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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"]
Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers – delivering critical care while navigating increasing financial pressures.
Women make up around 70% of the credentialed pharmacists who deliver HMRs, with two-thirds under the age of 40. HMR work is a constant balancing act that involves managing the significant demands of professional practice alongside raising young families.
With Mother’s Day approaching, the reality of HMR work mirrors a common narrative for women in pharmacy: highly skilled professionals delivering personalised care, while managing significant responsibilities at home.
These pressures increasingly undermine the sustainability of HMR practice.
[caption id="attachment_32039" align="alignright" width="300"]
Katie Phillips MPS[/caption]
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured,’ said credentialed pharmacist Katie Phillips MPS.
Critical care for vulnerable Australians
Pharmacists conducting HMRs play a crucial role in supporting quality use of medicines among vulnerable Australians at risk of medication misadventure.
Credentialed pharmacist Erica Stephenson MPS, told AP that one of the most important aspects of her role is just being there.
‘For an hour, I might have relieved somebody's loneliness by being in their home and having a chat with them about them and their medication.’
With current HMR caps set at 30 HMRs per month, access can become an issue, particularly in rural and remote areas. ‘No one should have to wait for a review when there are credentialed pharmacists able to provide the service but capped out for the month,’ Ms Phillips said.
Ms Stephenson added that ‘the cap gets you caught. At the end of the month, you might get that emergency, and you've already hit your cap and then can’t provide the service.’
[caption id="attachment_31991" align="aligncenter" width="400"]
Erica Stephenson MPS with her kids[/caption]
Flexibility with hidden costs
HMR work is often promoted for its flexibility, yet the reality is far more complicated. Alongside delivering the service, pharmacists have to grapple with long hours, extensive travel and significant unpaid work – including driving, documentation and reporting.
For mothers, these demands pose significant challenges when balancing professional and personal responsibilities. ‘When everything related to a HMR is taken into account, the pay rate is unsustainable, especially with many pharmacies/HMR businesses taking a cut of a pharmacist’s HMR earnings,’ Ms Phillips said.
As a mother of two young girls, Ms Phillips describes herself as ‘incredibly time poor and forever on the go,’ with HMRs often scheduled on her ‘days off’.
Ms Stephenson transitioned into HMR work as her sole form of employment to provide a sense of flexibility as a single mum with chronic health issues. And since becoming a credentialed diabetes educator, she is ‘busier than ever’.
When asked what would make HMRs more sustainable, Ms Phillips suggested telehealth as a pivotal follow-up method.
[caption id="attachment_32040" align="alignright" width="300"]
Katie Phillip MPS with her two daughters[/caption]
‘There is so much value in a follow-up call to close the loop of care,’ she said.
‘I have had a patient’s daughter text me almost daily, waiting out the month before [an HMR] follow-up, as various dose changes were made by the GP with not so great results.
‘I happily responded to all her texts, but I didn’t really need to see the patient in person again to be able to advise on what should be next, and there is no recognition or remuneration for this time,’ Ms Stephenson said.
The employment model piles on further strain. Most credentialed pharmacists are self-employed practitioners, so there is limited security – ranging from no superannuation, sick leave or annual leave – and time off is typically unpaid.
Ms Stephenson works 50 weeks of the year, taking time off only over Christmas as the backlog of referrals grows exponentially.
‘I joke that sometimes I'm on negative $5 an hour because I'm just so buried in admin. It's a full-time job just keeping on top of the admin, which is, of course, unpaid,’ Ms Stephenson said.
‘I don't really have any disposable income. I just pay my bills, and that's it. Which is unfair on my kids who are very independent and have their own jobs, but that’s just the way it is.’
These pressures are compounded by irregular referral patterns, which take a sense of financial stability out of the question. The Australian Health and Medical Research Workforce Audit shows that a lack of funding, job security and work-life balance are the main reasons individuals consider leaving the field.
Ms Stephenson urged younger mums looking to broaden their scope that HMRs are maybe not as clear cut as they seem as ‘You’re actually on the job 24/7 almost’.
Structural barriers
[caption id="attachment_32041" align="alignright" width="300"]
Deborah Hawthorne FPS with her two daughters[/caption]
HMR remuneration has not been indexed since 2019 and remains at $222.77 per review, raising consistent concerns regarding long-term sustainability of the practice.
Funded by the Australian Government under the Community Pharmacy Agreements, an increase in the cost of living has not been met with an increase in fees, meaning that each pharmacist is essentially taking a pay cut each year.
‘Once you take out tax, provisions for personal leave/annual leave etc., the hourly rate is pitiful. And when appointments are cancelled due to the clinician or patient, it can leave you high and dry financially,’ Ms Phillips said.
Ms Stephenson, a single mum of two teenagers, called for an ‘essential’ increase to remuneration. ‘For every $222, I take $26 out for superannuation, $55 for tax, and $10 if I want to treat myself to catch up with friends. That leaves me with $130 to run my car and pay subscriptions, household bills and mortgage,’ she said.
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured.'
katie phillips MPS
’[The] 200 km limit for travel is too high. I can drive for an hour to see somebody and still not be eligible for the rural travel allowance.’
The lack of employment entitlements further exacerbates the issue. ‘As a young mum, if I have to cancel HMRs because my kids are sick, I don’t get paid,’ she said.
‘[And I] might miss special moments like a bedtime story because [I’m] frantically trying to finish something that the doctor's waiting on urgently.’
Despite these mounting challenges, many pharmacists remain committed to delivering HMRs, driven by the impact they have on patient care – particularly for elderly Australians and those with chronic and complex conditions.
Sustainable HMR practice, Ms Phillips said, depends on ‘Being paid appropriately, with appropriately indexed remuneration reflecting the level of skills and experience required, travel costs, and allowances for lack of entitlements’.
With demand for medication reviews projected to grow, driven by an aging population, rising rates of polypharmacy and a need to manage preventable, medication-related hospital admissions, there are increasing calls to address indexation and structural barriers – ensuring the workforce remains viable and patients continue to receive the care they need.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => This Mother’s Day, let’s spotlight mums delivering HMR care
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Case scenarioJoe, a 76-year-old man, visits the pharmacy accompanied by his daughter, who expresses concern about his increasing forgetfulness and confusion over the past year. Joe has begun misplacing items, repeating questions and occasionally getting lost in familiar places. You ask Joe and his daughter about the progression of symptoms, daily functioning and any changes in mood or behaviour. He denies feeling depressed but expresses frustration with his poor memory. He is currently taking medicines for hypertension and type 2 diabetes. |
Dementia was the leading cause of death in 2024, with deaths from dementia increasing by 39% over the past decade.1 It is a progressive, life-limiting syndrome characterised by a decline in cognition and functional abilities.2 The most common cause of dementia is Alzheimer’s disease (50–75% of cases), followed by vascular dementia (20–30%), frontotemporal dementias (up to 10%), and dementia with Lewy bodies and Parkinson’s disease dementia (up to 10%).2
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD[/caption]
Table 1 (page 44) summarises the common causes of dementia and the current understanding of their pathogenesis.
| Causes of dementia | Descriptions |
| Alzheimer’s disease | The amyloid cascade hypothesis suggests that the deposition of amyloid-β (Aβ) plaques leads to neurofibrillary tangles, cell loss, vascular damage and dementia.3 For decades, this hypothesis has been the primary target for developing therapies for Alzheimer’s disease. In light of new evidence, several iterations of the theory have been proposed, highlighting a more complex aetiology involving polygenic, epigenetic, environmental, vascular, neuroinflammatory and metabolic factors.4 Today, the aetiological complexity surrounding the pathogenesis of Alzheimer’s disease has not been fully established. |
| Vascular dementia | Vascular dementia results from impaired blood supply to the brain, which damages brain tissue and subsequently leads to cognitive decline.5 Common neuropathological findings include multiple infarcts or single strategic infarcts caused by atherothromboembolic events or small vessel disease.5 |
| Mixed dementia | It is common for individuals to present with more than one type of dementia. The term ‘mixed dementia’ refers to the co-occurrence of more than one subtype of dementia, most commonly Alzheimer’s disease and vascular dementia. However, the use of this term is increasingly discouraged due to its ambiguity.6 |
| Lewy body dementia | Lewy body dementia is an umbrella term describing two forms of dementia: dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). DLB is characterised by the accumulation of α-synuclein in Lewy bodies and Lewy neurites in the brain, as well as neuronal loss in the substantia nigra, although typically less severe than that observed in Parkinson’s disease.6 PDD and DLB are both α-synucleinopathies.6 There is considerable clinical overlap between DLB and PDD.6 Generally, DLB presents at an older age, while PDD is preceded by a long period of motor symptoms.6 The arbitrary ‘1-year rule’ is commonly applied in clinical practice, whereby DLB is diagnosed when cognitive symptoms appear before or within 1 year of motor symptoms, whereas PDD is diagnosed when cognitive decline occurs in the context of established Parkinson’s disease.6 |
| Frontotemporal dementia | Frontotemporal dementia (FTD) is a common cause of early-onset dementia, typically affecting individuals aged 45–65 years.7 FTD is categorised as three variants: 1) behavioural-variant FTD (associated with behavioural and executive deficits), 2) non-fluent variant primary progressive aphasia (progressive deficits in speech, grammar and word output), and 3) semantic-variant primary progressive aphasia (impaired naming and single-word comprehension).8 As the name suggests, FTD involves progressive degeneration of the frontal and/or temporal lobes associated with characteristic protein inclusions.6 Genetic mutations and family history of dementia play an important role in its pathogenesis.6 |
| Other causes of dementia |
|
Clinical features
Dementia symptoms vary between individuals, with common symptoms outlined in Box 1.11 Early dementia symptoms are often subtle and easily overlooked, and dementia is still commonly perceived as a normal part of ageing.12 To address this, initiatives such as the National Dementia Action Plan 2024–2034 have been introduced to raise awareness, reduce risks and improve access to services across Australia.13
Box 1 – Common symptoms of dementia
|
As dementia progresses, individuals may also experience changes in behaviour or emotional state, such as14:
Collectively, these symptoms used to be clinically referred to as behavioural and psychological symptoms of dementia (BPSD). However, this terminology is increasingly being discouraged as it does not reflect the lived experience of people with dementia.15
Some alternative terms include changed behaviours or responsive behaviours.14 However, these terms are not universally preferred among all people living with dementia and their carers.
