.9 (57)	0.034	45.5 (51)	0.816
≥30 y	67.3 (70)		35.6 (37)		22.1 (23)		36.5 (38)		47.1 (49)
Degree
Bachelor	70.5 (129)	0.181	33.3 (61)	0.020	20.2 (37)	0.896	44.3 (81)	0.845	43.2 (79)	0.030
Master/PharmD	81.8 (27)		54.5 (18)		21.1 (7)		42.4 (14)		63.6 (21)
Time in practice
1–3 y	70.4 (50)	0.032	38.0 (27)	0.715	22.5 (16)	0.723	53.5 (38)	0.117	46.5 (33)	0.969
4–5 y	84.7 (50)		32.2 (19)		16.9 (10)		42.4 (25)		47.5 (28)
>5 y	65.1 (56)		38.4 (33)		20.9 (18)		37.2 (32)		45.3 (39)
Pharmacy type
Chain	73.3 (107)	0.614	34.2 (50)	0.305	14.4 (21)	0.002	46.6 (68)	0.267	47.3 (69)	0.682
Independent	70.0 (49)		41.4 (29)		32.9 (23)		38.6 (27)		44.3 (31)

Associations were tested using Pearson’s χ² test. Figures in bold are statistically significant at the 5% level.

Multivariate analysis

Multivariate analysis is described in Table 5. The binary logistic regression model explained between 4.3 and 8.1% of the variance in the dependent variable. Hosmer and Lemeshow test (χ²₍₁₀₎ = 10.114, p = 0.257) showed that the model adequately fit the data and predicted comprehensiveness of counseling with a borderline significance (Omnibus test χ²₍₈₎ = 14.235, p = 0.076). Of the seven variables entered in the model, only the pharmacists’ qualification was a significant predictor of the comprehensiveness of counseling. Pharmacists with masters or PharmD degree were more likely to provide comprehensive counseling as compared to those with only a bachelor degree (OR = 2.409, 95% CI 1.045–5.555, p = 0.039).

Table 5

Pharmacist and pharmacy characteristics associated with comprehensive counseling

Pharmacist/pharmacy characteristics		Adjusted odds ratio	95% confidence interval	p
Sex	Female	1.184	0.576–2.436	0.646
Age group	≥30 y	0.466	0.206–1.055	0.067
Degree	Master/PharmD	2.409	1.045–5.555	0.039
Time in practice	4–5 y	1.685	0.733–3.873	0.219
	>5 y	1.116	0.407–3.059	0.831
Pharmacy type	Independent	0.701	0.336–1.464	0.344
Total ADKS score		1.038	0.946–1.139	0.433
Total ADPM score		1.046	0.890–1.229	0.584

Reference groups: sex: male; age group: 23–29 years; degree: bachelor; time in practice: 1–3 years; pharmacy type: chain.

DISCUSSION

This study is the first to assess community pharmacists’ role in caring for community-dwelling individuals with AD in an Arabic-speaking country (UAE). Currently, pharmacists’ limited knowledge and poor counseling practices possibly destined people with AD and their caregivers to miss a key opportunity to receive the support necessary to use prescribed medications effectively and improve their quality of life. A few pharmacists provided comprehensive counseling, and the results of the multivariate analysis yielded new insights into pharmacist characteristics associated with comprehensive counseling. Pharmacists with masters or PharmD degrees were more likely to provide comprehensive counseling compared with those with only a bachelor degree. Within the socio-cultural context of Arabic-speaking countries, whereby people with AD typically reside with family members, it is crucial for community pharmacists to recognize their important role in supporting caregivers of people with AD and be able to provide patient-centered medication management strategies.