Changed behaviours typically intensify with disease progression and are often triggered by underlying factors such as unmet needs (e.g. hunger, thirst, toileting), physical illness, pain, psychiatric conditions, constipation, fatigue, loneliness and environmental stressors.14 A comprehensive assessment is essential for identifying and addressing these contributing factors.
Changed behaviours can be distressing for both the individual and their carers, and person-centred care approaches are critical to managing these challenges effectively to minimise harm.
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac[/caption]
Reversible causes of cognitive impairment should be excluded as part of the dementia assessment and treated as appropriate. Examples include9:
Some medicines adversely affect cognition. In individuals receiving cholinesterase inhibitors and medicines that have anticholinergic properties, clinicians should first consider deprescribing anticholinergics due to the potential adverse impact on cognitive function.16 Other medicines associated with cognitive impairment include psychotropics, GABAergic agents, opioids, corticosteroids and antibiotics.17
Dementia diagnosis requires a comprehensive physical examination and cognitive test using validated tools, such as the Mini-Mental State Examination (MMSE), General Practitioner Assessment of Cognition (GPCOG), and Montreal Cognitive Assessment (MoCA).9 For Aboriginal and Torres Strait Islander peoples, the Kimberley Indigenous Cognitive Assessment (KICA) is a culturally appropriate dementia screening tool that has been validated in this population in Australia.18
While challenging, identifying the specific type of dementia is crucial for guiding appropriate treatment and support. Input from specialists (e.g. neurologist, neuropsychologist or geriatrician) is often required, in collaboration with the individual and their family or support network.
Dementia risk factors are broadly categorised into potentially modifiable and non-modifiable.
Non-modifiable risk factors include age, parental family history of dementia and the possession of the APOE4 allele.19 Dementia incidence increases exponentially with age, doubling approximately every 5 years from 65 and 90 years.20 Despite age being a major risk factor, dementia can affect individuals of all ages.
Potentially modifiable risk factors include air pollution, smoking (including second-hand exposure), high alcohol intake, low education, head injuries, hearing impairment, hypertension, obesity, sedentary lifestyle and social isolation.9,19 Addressing modifiable risk factors is important for reducing dementia risk and preventing other chronic diseases.9 Key strategies include increasing physical activity, preventing head injury and hearing loss (e.g. wearing hearing protection when exposed to loud noise), quitting smoking, avoiding second-hand smoke exposure, maintaining a healthy and balanced diet, reducing or ceasing alcohol use, managing a normal weight and blood pressure, staying socially connected, engaging in cognitively stimulating activities, and promoting community inclusion.9
There is currently no cure for dementia. The primary goal of management is to support the individual’s quality of life, maintain independence for as long as possible, and provide holistic care throughout the disease trajectory.
A dementia care plan should aim to9:
Non-pharmacological approaches are the first-line treatment for managing changed behaviours in dementia and should be continued even when medicine is commenced. Non-pharmacological interventions are person-centred and aim to address unmet needs, environmental stressors and emotional distress.2 Evidence-based psychosocial interventions that can be delivered in both the community and facility settings include reminiscence therapy, validation therapy, cognitive stimulation therapies and reality orientation.21,22
Other non-pharmacological practices include structured care approaches (e.g. bathing, oral care routines), sensory interventions (e.g. aromatherapy, massage, multisensory stimulation, bright light therapy), psychosocial practices (music therapy, pet therapy, meaningful activities), and social engagement.21,22 Approaches for managing dementia should be tailored to the individual’s preferences, cultural background and life history – and involve carers in the planning and delivery.
Pharmacological interventions are not recommended as first-line treatments for changed behaviours due to limited efficacy and risk of serious harm.2,14,23 They were associated with increased risks of cardiovascular or cerebrovascular events (stroke, venous thromboembolism, myocardial infarction, heart failure), fracture, pneumonia and acute kidney injury.24
As such, psychotropic medicines should only be considered when acute behavioural disturbance is severe, posing an imminent risk of harm to the individual or others, and the required expertise is available.2
The two main classes of medicines used in the treatment of dementia are anticholinesterases (donepezil, galantamine and rivastigmine) and memantine (an N-methyl-D-aspartate receptor antagonist).25 They provide modest symptomatic relief and do not alter the course of the disease. 2,23
Anticholinesterases are indicated for mild to moderate Alzheimer’s disease,26 and may also be used off-label for Lewy body dementia, vascular dementia or mixed dementia. Common adverse effects include nausea, vomiting, diarrhoea and insomnia.25 Memantine is indicated for moderate to severe Alzheimer’s disease or when anticholinesterases are unsuitable and can sometimes be combined with an anticholinesterase, though benefits vary between individuals.23 Before initiating treatment, clinicians should perform an electrocardiogram, record baseline weight and assess fall risk.9 A review shortly after initiation (e.g. 1 month) is recommended to assess adverse events and dose titration, and within 6 months to determine responses on cognition, daily function and physical symptoms.9,23
Many people living with dementia are living with other comorbidities, and the cumulative burden of polypharmacy can present a great risk to their quality of life and health. Deprescribing should be considered and offered if the person16:
The MATCH-D (medication appropriateness tool for comorbid health conditions in dementia) criteria is a practical tool that allows pharmacists to optimise medicine use in people with dementia.27 The tool is freely available at www.match-d.com.au, and can be used by pharmacists to decide whether medicines are used appropriately for comorbidities during the different stages of dementia.
Other tools for optimising medicine regimens include the Clinical Practice Guidelines for Deprescribing in Older People (available at deprescribing.com)16 and the Drug Burden Index tool for calculating the cumulative exposure to anticholinergic and sedative medicines (available at www.gmedss.com/about).28
New and emerging therapies
Research into disease-modifying treatments for dementia is ongoing. Recent developments have focused on monoclonal antibodies that target Aβ plaques, a hallmark of Alzheimer’s disease pathology.26 Donanemab and lecanemab are newly approved monoclonal antibody therapies for adults with early symptomatic Alzheimer’s disease who have a specific genetic profile and confirmed Aβ plaque presence.26 These medicines are administered by intravenous infusion every 2–4 weeks, and can cause brain oedema and microhaemorrhages, necessitating regular MRI monitoring.
They are not subsidised by the Pharmaceutical Benefits Scheme at the time of writing, and their high cost may further limit uptake. While anti-amyloid therapies have demonstrated a significant reduction in brain amyloid in people with early Alzheimer’s disease,26 clinically meaningful cognitive and functional improvements are modest.29
In addition to monoclonal antibodies, there are over 100 compounds currently in the pharmaceutical research pipeline.30 These include potential peptide-based vaccines aimed at prevention,31 as well as biomarker-driven screening tools to identify individuals at risk earlier in the disease process.32
Most people with dementia live in the community1 and are often supported by family members. Families should be encouraged to apply for aged care support and request an assessment through My Aged Care. Legal arrangements such as enduring power of attorney, wills, property management and advance care planning should be discussed early. A wide range of resources is available to support carers and families, including those provided by Dementia Australia, the Wicking Dementia Research and Education Centre, Services Australia, Carers Australia, Carer Gateway (1800 422 737), the National Dementia Helpline (1800 100 500), and the Dementia Behaviour Management Advisory Service (1800 699 799).
A national survey revealed gaps in community awareness of dementia, finding that Australians hold diverse and often stigmatising views about dementia.12 Such stigma may deter individuals experiencing cognitive changes from seeking medical advice due to fears of unfair treatment.33
Aboriginal and Torres Strait Islander peoples are disproportionately affected by dementia and may face additional barriers to accessing services.15 Dementia Australia offers culturally appropriate resources, including materials for people with dementia, families and carers, communication cards, and language guidelines.34,35 Pharmacists play a vital role in reducing these barriers and supporting ongoing culturally safe care.
Pharmacists are trusted professionals with the knowledge to support people living with dementia through safe, person-centred medicines management. Pharmacists are key members of the broader healthcare team. Our roles include reconciling medicines aligned with individuals’ goals of care, early identification of adverse effects, recognising potentially inappropriate medicines and suggesting deprescribing where appropriate. Having a comprehensive understanding of the condition and its impact on individuals is essential for delivering person-centred care. Pharmacists can contribute by identifying early signs of cognitive decline – facilitating referrals to appropriate support services and assisting with symptoms and medicines management.
Clinical pharmacists also have the potential to extend their scope beyond medicines management, contributing to proactive, multidisciplinary dementia care in primary care settings.36 Dementia-specific training and a supportive workplace environment are essential for pharmacists to effectively fulfil these roles. Dementia support pharmacists have demonstrated the great value of this role.37
Dementia is a debilitating condition with high morbidity and mortality. Pharmacists play a vital role in reducing stigma by deepening their understanding of dementia – improving access to support and services, and ensuring safe, person-centred medicines management. By identifying inappropriate medicines and supporting optimal treatment outcomes, pharmacists help individuals maintain independence and quality of life.
Case scenario continuedBased on the conversation, you provide information about cognitive screening tools such as the Mini-Cog and refer Joe to a GP for further assessments. You explain that the GP may refer Joe to a neurologist or geriatrician for a comprehensive evaluation, which could include neuropsychological testing and brain imaging. You also discuss lifestyle strategies that may support cognitive health, including regular exercise, mental stimulation, social interaction and a balanced diet. Joe and his daughter appreciate the guidance and feel reassured about the next steps. |
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is supported by an Australian Government Research Training Program Scholarship at the University of Western Australia.
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD has received multiple grants through the Medical Research Future Fund (MRFF) and the Western Australian Future Health Research and Innovation Fund/WA Department of Health. She is an employee of the University of Western Australia.
Our reviewer
Morna Falkland BPharm
Conflict of interest declaration None declared.
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers – delivering critical care while navigating increasing financial pressures.
Women make up around 70% of the credentialed pharmacists who deliver HMRs, with two-thirds under the age of 40. HMR work is a constant balancing act that involves managing the significant demands of professional practice alongside raising young families.
With Mother’s Day approaching, the reality of HMR work mirrors a common narrative for women in pharmacy: highly skilled professionals delivering personalised care, while managing significant responsibilities at home.
These pressures increasingly undermine the sustainability of HMR practice.
[caption id="attachment_32039" align="alignright" width="300"] Katie Phillips MPS[/caption]
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured,’ said credentialed pharmacist Katie Phillips MPS.
Critical care for vulnerable Australians
Pharmacists conducting HMRs play a crucial role in supporting quality use of medicines among vulnerable Australians at risk of medication misadventure.
Credentialed pharmacist Erica Stephenson MPS, told AP that one of the most important aspects of her role is just being there.
‘For an hour, I might have relieved somebody's loneliness by being in their home and having a chat with them about them and their medication.’
With current HMR caps set at 30 HMRs per month, access can become an issue, particularly in rural and remote areas. ‘No one should have to wait for a review when there are credentialed pharmacists able to provide the service but capped out for the month,’ Ms Phillips said.
Ms Stephenson added that ‘the cap gets you caught. At the end of the month, you might get that emergency, and you've already hit your cap and then can’t provide the service.’
[caption id="attachment_31991" align="aligncenter" width="400"] Erica Stephenson MPS with her kids[/caption]
Flexibility with hidden costs
HMR work is often promoted for its flexibility, yet the reality is far more complicated. Alongside delivering the service, pharmacists have to grapple with long hours, extensive travel and significant unpaid work – including driving, documentation and reporting.
For mothers, these demands pose significant challenges when balancing professional and personal responsibilities. ‘When everything related to a HMR is taken into account, the pay rate is unsustainable, especially with many pharmacies/HMR businesses taking a cut of a pharmacist’s HMR earnings,’ Ms Phillips said.
As a mother of two young girls, Ms Phillips describes herself as ‘incredibly time poor and forever on the go,’ with HMRs often scheduled on her ‘days off’.
Ms Stephenson transitioned into HMR work as her sole form of employment to provide a sense of flexibility as a single mum with chronic health issues. And since becoming a credentialed diabetes educator, she is ‘busier than ever’.
When asked what would make HMRs more sustainable, Ms Phillips suggested telehealth as a pivotal follow-up method.
[caption id="attachment_32040" align="alignright" width="300"] Katie Phillip MPS with her two daughters[/caption]
‘There is so much value in a follow-up call to close the loop of care,’ she said.
‘I have had a patient’s daughter text me almost daily, waiting out the month before [an HMR] follow-up, as various dose changes were made by the GP with not so great results.
‘I happily responded to all her texts, but I didn’t really need to see the patient in person again to be able to advise on what should be next, and there is no recognition or remuneration for this time,’ Ms Stephenson said.
The employment model piles on further strain. Most credentialed pharmacists are self-employed practitioners, so there is limited security – ranging from no superannuation, sick leave or annual leave – and time off is typically unpaid.
Ms Stephenson works 50 weeks of the year, taking time off only over Christmas as the backlog of referrals grows exponentially.
‘I joke that sometimes I'm on negative $5 an hour because I'm just so buried in admin. It's a full-time job just keeping on top of the admin, which is, of course, unpaid,’ Ms Stephenson said.
‘I don't really have any disposable income. I just pay my bills, and that's it. Which is unfair on my kids who are very independent and have their own jobs, but that’s just the way it is.’
These pressures are compounded by irregular referral patterns, which take a sense of financial stability out of the question. The Australian Health and Medical Research Workforce Audit shows that a lack of funding, job security and work-life balance are the main reasons individuals consider leaving the field.
Ms Stephenson urged younger mums looking to broaden their scope that HMRs are maybe not as clear cut as they seem as ‘You’re actually on the job 24/7 almost’.
Structural barriers
[caption id="attachment_32041" align="alignright" width="300"] Deborah Hawthorne FPS with her two daughters[/caption]
HMR remuneration has not been indexed since 2019 and remains at $222.77 per review, raising consistent concerns regarding long-term sustainability of the practice.
Funded by the Australian Government under the Community Pharmacy Agreements, an increase in the cost of living has not been met with an increase in fees, meaning that each pharmacist is essentially taking a pay cut each year.
‘Once you take out tax, provisions for personal leave/annual leave etc., the hourly rate is pitiful. And when appointments are cancelled due to the clinician or patient, it can leave you high and dry financially,’ Ms Phillips said.
Ms Stephenson, a single mum of two teenagers, called for an ‘essential’ increase to remuneration. ‘For every $222, I take $26 out for superannuation, $55 for tax, and $10 if I want to treat myself to catch up with friends. That leaves me with $130 to run my car and pay subscriptions, household bills and mortgage,’ she said.
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured.'
katie phillips MPS
’[The] 200 km limit for travel is too high. I can drive for an hour to see somebody and still not be eligible for the rural travel allowance.’
The lack of employment entitlements further exacerbates the issue. ‘As a young mum, if I have to cancel HMRs because my kids are sick, I don’t get paid,’ she said.
‘[And I] might miss special moments like a bedtime story because [I’m] frantically trying to finish something that the doctor's waiting on urgently.’
Despite these mounting challenges, many pharmacists remain committed to delivering HMRs, driven by the impact they have on patient care – particularly for elderly Australians and those with chronic and complex conditions.
Sustainable HMR practice, Ms Phillips said, depends on ‘Being paid appropriately, with appropriately indexed remuneration reflecting the level of skills and experience required, travel costs, and allowances for lack of entitlements’.
With demand for medication reviews projected to grow, driven by an aging population, rising rates of polypharmacy and a need to manage preventable, medication-related hospital admissions, there are increasing calls to address indexation and structural barriers – ensuring the workforce remains viable and patients continue to receive the care they need.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => This Mother’s Day, let’s spotlight mums delivering HMR care
[post_excerpt] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers.
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[title_attribute] => This Mother’s Day, let’s spotlight mums delivering HMR care
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Case scenarioJoe, a 76-year-old man, visits the pharmacy accompanied by his daughter, who expresses concern about his increasing forgetfulness and confusion over the past year. Joe has begun misplacing items, repeating questions and occasionally getting lost in familiar places. You ask Joe and his daughter about the progression of symptoms, daily functioning and any changes in mood or behaviour. He denies feeling depressed but expresses frustration with his poor memory. He is currently taking medicines for hypertension and type 2 diabetes. |
Dementia was the leading cause of death in 2024, with deaths from dementia increasing by 39% over the past decade.1 It is a progressive, life-limiting syndrome characterised by a decline in cognition and functional abilities.2 The most common cause of dementia is Alzheimer’s disease (50–75% of cases), followed by vascular dementia (20–30%), frontotemporal dementias (up to 10%), and dementia with Lewy bodies and Parkinson’s disease dementia (up to 10%).2
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD[/caption]
Table 1 (page 44) summarises the common causes of dementia and the current understanding of their pathogenesis.
| Causes of dementia | Descriptions |
| Alzheimer’s disease | The amyloid cascade hypothesis suggests that the deposition of amyloid-β (Aβ) plaques leads to neurofibrillary tangles, cell loss, vascular damage and dementia.3 For decades, this hypothesis has been the primary target for developing therapies for Alzheimer’s disease. In light of new evidence, several iterations of the theory have been proposed, highlighting a more complex aetiology involving polygenic, epigenetic, environmental, vascular, neuroinflammatory and metabolic factors.4 Today, the aetiological complexity surrounding the pathogenesis of Alzheimer’s disease has not been fully established. |
| Vascular dementia | Vascular dementia results from impaired blood supply to the brain, which damages brain tissue and subsequently leads to cognitive decline.5 Common neuropathological findings include multiple infarcts or single strategic infarcts caused by atherothromboembolic events or small vessel disease.5 |
| Mixed dementia | It is common for individuals to present with more than one type of dementia. The term ‘mixed dementia’ refers to the co-occurrence of more than one subtype of dementia, most commonly Alzheimer’s disease and vascular dementia. However, the use of this term is increasingly discouraged due to its ambiguity.6 |
| Lewy body dementia | Lewy body dementia is an umbrella term describing two forms of dementia: dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). DLB is characterised by the accumulation of α-synuclein in Lewy bodies and Lewy neurites in the brain, as well as neuronal loss in the substantia nigra, although typically less severe than that observed in Parkinson’s disease.6 PDD and DLB are both α-synucleinopathies.6 There is considerable clinical overlap between DLB and PDD.6 Generally, DLB presents at an older age, while PDD is preceded by a long period of motor symptoms.6 The arbitrary ‘1-year rule’ is commonly applied in clinical practice, whereby DLB is diagnosed when cognitive symptoms appear before or within 1 year of motor symptoms, whereas PDD is diagnosed when cognitive decline occurs in the context of established Parkinson’s disease.6 |
| Frontotemporal dementia | Frontotemporal dementia (FTD) is a common cause of early-onset dementia, typically affecting individuals aged 45–65 years.7 FTD is categorised as three variants: 1) behavioural-variant FTD (associated with behavioural and executive deficits), 2) non-fluent variant primary progressive aphasia (progressive deficits in speech, grammar and word output), and 3) semantic-variant primary progressive aphasia (impaired naming and single-word comprehension).8 As the name suggests, FTD involves progressive degeneration of the frontal and/or temporal lobes associated with characteristic protein inclusions.6 Genetic mutations and family history of dementia play an important role in its pathogenesis.6 |
| Other causes of dementia |
|
Clinical features
Dementia symptoms vary between individuals, with common symptoms outlined in Box 1.11 Early dementia symptoms are often subtle and easily overlooked, and dementia is still commonly perceived as a normal part of ageing.12 To address this, initiatives such as the National Dementia Action Plan 2024–2034 have been introduced to raise awareness, reduce risks and improve access to services across Australia.13
Box 1 – Common symptoms of dementia
|
As dementia progresses, individuals may also experience changes in behaviour or emotional state, such as14:
Collectively, these symptoms used to be clinically referred to as behavioural and psychological symptoms of dementia (BPSD). However, this terminology is increasingly being discouraged as it does not reflect the lived experience of people with dementia.15
Some alternative terms include changed behaviours or responsive behaviours.14 However, these terms are not universally preferred among all people living with dementia and their carers.