In this study, pharmacists’ knowledge about AD and its management was substantially lower than reported in other countries [27, 32]. A study in Malta that assessed the knowledge of community pharmacists on AD and its management showed that pharmacists achieved a score of 71.5% in the ADKS, compared to 57% in this study, whereas the mean scores of pharmacotherapy knowledge were similar [27]. The same study also showed that the number of years working in a community pharmacy were negatively correlated with knowledge, whereby younger pharmacists achieved higher ADKS and ADPM scores. The increased knowledge among younger pharmacists was attributed to the recent emphasis of undergraduate education in Malta on the field of dementia. In contrast to these findings, our results showed that older pharmacists and those with more years in practice had higher pharmacotherapy knowledge scores. This discrepancy could be explained by the fact that pharmacy-related AD care remains inadequately covered in undergraduate pharmacy curricula in the region. As a result, pharmacists seem to rely on time in practice to develop their knowledge. The main socio-demographic characteristics associated with differences in the ADPM scores of the pharmacists were the age and the number of years working in a community pharmacy—older pharmacists and those practicing for a longer time achieved higher scores.

We assert, however, that time spent in practice is not an effective learning modality for pharmacists to gain knowledge and develop skills to provide enhanced care for people with AD and their caregivers. This argument is supported by the small magnitude of difference in knowledge scores within age and time in practice groups.

A study conducted in Australia measuring nursing, medical, allied health, and support staff knowledge about AD reported knowledge deficits in specific areas such as items related to risk factors and course of the disease [33]. Similarly, in this study, pharmacists scored lowest in the risk factors and caregiving domains, this could indicate low awareness and involvement of the pharmacists with people with AD and their families.

Currently, there are shortcomings in pharmacist-delivered care for people with AD in the UAE. Pharmacists did not offer appropriate counseling that enables people with AD and their caregivers to manage prescribed treatment effectively. For example, they failed to provide strategies to promote medication adherence, did not address drug administration challenges, neglected screening for drug interactions, and provided limited advice on adverse effects. Compared to those with more years in practice, younger pharmacists tended to provide more instructions on taking the medications and lifestyle advice, which could be a reflection of the recent emphasis of undergraduate education in the UAE on the importance of counseling. Pharmacists do not routinely provide medication counseling in the UAE. In comparison with a previous study that assessed pharmacist counseling in general, pharmacists in this study counseled less frequently about AD medications [34, 35]. This could be partially explained by pharmacists’ lack of familiarity with AD medications as reflected with their knowledge score.

Several challenges to the provision of pharmacist-delivered AD care have been identified in international literature. These included the inability to have timely access to the patient’s medical record, insufficient information exchange between healthcare professionals, lack of recognition of pharmacists’ key role in the care for people with AD, lack of reimbursement for expanded AD services, and difficulties in coordination of care [20]. Pharmacist remuneration for AD-related care is a common challenge in many countries. Interestingly, evidence from a recent systematic review showed that pharmacist-led medication reviews and post-discharge follow-up calls resulted in USD 804 savings per participant [21].

The current picture in the UAE with limited provision of enhanced pharmacy services, including pharmacy-related AD care is a candidate for much improvement [35]. Several factors in the UAE hinder meaningful pharmacist involvement in consistent patient-centered care and preclude them from being integrated into primary care networks. These include the limited scope of practice of community pharmacists, inadequate infrastructure in most pharmacies (e.g., lack of dispensing/patient records and private counseling areas, and understaffing with pharmacists and supporting staff), and public perception of the community pharmacy as a predominantly business enterprise where pharmacists do not exhibit a caring attitude toward patient needs [34 –36].

Interestingly, evidence suggests that it is still feasible for community pharmacists in the UAE to maintain their independent practice while engaging in coordinated relationships with physicians, which would lead to enhanced pharmacist engagement and provision of care to patients [37]. Physicians identified collaborating with pharmacists has great benefit to patient safety and care outcomes, provided clear pharmacist-physician role definition, efficient communication, and assured pharmacist competence are established [37].

The laws governing pharmacy practice in the UAE do not define standards related to community pharmacist-provided patient assessment, information giving and counseling. Such standards are urgently needed to define the competencies that need to be acquired by pharmacists. To improve patient outcomes, the laws and regulations that restrict dispensing of POMs to patients without a physician’s order should be enforced. Additionally, there is a need for health authorities in the UAE to modify regulations to allow pharmacists to provide enhanced services and receive appropriate remuneration. The current business model of most community pharmacies that emphasizes profit-making at the expense of health service provision has negatively affected pharmacist job satisfaction, public perception of pharmacists, and decreased consumer demand for professional pharmacy services [38]. Efforts must be placed on promoting pharmacist-delivered patient-centered care across the health system and increasing the awareness about community pharmacist’s role beyond dispensing.