Changed behaviours typically intensify with disease progression and are often triggered by underlying factors such as unmet needs (e.g. hunger, thirst, toileting), physical illness, pain, psychiatric conditions, constipation, fatigue, loneliness and environmental stressors.14 A comprehensive assessment is essential for identifying and addressing these contributing factors.
Changed behaviours can be distressing for both the individual and their carers, and person-centred care approaches are critical to managing these challenges effectively to minimise harm.
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac[/caption]
Reversible causes of cognitive impairment should be excluded as part of the dementia assessment and treated as appropriate. Examples include9:
Some medicines adversely affect cognition. In individuals receiving cholinesterase inhibitors and medicines that have anticholinergic properties, clinicians should first consider deprescribing anticholinergics due to the potential adverse impact on cognitive function.16 Other medicines associated with cognitive impairment include psychotropics, GABAergic agents, opioids, corticosteroids and antibiotics.17
Dementia diagnosis requires a comprehensive physical examination and cognitive test using validated tools, such as the Mini-Mental State Examination (MMSE), General Practitioner Assessment of Cognition (GPCOG), and Montreal Cognitive Assessment (MoCA).9 For Aboriginal and Torres Strait Islander peoples, the Kimberley Indigenous Cognitive Assessment (KICA) is a culturally appropriate dementia screening tool that has been validated in this population in Australia.18
While challenging, identifying the specific type of dementia is crucial for guiding appropriate treatment and support. Input from specialists (e.g. neurologist, neuropsychologist or geriatrician) is often required, in collaboration with the individual and their family or support network.
Dementia risk factors are broadly categorised into potentially modifiable and non-modifiable.
Non-modifiable risk factors include age, parental family history of dementia and the possession of the APOE4 allele.19 Dementia incidence increases exponentially with age, doubling approximately every 5 years from 65 and 90 years.20 Despite age being a major risk factor, dementia can affect individuals of all ages.
Potentially modifiable risk factors include air pollution, smoking (including second-hand exposure), high alcohol intake, low education, head injuries, hearing impairment, hypertension, obesity, sedentary lifestyle and social isolation.9,19 Addressing modifiable risk factors is important for reducing dementia risk and preventing other chronic diseases.9 Key strategies include increasing physical activity, preventing head injury and hearing loss (e.g. wearing hearing protection when exposed to loud noise), quitting smoking, avoiding second-hand smoke exposure, maintaining a healthy and balanced diet, reducing or ceasing alcohol use, managing a normal weight and blood pressure, staying socially connected, engaging in cognitively stimulating activities, and promoting community inclusion.9
There is currently no cure for dementia. The primary goal of management is to support the individual’s quality of life, maintain independence for as long as possible, and provide holistic care throughout the disease trajectory.
A dementia care plan should aim to9:
Non-pharmacological approaches are the first-line treatment for managing changed behaviours in dementia and should be continued even when medicine is commenced. Non-pharmacological interventions are person-centred and aim to address unmet needs, environmental stressors and emotional distress.2 Evidence-based psychosocial interventions that can be delivered in both the community and facility settings include reminiscence therapy, validation therapy, cognitive stimulation therapies and reality orientation.21,22
Other non-pharmacological practices include structured care approaches (e.g. bathing, oral care routines), sensory interventions (e.g. aromatherapy, massage, multisensory stimulation, bright light therapy), psychosocial practices (music therapy, pet therapy, meaningful activities), and social engagement.21,22 Approaches for managing dementia should be tailored to the individual’s preferences, cultural background and life history – and involve carers in the planning and delivery.
Pharmacological interventions are not recommended as first-line treatments for changed behaviours due to limited efficacy and risk of serious harm.2,14,23 They were associated with increased risks of cardiovascular or cerebrovascular events (stroke, venous thromboembolism, myocardial infarction, heart failure), fracture, pneumonia and acute kidney injury.24
As such, psychotropic medicines should only be considered when acute behavioural disturbance is severe, posing an imminent risk of harm to the individual or others, and the required expertise is available.2
The two main classes of medicines used in the treatment of dementia are anticholinesterases (donepezil, galantamine and rivastigmine) and memantine (an N-methyl-D-aspartate receptor antagonist).25 They provide modest symptomatic relief and do not alter the course of the disease. 2,23
Anticholinesterases are indicated for mild to moderate Alzheimer’s disease,26 and may also be used off-label for Lewy body dementia, vascular dementia or mixed dementia. Common adverse effects include nausea, vomiting, diarrhoea and insomnia.25 Memantine is indicated for moderate to severe Alzheimer’s disease or when anticholinesterases are unsuitable and can sometimes be combined with an anticholinesterase, though benefits vary between individuals.23 Before initiating treatment, clinicians should perform an electrocardiogram, record baseline weight and assess fall risk.9 A review shortly after initiation (e.g. 1 month) is recommended to assess adverse events and dose titration, and within 6 months to determine responses on cognition, daily function and physical symptoms.9,23
Many people living with dementia are living with other comorbidities, and the cumulative burden of polypharmacy can present a great risk to their quality of life and health. Deprescribing should be considered and offered if the person16:
The MATCH-D (medication appropriateness tool for comorbid health conditions in dementia) criteria is a practical tool that allows pharmacists to optimise medicine use in people with dementia.27 The tool is freely available at www.match-d.com.au, and can be used by pharmacists to decide whether medicines are used appropriately for comorbidities during the different stages of dementia.
Other tools for optimising medicine regimens include the Clinical Practice Guidelines for Deprescribing in Older People (available at deprescribing.com)16 and the Drug Burden Index tool for calculating the cumulative exposure to anticholinergic and sedative medicines (available at www.gmedss.com/about).28
New and emerging therapies
Research into disease-modifying treatments for dementia is ongoing. Recent developments have focused on monoclonal antibodies that target Aβ plaques, a hallmark of Alzheimer’s disease pathology.26 Donanemab and lecanemab are newly approved monoclonal antibody therapies for adults with early symptomatic Alzheimer’s disease who have a specific genetic profile and confirmed Aβ plaque presence.26 These medicines are administered by intravenous infusion every 2–4 weeks, and can cause brain oedema and microhaemorrhages, necessitating regular MRI monitoring.
They are not subsidised by the Pharmaceutical Benefits Scheme at the time of writing, and their high cost may further limit uptake. While anti-amyloid therapies have demonstrated a significant reduction in brain amyloid in people with early Alzheimer’s disease,26 clinically meaningful cognitive and functional improvements are modest.29
In addition to monoclonal antibodies, there are over 100 compounds currently in the pharmaceutical research pipeline.30 These include potential peptide-based vaccines aimed at prevention,31 as well as biomarker-driven screening tools to identify individuals at risk earlier in the disease process.32
Most people with dementia live in the community1 and are often supported by family members. Families should be encouraged to apply for aged care support and request an assessment through My Aged Care. Legal arrangements such as enduring power of attorney, wills, property management and advance care planning should be discussed early. A wide range of resources is available to support carers and families, including those provided by Dementia Australia, the Wicking Dementia Research and Education Centre, Services Australia, Carers Australia, Carer Gateway (1800 422 737), the National Dementia Helpline (1800 100 500), and the Dementia Behaviour Management Advisory Service (1800 699 799).
A national survey revealed gaps in community awareness of dementia, finding that Australians hold diverse and often stigmatising views about dementia.12 Such stigma may deter individuals experiencing cognitive changes from seeking medical advice due to fears of unfair treatment.33
Aboriginal and Torres Strait Islander peoples are disproportionately affected by dementia and may face additional barriers to accessing services.15 Dementia Australia offers culturally appropriate resources, including materials for people with dementia, families and carers, communication cards, and language guidelines.34,35 Pharmacists play a vital role in reducing these barriers and supporting ongoing culturally safe care.
Pharmacists are trusted professionals with the knowledge to support people living with dementia through safe, person-centred medicines management. Pharmacists are key members of the broader healthcare team. Our roles include reconciling medicines aligned with individuals’ goals of care, early identification of adverse effects, recognising potentially inappropriate medicines and suggesting deprescribing where appropriate. Having a comprehensive understanding of the condition and its impact on individuals is essential for delivering person-centred care. Pharmacists can contribute by identifying early signs of cognitive decline – facilitating referrals to appropriate support services and assisting with symptoms and medicines management.
Clinical pharmacists also have the potential to extend their scope beyond medicines management, contributing to proactive, multidisciplinary dementia care in primary care settings.36 Dementia-specific training and a supportive workplace environment are essential for pharmacists to effectively fulfil these roles. Dementia support pharmacists have demonstrated the great value of this role.37
Dementia is a debilitating condition with high morbidity and mortality. Pharmacists play a vital role in reducing stigma by deepening their understanding of dementia – improving access to support and services, and ensuring safe, person-centred medicines management. By identifying inappropriate medicines and supporting optimal treatment outcomes, pharmacists help individuals maintain independence and quality of life.
Case scenario continuedBased on the conversation, you provide information about cognitive screening tools such as the Mini-Cog and refer Joe to a GP for further assessments. You explain that the GP may refer Joe to a neurologist or geriatrician for a comprehensive evaluation, which could include neuropsychological testing and brain imaging. You also discuss lifestyle strategies that may support cognitive health, including regular exercise, mental stimulation, social interaction and a balanced diet. Joe and his daughter appreciate the guidance and feel reassured about the next steps. |
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is supported by an Australian Government Research Training Program Scholarship at the University of Western Australia.
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD has received multiple grants through the Medical Research Future Fund (MRFF) and the Western Australian Future Health Research and Innovation Fund/WA Department of Health. She is an employee of the University of Western Australia.
Our reviewer
Morna Falkland BPharm
Conflict of interest declaration None declared.
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers – delivering critical care while navigating increasing financial pressures.
Women make up around 70% of the credentialed pharmacists who deliver HMRs, with two-thirds under the age of 40. HMR work is a constant balancing act that involves managing the significant demands of professional practice alongside raising young families.
With Mother’s Day approaching, the reality of HMR work mirrors a common narrative for women in pharmacy: highly skilled professionals delivering personalised care, while managing significant responsibilities at home.
These pressures increasingly undermine the sustainability of HMR practice.
[caption id="attachment_32039" align="alignright" width="300"] Katie Phillips MPS[/caption]
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured,’ said credentialed pharmacist Katie Phillips MPS.
Critical care for vulnerable Australians
Pharmacists conducting HMRs play a crucial role in supporting quality use of medicines among vulnerable Australians at risk of medication misadventure.
Credentialed pharmacist Erica Stephenson MPS, told AP that one of the most important aspects of her role is just being there.
‘For an hour, I might have relieved somebody's loneliness by being in their home and having a chat with them about them and their medication.’
With current HMR caps set at 30 HMRs per month, access can become an issue, particularly in rural and remote areas. ‘No one should have to wait for a review when there are credentialed pharmacists able to provide the service but capped out for the month,’ Ms Phillips said.
Ms Stephenson added that ‘the cap gets you caught. At the end of the month, you might get that emergency, and you've already hit your cap and then can’t provide the service.’
[caption id="attachment_31991" align="aligncenter" width="400"] Erica Stephenson MPS with her kids[/caption]
Flexibility with hidden costs
HMR work is often promoted for its flexibility, yet the reality is far more complicated. Alongside delivering the service, pharmacists have to grapple with long hours, extensive travel and significant unpaid work – including driving, documentation and reporting.
For mothers, these demands pose significant challenges when balancing professional and personal responsibilities. ‘When everything related to a HMR is taken into account, the pay rate is unsustainable, especially with many pharmacies/HMR businesses taking a cut of a pharmacist’s HMR earnings,’ Ms Phillips said.
As a mother of two young girls, Ms Phillips describes herself as ‘incredibly time poor and forever on the go,’ with HMRs often scheduled on her ‘days off’.
Ms Stephenson transitioned into HMR work as her sole form of employment to provide a sense of flexibility as a single mum with chronic health issues. And since becoming a credentialed diabetes educator, she is ‘busier than ever’.
When asked what would make HMRs more sustainable, Ms Phillips suggested telehealth as a pivotal follow-up method.
[caption id="attachment_32040" align="alignright" width="300"] Katie Phillip MPS with her two daughters[/caption]
‘There is so much value in a follow-up call to close the loop of care,’ she said.
‘I have had a patient’s daughter text me almost daily, waiting out the month before [an HMR] follow-up, as various dose changes were made by the GP with not so great results.
‘I happily responded to all her texts, but I didn’t really need to see the patient in person again to be able to advise on what should be next, and there is no recognition or remuneration for this time,’ Ms Stephenson said.
The employment model piles on further strain. Most credentialed pharmacists are self-employed practitioners, so there is limited security – ranging from no superannuation, sick leave or annual leave – and time off is typically unpaid.
Ms Stephenson works 50 weeks of the year, taking time off only over Christmas as the backlog of referrals grows exponentially.
‘I joke that sometimes I'm on negative $5 an hour because I'm just so buried in admin. It's a full-time job just keeping on top of the admin, which is, of course, unpaid,’ Ms Stephenson said.
‘I don't really have any disposable income. I just pay my bills, and that's it. Which is unfair on my kids who are very independent and have their own jobs, but that’s just the way it is.’
These pressures are compounded by irregular referral patterns, which take a sense of financial stability out of the question. The Australian Health and Medical Research Workforce Audit shows that a lack of funding, job security and work-life balance are the main reasons individuals consider leaving the field.
Ms Stephenson urged younger mums looking to broaden their scope that HMRs are maybe not as clear cut as they seem as ‘You’re actually on the job 24/7 almost’.
Structural barriers
[caption id="attachment_32041" align="alignright" width="300"] Deborah Hawthorne FPS with her two daughters[/caption]
HMR remuneration has not been indexed since 2019 and remains at $222.77 per review, raising consistent concerns regarding long-term sustainability of the practice.
Funded by the Australian Government under the Community Pharmacy Agreements, an increase in the cost of living has not been met with an increase in fees, meaning that each pharmacist is essentially taking a pay cut each year.
‘Once you take out tax, provisions for personal leave/annual leave etc., the hourly rate is pitiful. And when appointments are cancelled due to the clinician or patient, it can leave you high and dry financially,’ Ms Phillips said.
Ms Stephenson, a single mum of two teenagers, called for an ‘essential’ increase to remuneration. ‘For every $222, I take $26 out for superannuation, $55 for tax, and $10 if I want to treat myself to catch up with friends. That leaves me with $130 to run my car and pay subscriptions, household bills and mortgage,’ she said.
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured.'
katie phillips MPS
’[The] 200 km limit for travel is too high. I can drive for an hour to see somebody and still not be eligible for the rural travel allowance.’
The lack of employment entitlements further exacerbates the issue. ‘As a young mum, if I have to cancel HMRs because my kids are sick, I don’t get paid,’ she said.
‘[And I] might miss special moments like a bedtime story because [I’m] frantically trying to finish something that the doctor's waiting on urgently.’
Despite these mounting challenges, many pharmacists remain committed to delivering HMRs, driven by the impact they have on patient care – particularly for elderly Australians and those with chronic and complex conditions.
Sustainable HMR practice, Ms Phillips said, depends on ‘Being paid appropriately, with appropriately indexed remuneration reflecting the level of skills and experience required, travel costs, and allowances for lack of entitlements’.
With demand for medication reviews projected to grow, driven by an aging population, rising rates of polypharmacy and a need to manage preventable, medication-related hospital admissions, there are increasing calls to address indexation and structural barriers – ensuring the workforce remains viable and patients continue to receive the care they need.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => This Mother’s Day, let’s spotlight mums delivering HMR care
[post_excerpt] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers.
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[title_attribute] => This Mother’s Day, let’s spotlight mums delivering HMR care
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Case scenarioJoe, a 76-year-old man, visits the pharmacy accompanied by his daughter, who expresses concern about his increasing forgetfulness and confusion over the past year. Joe has begun misplacing items, repeating questions and occasionally getting lost in familiar places. You ask Joe and his daughter about the progression of symptoms, daily functioning and any changes in mood or behaviour. He denies feeling depressed but expresses frustration with his poor memory. He is currently taking medicines for hypertension and type 2 diabetes. |
Dementia was the leading cause of death in 2024, with deaths from dementia increasing by 39% over the past decade.1 It is a progressive, life-limiting syndrome characterised by a decline in cognition and functional abilities.2 The most common cause of dementia is Alzheimer’s disease (50–75% of cases), followed by vascular dementia (20–30%), frontotemporal dementias (up to 10%), and dementia with Lewy bodies and Parkinson’s disease dementia (up to 10%).2
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD[/caption]
Table 1 (page 44) summarises the common causes of dementia and the current understanding of their pathogenesis.