Some methodological issues must be considered. Pharmacists’ poor completion of several open-ended items, particularly those that followed categorical responses, about dispensing and counseling practices, was notable. Despite efforts of data collectors to point out unanswered items, pharmacists failed to describe their approach to history taking, routine dispensing practices, assessment of medication adherence, and mechanism of referral. The unsatisfactory completion of these items may be due to the response burden associated with the length of the questionnaire, particularly if they chose to complete the survey on the spot. However, it may also be a symptom of inadequate clinical knowledge and skills of these pharmacists, and hence most did not respond to open-ended questions that assess the ‘how to’. Language was not reported as a barrier to completing the survey; pharmacists are required to be proficient in Arabic and English for licensure in the UAE. On a separate note, although the amount of variance explained by multivariate analysis was small, however, the significant p-value indicated a significant explanatory power that is different from zero.

Based on authors’ experience in conducting studies in the UAE, a tendency of community pharmacists towards inflating their practices was noted. Therefore, open-ended questions were used as a follow-up to categorical items to minimize social desirability bias and verify the accuracy of categorical responses. The response rate was not calculated; data collectors sometimes failed to document the number of pharmacies who refused to participate. However, the response rate was generally very good; research assistants reported that only a few pharmacists refused to participate.

Implications to practice and policy

The predicted increase in the prevalence of AD and its societal burden places increasing demands and pressure on health systems to create new models of care that meet the needs of these vulnerable groups. In the UAE, the scarcity of appropriate health services for people with AD in the primary care setting calls for increasing the capacity to deliver such services through community pharmacies. The following four recommendations are suggested for the pharmacy profession and regulatory bodies to enable the positioning of community pharmacists as a valuable resource to help improve care for individuals with AD:

Revise undergraduate curricula to enhance the education on AD management and particularly on pharmacist-delivered AD care. For example, new curricula should focus on improving clinical knowledge and communication skills that enable pharmacists to provide appropriate AD management. Emphasis should be placed on assisting young pharmacy graduates to evaluate prescribed treatment for appropriateness, effectiveness, and safety, identify adherence challenges, and recognize the early signs and symptoms of AD.

Provide training to practicing community pharmacists to develop the patient-centered communication skills that enable them to engage in a comprehensive, informed, and interactive discussion with patients and their caregivers and facilitate shared decision making. Pharmacists should also receive additional training on the impact of AD on the caregiver, critical issues associated with medication management, and how to recognize signs of memory loss so that at-risk individuals can be referred to physicians for appropriate assessment, diagnosis, and follow-up.

Increase healthcare provider’s recognition of pharmacists’ role in AD management and create collaborative care plans with structured referral pathways.

Create remuneration schemes for enhanced pharmacy-based health services and revise pharmacy legislation to widen the scope of practice.

Conclusion

There were considerable shortcomings in pharmacist-delivered care for people with AD. Community pharmacists did not provide adequate counseling, did not assess adherence-related issues appropriately, and had deficient knowledge. To develop patient-centered pharmacy-based services for Arabic-speaking communities, a multifaceted approach is required that goes beyond improving pharmacy workforce knowledge and communication skills to address broader sociocultural, legislative, financial factors.

Footnotes

ACKNOWLEDGMENTS

This work was financially supported by operational grant from the Sharjah Institute for Medical Research, University of Sharjah.

The authors would like to thank field team Ms. Jumanah Saleh and Ms. Hind Adwan for their great efforts in collecting completed questionnaires. Special thanks to Dubai Health Authority and Sharjah Economic Development Authority for providing the lists of registered community pharmacies.

Authors’ disclosures available online ().

The supplementary material is available in the electronic version of this article: .

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