| Causes of dementia | Descriptions |
| Alzheimer’s disease | The amyloid cascade hypothesis suggests that the deposition of amyloid-β (Aβ) plaques leads to neurofibrillary tangles, cell loss, vascular damage and dementia.3 For decades, this hypothesis has been the primary target for developing therapies for Alzheimer’s disease. In light of new evidence, several iterations of the theory have been proposed, highlighting a more complex aetiology involving polygenic, epigenetic, environmental, vascular, neuroinflammatory and metabolic factors.4 Today, the aetiological complexity surrounding the pathogenesis of Alzheimer’s disease has not been fully established. |
| Vascular dementia | Vascular dementia results from impaired blood supply to the brain, which damages brain tissue and subsequently leads to cognitive decline.5 Common neuropathological findings include multiple infarcts or single strategic infarcts caused by atherothromboembolic events or small vessel disease.5 |
| Mixed dementia | It is common for individuals to present with more than one type of dementia. The term ‘mixed dementia’ refers to the co-occurrence of more than one subtype of dementia, most commonly Alzheimer’s disease and vascular dementia. However, the use of this term is increasingly discouraged due to its ambiguity.6 |
| Lewy body dementia | Lewy body dementia is an umbrella term describing two forms of dementia: dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). DLB is characterised by the accumulation of α-synuclein in Lewy bodies and Lewy neurites in the brain, as well as neuronal loss in the substantia nigra, although typically less severe than that observed in Parkinson’s disease.6 PDD and DLB are both α-synucleinopathies.6 There is considerable clinical overlap between DLB and PDD.6 Generally, DLB presents at an older age, while PDD is preceded by a long period of motor symptoms.6 The arbitrary ‘1-year rule’ is commonly applied in clinical practice, whereby DLB is diagnosed when cognitive symptoms appear before or within 1 year of motor symptoms, whereas PDD is diagnosed when cognitive decline occurs in the context of established Parkinson’s disease.6 |
| Frontotemporal dementia | Frontotemporal dementia (FTD) is a common cause of early-onset dementia, typically affecting individuals aged 45–65 years.7 FTD is categorised as three variants: 1) behavioural-variant FTD (associated with behavioural and executive deficits), 2) non-fluent variant primary progressive aphasia (progressive deficits in speech, grammar and word output), and 3) semantic-variant primary progressive aphasia (impaired naming and single-word comprehension).8 As the name suggests, FTD involves progressive degeneration of the frontal and/or temporal lobes associated with characteristic protein inclusions.6 Genetic mutations and family history of dementia play an important role in its pathogenesis.6 |
| Other causes of dementia |
|
Clinical features
Dementia symptoms vary between individuals, with common symptoms outlined in Box 1.11 Early dementia symptoms are often subtle and easily overlooked, and dementia is still commonly perceived as a normal part of ageing.12 To address this, initiatives such as the National Dementia Action Plan 2024–2034 have been introduced to raise awareness, reduce risks and improve access to services across Australia.13
Box 1 – Common symptoms of dementia
|
As dementia progresses, individuals may also experience changes in behaviour or emotional state, such as14:
Collectively, these symptoms used to be clinically referred to as behavioural and psychological symptoms of dementia (BPSD). However, this terminology is increasingly being discouraged as it does not reflect the lived experience of people with dementia.15
Some alternative terms include changed behaviours or responsive behaviours.14 However, these terms are not universally preferred among all people living with dementia and their carers.
Changed behaviours typically intensify with disease progression and are often triggered by underlying factors such as unmet needs (e.g. hunger, thirst, toileting), physical illness, pain, psychiatric conditions, constipation, fatigue, loneliness and environmental stressors.14 A comprehensive assessment is essential for identifying and addressing these contributing factors.
Changed behaviours can be distressing for both the individual and their carers, and person-centred care approaches are critical to managing these challenges effectively to minimise harm.
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac[/caption]
Reversible causes of cognitive impairment should be excluded as part of the dementia assessment and treated as appropriate. Examples include9:
Some medicines adversely affect cognition. In individuals receiving cholinesterase inhibitors and medicines that have anticholinergic properties, clinicians should first consider deprescribing anticholinergics due to the potential adverse impact on cognitive function.16 Other medicines associated with cognitive impairment include psychotropics, GABAergic agents, opioids, corticosteroids and antibiotics.17
Dementia diagnosis requires a comprehensive physical examination and cognitive test using validated tools, such as the Mini-Mental State Examination (MMSE), General Practitioner Assessment of Cognition (GPCOG), and Montreal Cognitive Assessment (MoCA).9 For Aboriginal and Torres Strait Islander peoples, the Kimberley Indigenous Cognitive Assessment (KICA) is a culturally appropriate dementia screening tool that has been validated in this population in Australia.18
While challenging, identifying the specific type of dementia is crucial for guiding appropriate treatment and support. Input from specialists (e.g. neurologist, neuropsychologist or geriatrician) is often required, in collaboration with the individual and their family or support network.
Dementia risk factors are broadly categorised into potentially modifiable and non-modifiable.
Non-modifiable risk factors include age, parental family history of dementia and the possession of the APOE4 allele.19 Dementia incidence increases exponentially with age, doubling approximately every 5 years from 65 and 90 years.20 Despite age being a major risk factor, dementia can affect individuals of all ages.
Potentially modifiable risk factors include air pollution, smoking (including second-hand exposure), high alcohol intake, low education, head injuries, hearing impairment, hypertension, obesity, sedentary lifestyle and social isolation.9,19 Addressing modifiable risk factors is important for reducing dementia risk and preventing other chronic diseases.9 Key strategies include increasing physical activity, preventing head injury and hearing loss (e.g. wearing hearing protection when exposed to loud noise), quitting smoking, avoiding second-hand smoke exposure, maintaining a healthy and balanced diet, reducing or ceasing alcohol use, managing a normal weight and blood pressure, staying socially connected, engaging in cognitively stimulating activities, and promoting community inclusion.9
There is currently no cure for dementia. The primary goal of management is to support the individual’s quality of life, maintain independence for as long as possible, and provide holistic care throughout the disease trajectory.
A dementia care plan should aim to9:
Non-pharmacological approaches are the first-line treatment for managing changed behaviours in dementia and should be continued even when medicine is commenced. Non-pharmacological interventions are person-centred and aim to address unmet needs, environmental stressors and emotional distress.2 Evidence-based psychosocial interventions that can be delivered in both the community and facility settings include reminiscence therapy, validation therapy, cognitive stimulation therapies and reality orientation.21,22
Other non-pharmacological practices include structured care approaches (e.g. bathing, oral care routines), sensory interventions (e.g. aromatherapy, massage, multisensory stimulation, bright light therapy), psychosocial practices (music therapy, pet therapy, meaningful activities), and social engagement.21,22 Approaches for managing dementia should be tailored to the individual’s preferences, cultural background and life history – and involve carers in the planning and delivery.
Pharmacological interventions are not recommended as first-line treatments for changed behaviours due to limited efficacy and risk of serious harm.2,14,23 They were associated with increased risks of cardiovascular or cerebrovascular events (stroke, venous thromboembolism, myocardial infarction, heart failure), fracture, pneumonia and acute kidney injury.24
As such, psychotropic medicines should only be considered when acute behavioural disturbance is severe, posing an imminent risk of harm to the individual or others, and the required expertise is available.2
The two main classes of medicines used in the treatment of dementia are anticholinesterases (donepezil, galantamine and rivastigmine) and memantine (an N-methyl-D-aspartate receptor antagonist).25 They provide modest symptomatic relief and do not alter the course of the disease. 2,23
Anticholinesterases are indicated for mild to moderate Alzheimer’s disease,26 and may also be used off-label for Lewy body dementia, vascular dementia or mixed dementia. Common adverse effects include nausea, vomiting, diarrhoea and insomnia.25 Memantine is indicated for moderate to severe Alzheimer’s disease or when anticholinesterases are unsuitable and can sometimes be combined with an anticholinesterase, though benefits vary between individuals.23 Before initiating treatment, clinicians should perform an electrocardiogram, record baseline weight and assess fall risk.9 A review shortly after initiation (e.g. 1 month) is recommended to assess adverse events and dose titration, and within 6 months to determine responses on cognition, daily function and physical symptoms.9,23
Many people living with dementia are living with other comorbidities, and the cumulative burden of polypharmacy can present a great risk to their quality of life and health. Deprescribing should be considered and offered if the person16:
The MATCH-D (medication appropriateness tool for comorbid health conditions in dementia) criteria is a practical tool that allows pharmacists to optimise medicine use in people with dementia.27 The tool is freely available at www.match-d.com.au, and can be used by pharmacists to decide whether medicines are used appropriately for comorbidities during the different stages of dementia.
Other tools for optimising medicine regimens include the Clinical Practice Guidelines for Deprescribing in Older People (available at deprescribing.com)16 and the Drug Burden Index tool for calculating the cumulative exposure to anticholinergic and sedative medicines (available at www.gmedss.com/about).28
New and emerging therapies
Research into disease-modifying treatments for dementia is ongoing. Recent developments have focused on monoclonal antibodies that target Aβ plaques, a hallmark of Alzheimer’s disease pathology.26 Donanemab and lecanemab are newly approved monoclonal antibody therapies for adults with early symptomatic Alzheimer’s disease who have a specific genetic profile and confirmed Aβ plaque presence.26 These medicines are administered by intravenous infusion every 2–4 weeks, and can cause brain oedema and microhaemorrhages, necessitating regular MRI monitoring.
They are not subsidised by the Pharmaceutical Benefits Scheme at the time of writing, and their high cost may further limit uptake. While anti-amyloid therapies have demonstrated a significant reduction in brain amyloid in people with early Alzheimer’s disease,26 clinically meaningful cognitive and functional improvements are modest.29
In addition to monoclonal antibodies, there are over 100 compounds currently in the pharmaceutical research pipeline.30 These include potential peptide-based vaccines aimed at prevention,31 as well as biomarker-driven screening tools to identify individuals at risk earlier in the disease process.32
Most people with dementia live in the community1 and are often supported by family members. Families should be encouraged to apply for aged care support and request an assessment through My Aged Care. Legal arrangements such as enduring power of attorney, wills, property management and advance care planning should be discussed early. A wide range of resources is available to support carers and families, including those provided by Dementia Australia, the Wicking Dementia Research and Education Centre, Services Australia, Carers Australia, Carer Gateway (1800 422 737), the National Dementia Helpline (1800 100 500), and the Dementia Behaviour Management Advisory Service (1800 699 799).
A national survey revealed gaps in community awareness of dementia, finding that Australians hold diverse and often stigmatising views about dementia.12 Such stigma may deter individuals experiencing cognitive changes from seeking medical advice due to fears of unfair treatment.33
Aboriginal and Torres Strait Islander peoples are disproportionately affected by dementia and may face additional barriers to accessing services.15 Dementia Australia offers culturally appropriate resources, including materials for people with dementia, families and carers, communication cards, and language guidelines.34,35 Pharmacists play a vital role in reducing these barriers and supporting ongoing culturally safe care.
Pharmacists are trusted professionals with the knowledge to support people living with dementia through safe, person-centred medicines management. Pharmacists are key members of the broader healthcare team. Our roles include reconciling medicines aligned with individuals’ goals of care, early identification of adverse effects, recognising potentially inappropriate medicines and suggesting deprescribing where appropriate. Having a comprehensive understanding of the condition and its impact on individuals is essential for delivering person-centred care. Pharmacists can contribute by identifying early signs of cognitive decline – facilitating referrals to appropriate support services and assisting with symptoms and medicines management.
Clinical pharmacists also have the potential to extend their scope beyond medicines management, contributing to proactive, multidisciplinary dementia care in primary care settings.36 Dementia-specific training and a supportive workplace environment are essential for pharmacists to effectively fulfil these roles. Dementia support pharmacists have demonstrated the great value of this role.37
Dementia is a debilitating condition with high morbidity and mortality. Pharmacists play a vital role in reducing stigma by deepening their understanding of dementia – improving access to support and services, and ensuring safe, person-centred medicines management. By identifying inappropriate medicines and supporting optimal treatment outcomes, pharmacists help individuals maintain independence and quality of life.
Case scenario continuedBased on the conversation, you provide information about cognitive screening tools such as the Mini-Cog and refer Joe to a GP for further assessments. You explain that the GP may refer Joe to a neurologist or geriatrician for a comprehensive evaluation, which could include neuropsychological testing and brain imaging. You also discuss lifestyle strategies that may support cognitive health, including regular exercise, mental stimulation, social interaction and a balanced diet. Joe and his daughter appreciate the guidance and feel reassured about the next steps. |
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is supported by an Australian Government Research Training Program Scholarship at the University of Western Australia.
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD has received multiple grants through the Medical Research Future Fund (MRFF) and the Western Australian Future Health Research and Innovation Fund/WA Department of Health. She is an employee of the University of Western Australia.
Our reviewer
Morna Falkland BPharm
Conflict of interest declaration None declared.
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[post_content] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps placing pressure on both practitioners and patients.
HMR services remain a vital safeguard for improving health literacy among vulnerable Australians living with chronic illnesses, complex medicine regimens and mental health conditions.
But pharmacists on the ground warn the model is increasingly unsustainable under current funding arrangements. Restrictive caps, rising fuel costs, and extensive travel times are making the reality of HMRs nearly impossible to keep up with.
AP spoke with Mitchell Everlyn, consultant pharmacist, qualified diabetes educator, and locum based in Brisbane, Australia, about the impact of these pressures.
Unsustainability of HMRs
Growing demand for HMRs, increased clinical complexity and systemic constraints are reshaping the extent of the services pharmacists can realistically provide.
Balancing extreme travel distances with capped funding arrangements has left many questioning how long they can continue carrying the weight of HMR practice.
When asked about the sustainability of HMRs, Mr Everlyn said that ‘unless funding increases with caps or indexes upwards, I'm better off working in a pharmacy than I am doing consultant stuff.’
With 30-per-month caps set in place, Mr Everlyn said that ‘the time and money you're getting back from HMRs works out to be about $22 an hour. These financial pressures directly impact which patients pharmacists can realistically afford to fit in.’
At the same time, patient demands continue to climb. HMR waitlists can stretch for months for many pharmacists, particularly in rural areas where these services are a cornerstone in healthcare.
Urgent referrals continue to flood in, yet pharmacists are unable to exceed service limits.
‘I get follow-up emails asking why I haven't seen an acute patient… and it’s because I’ve hit my cap and I can’t,’ Mr Everlyn said.
Despite the growing clinical complexity of patients receiving HMRs, remuneration has been at a standstill since 2019, and service caps have remained largely unchanged, creating a widening gap between the work required and the compensation available.
Under PSA’s 2026-27 Federal Budget recommendations, caps have been recommended to increase to 60 HMRs per month from 1 July 2026.
Professional isolation in rural practice
For pharmacists servicing rural and regional areas, the challenges extend well beyond funding, triggering a push towards incorporating telehealth to ease the strain of providing rural HMR services.
Loading allowance is only extended to $125 per visit, which is designed to contribute towards the costs incurred, not necessarily to cover all costs, ultimately leaving pharmacists out of pocket.
The PSA has estimated that reforming HMR delivery would cost $135.1 million over 4 years, which includes introducing HMR payments linked to rurality (MMM3-7). Such investments would reduce preventable hospitalisations and improve rural access.
Mr Everlyn recently had to reduce the distance he travels due to financial strain.
‘I'm now needing to prioritise HMRs that are a lot closer to home, which sucks to say.’
Mr Everlyn has been increasingly providing private HMRs, explaining that patients are not prepared to wait 3 months.
Mr Everlyn recalled one HMR consult in a completely isolated area where healthcare access was severely limited, Mr Everlyn said ‘the patient was having an acute schizophrenic attack, and the closest hospital was an hour away.’
It is commonplace for credentialed pharmacists to conduct reviews completely alone, which leaves them with the task of navigating highly complex medical situations without any form of backup.
Patient and practitioner safety
As wait times blow out across the healthcare system, pharmacists are increasingly encountering patients whose conditions have escalated well beyond medicines management.
‘There have been times where I've gone to a patient's house and had to call ambulances because they need acute care,’ Mr Everlyn said.
‘I saw someone recently who's been in hospital three times this year for suicide attempts, and there is a 6-month wait list for a psychiatrist. So then you’re talking about patient safety.’
Naturally, these experiences have an impact on a practitioner's emotional wellbeing. ‘After situations like that, who do you call? Where's the support net? It can be very isolating,’ Mr Everlyn said.
Fuel crisis and a push to telehealth
Fuel shortages and rising petrol costs are putting the longevity of HMR practice in a compromising position, which places vulnerable patients at immense risk.
Increasing fuel prices have added yet another layer of pressure for pharmacists who are already operating on tight margins.
With travel taking up large portions of the workday, and an increase in fuel costs, there has been a recent push towards incorporating telehealth into HMR services.
PSA national president Professor Mark Naunton MPS said ‘the support these patients need, such as medication reviews, is becoming rapidly unsustainable amid the current fuel crisis, unless the government reinstates telehealth.’
‘We know telehealth worked effectively and efficiently during the COVID-19 pandemic, so why not now?
‘I did one HMR on Easter Sunday, which was a 120 km round trip, and then with roadworks, it took me two hours to get there. One full day's work worked out to be $200,’ Mr Everlyn added.
‘The push over to telehealth would alleviate so much time.’
While he acknowledges the value of in-person assessments, he argues that not every consultation requires pharmacists to travel hours to gain the required clinical information.
‘You can tell a lot by how someone's moving… but I don't need to travel 3 hours one way just to see that.’
For many pharmacists, the reluctance to modernise HMR services feels increasingly behind broader innovation.
‘In this day and age we have AI, but we can't do telehealth,’ Mr Everlyn says.
The reinstatement of telehealth is included in the reforms PSA is advocating for to ensure that care is accessible for all Australians.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => HMR waitlists can stretch for months
[post_excerpt] => Home Medicines Reviews (HMRs) are becoming increasingly difficult to sustain, with rising fuel costs and restrictive caps.
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[post_content] => Busy pharmacies, bright lights and confined spaces can heighten fear surrounding vaccination, particularly among children who are neurodiverse.
[caption id="attachment_32071" align="alignright" width="300"] Yvette Anderson MPS[/caption]
Understanding how to create a safe, calm environment is essential to delivering patient-centred care.
A time sensitive vaccination window
With winter around the corner, pharmacies should be in peak winter vaccine campaign mode – including the recently introduced intranasal vaccine, FluMist.
But pharmacists new to vaccinating children are often nervous that immunising school-aged children can be tricky. The Child Health Poll reported that 1 in 4 children experience needlephobia – which often intensifies with age. These challenges are amplified amongst children who are neurodiverse, calling for an enhancement of personalised care throughout the vaccination process.
Yvette Anderson MPS – founder of Spectrum Pharmacist, which sets out to bridge the gap for neurodivergent families – told AP her top tips.
Fear surrounding the vaccination experience
Neurodiverse children can often experience heightened levels of sensory sensitivity, differences in communication, and increased anxiety in unfamiliar settings.
‘Early signs of anxiety and sensory overload vary from child to child,’ Ms Anderson said. ‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.’
During vaccination, early signs of overwhelm may include:
‘It is helpful to understand the child’s usual baseline before the appointment, because some behaviours may be part of their normal coping style rather than a sign of distress.'
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Case scenarioDavid, 68, presents to the pharmacy 7 days before a scheduled colonoscopy. He says the written instructions from the clinic were ‘hard to follow’ and asks whether he should stop ‘all his tablets’. David has type 2 diabetes, hypertension and atrial fibrillation. He uses a weekly dose administration aid (DAA) prepared by the pharmacy. His regular medicines include apixaban, ramipril, empagliflozin, metformin and atorvastatin. He also takes ibuprofen intermittently for knee pain and a garlic supplement. He has been advised to fast and complete bowel preparation the day before the procedure and is unsure which medicines to continue, stop or restart. |
Australians make 440 million visits to their pharmacist each year,1 with community pharmacists frequently consulted by patients preparing for diagnostic or minor surgical procedures. These encounters often occur when instructions are unclear, leaving patients unsure which medicines to stop, when to stop them, and how to safely resume therapy. Temporary medicine changes can be particularly confusing for patients using dose administration aids (DAAs), increasing the risk of dosing errors or procedural delays.
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Pharmacists are well placed to address this gap. As accessible healthcare professionals with medicines expertise, pharmacists can identify medicines that increase peri-procedural risk, clarify instructions, and support safe temporary changes.
This article provides a practical, evidence-based overview of medicines commonly withheld prior to procedures, counselling strategies to minimise confusion, guidance for managing DAAs, and pharmacy-based interventions to support patient safety.
Patients preparing for diagnostic investigations or minor surgical procedures are often advised to temporarily withhold selected medicines to reduce peri-procedural risk. The decision to continue or withhold a medicine involves balancing potential risks of the procedure (such as bleeding, infection, haemodynamic instability, renal impairment, metabolic disturbance or interactions with medicines used in the peri-procedural period) against the risk of disease exacerbation or withdrawal effects. Pharmacists play a critical role in identifying medicines that may require review, clarifying prescriber instructions and supporting safe temporary modification of therapy.2
Anticoagulants and antiplatelet agents are among the most frequently managed medicines in the peri-procedural setting. Oral anticoagulants, including warfarin and direct oral anticoagulants, increase bleeding risk during procedures such as colonoscopy, dermatological excisions, and some dental or ophthalmic surgeries.3 Antiplatelet therapy presents a more nuanced risk-benefit balance. For many minor procedures, including cataract surgery and simple dental or dermatological procedures, aspirin may be safely continued, while procedures with a higher bleeding risk may necessitate temporary cessation.4
The decision to withhold antithrombotic therapy is highly individualised and should always be clinician-directed. Pharmacists should avoid advising cessation independently but can support patient safety by reinforcing clear stop and restart dates, and emphasising the importance of timely recommencement to minimise thromboembolic risk.3,4
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly withheld prior to procedures due to their reversible inhibition of platelet aggregation and their potential to impair renal perfusion, particularly in the context of peri-procedural dehydration or exposure to contrast media.2,5 Platelet function typically normalises within several days of NSAID discontinuation, although this varies by agent.5 From a pharmacy perspective, the most significant risk arises from unrecognised over-the-counter NSAID use. Pharmacists should proactively enquire about non-prescription analgesics and recommend suitable alternatives, such as paracetamol, where appropriate.2,5
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) remain an area of clinical debate. Continuation has been associated with an increased risk of intraoperative hypotension, while cessation may increase the likelihood of postoperative hypertension.9-11 Evidence supports an individualised approach, taking into account the indication for therapy, baseline blood pressure, and the nature of the procedure and anaesthesia.9,10 In practice, many clinicians elect to withhold these agents on the morning of surgery when hypotension risk is high and resume therapy promptly post-procedure. Failure to recommence ACEIs or ARBs within 24–48 hours postoperatively has been associated with increased short-term mortality.9–11 Pharmacists should reinforce clinicians’ pre-procedure instructions, provide rationale and highlight the importance of timely recommencement.
Complementary and herbal products require review in the peri-procedural period, as evidence indicates their use remains highly prevalent among surgical patients, yet disclosure to healthcare professionals is often incomplete.1,12 Herbal medicines may exert clinically significant pharmacodynamic and pharmacokinetic effects that increase peri-procedural risk, including impaired platelet aggregation (e.g. garlic, ginkgo biloba, ginseng), increased sedative effect (e.g. kava, valerian) and altered metabolism of anaesthetic or perioperative medicines through cytochrome P450 enzyme induction (e.g. St John’s wort).2,13 Risk assessment is further complicated by variability in product composition, dosing and bioactive constituents, meaning effects are not always predictable or dose dependent.11 As a result, many contemporary guidelines recommend discontinuation of non-essential herbal medicines at least 1–2 weeks prior to procedures, depending on the agent and procedural risk.2,13
Diabetes medicines and peri-procedural blood glucose managementMedicines used to manage diabetes often require review in the peri-procedural period. Temporary changes may be needed to reduce medicine-related risk during fasting and recovery, and pharmacists play an important role in supporting patient understanding and continuity of care.
Sodium-glucose co-transporter-2 (SGLT2) inhibitors warrant specific attention in the peri-procedural period due to the risk of diabetic ketoacidosis (DKA), which may occur with near-normal or only mildly elevated blood glucose levels (euglycaemic DKA). The risk is increased during periods of fasting, reduced carbohydrate intake (including bowel preparation), dehydration, acute illness and surgical stress. Importantly, normoglycaemia does not exclude DKA, and blood ketone testing should be considered where clinical suspicion exists. Clinical guidelines advise that SGLT2 inhibitors should be withheld for at least 3 days prior to procedures requiring fasting or bowel preparation (and 4 days for ertugliflozin).6
Physiological stress related to illness, fasting, anxiety and surgical intervention activates counter-regulatory hormones such as cortisol and catecholamines, leading to increased hepatic glucose output and reduced insulin sensitivity.7 When combined with altered oral intake and temporary medicines changes, this stress response can result in significant glycaemic variability, even in patients with previously stable diabetes.2,3
Extremes of blood glucose pose specific risks in the peri-procedural setting. Hyperglycaemia is associated with dehydration, impaired immune function and an increased risk of postoperative infection, while hypoglycaemia may result in neuroglycopenic symptoms, cardiovascular instability or loss of consciousness – particularly in the context of fasting or reduced caloric intake.8 For most adults, general peri-procedural targets include fasting blood glucose levels of approximately 4–8 mmol/L and random levels below 10 mmol/L, although individual targets should be tailored based on comorbidities, frailty and procedural complexity.8 Pharmacists play an important role in reinforcing blood glucose monitoring plans, supporting sick-day management principles, therapy modification during temporary medicine cessation, and identifying when abnormal readings require medical review. Clear counselling on when and how to safely recommence withheld medicines once normal oral intake has resumed is essential to minimise metabolic complications and support safe transitions of care.2,6
Patients who use DAAs are at increased risk of medication error when medicines are changed, particularly when temporarily withheld in the peri-procedural period.14 These patients often rely on the pack as their primary prompt for medicine administration and may not be familiar with individual medicines or their indications. Temporary cessation without appropriate pharmacist intervention can lead to duplication or unintended continuation of withheld medicines. Pharmacists therefore play a critical role in coordinating safe, structured modifications in response to procedural instructions.
Best practice involves pharmacist-led removal of specific medicines from affected doses, rather than advising patients to self-remove tablets, which increases the risk of error and pack disruption. Clear documentation should accompany any changes, including written instructions outlining which medicines have been withheld, the duration of cessation, and the planned date of recommencement, where possible. If feasible, pharmacists should provide a simple, procedure-specific DAA and schedule follow-up to ensure medicines are safely reintroduced post-procedure.
Liaison with prescribers may be required if instructions are unclear or if the patient’s clinical status changes. Through proactive management of DAAs, pharmacists can significantly reduce confusion, support continuity of care, and minimise preventable medicine-related harm and delays in the peri-procedural setting.
Community pharmacists can proactively review medicines prior to procedures, identify medicines that may require temporary cessation, clarify clinician-directed stop-restart instructions, and manage changes to DAAs.
By reinforcing written advice, reviewing over-the-counter and complementary medicine use, and supporting blood glucose monitoring during periods of fasting or medicine withholding, pharmacists minimise confusion and prevent medicine-related harm. Pharmacists can also support peri-procedural care by encouraging patients to bring all medicines for review and by providing an accurate medicines list to assist communication across care settings.
Pharmacists play a critical role in supporting patients preparing for common procedures through proactive medicines review, clear counselling and practical support for temporary medicine changes. This role is particularly important for patients using DAAs, where structured pack modification and follow-up can reduce medication errors and delays to care. As peri-procedural medicines management becomes increasingly complex, pharmacist-led interventions are essential to safe, coordinated and patient-centred care.
| Case scenario continued You review all prescription, over-the-counter and complementary medicines, and clarify the clinic’s instructions. High-risk medicines potentially requiring temporary cessation are identified, including apixaban, empagliflozin, ibuprofen and the garlic supplement, while other medicines can be continued as directed. Given David’s use of a DAA, you undertake pharmacist-led pack modification based on the clinic’s instructions. You provide clear written directions outlining withheld medicines, monitoring advice during fasting, and when medicines should be restarted once oral intake resumes. You use the teach-back method to confirm understanding, and a follow-up is arranged after the procedure to safely reintroduce medicines into the DAA. |
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[post_content] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers – delivering critical care while navigating increasing financial pressures.
Women make up around 70% of the credentialed pharmacists who deliver HMRs, with two-thirds under the age of 40. HMR work is a constant balancing act that involves managing the significant demands of professional practice alongside raising young families.
With Mother’s Day approaching, the reality of HMR work mirrors a common narrative for women in pharmacy: highly skilled professionals delivering personalised care, while managing significant responsibilities at home.
These pressures increasingly undermine the sustainability of HMR practice.
[caption id="attachment_32039" align="alignright" width="300"] Katie Phillips MPS[/caption]
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured,’ said credentialed pharmacist Katie Phillips MPS.
Critical care for vulnerable Australians
Pharmacists conducting HMRs play a crucial role in supporting quality use of medicines among vulnerable Australians at risk of medication misadventure.
Credentialed pharmacist Erica Stephenson MPS, told AP that one of the most important aspects of her role is just being there.
‘For an hour, I might have relieved somebody's loneliness by being in their home and having a chat with them about them and their medication.’
With current HMR caps set at 30 HMRs per month, access can become an issue, particularly in rural and remote areas. ‘No one should have to wait for a review when there are credentialed pharmacists able to provide the service but capped out for the month,’ Ms Phillips said.
Ms Stephenson added that ‘the cap gets you caught. At the end of the month, you might get that emergency, and you've already hit your cap and then can’t provide the service.’
[caption id="attachment_31991" align="aligncenter" width="400"] Erica Stephenson MPS with her kids[/caption]
Flexibility with hidden costs
HMR work is often promoted for its flexibility, yet the reality is far more complicated. Alongside delivering the service, pharmacists have to grapple with long hours, extensive travel and significant unpaid work – including driving, documentation and reporting.
For mothers, these demands pose significant challenges when balancing professional and personal responsibilities. ‘When everything related to a HMR is taken into account, the pay rate is unsustainable, especially with many pharmacies/HMR businesses taking a cut of a pharmacist’s HMR earnings,’ Ms Phillips said.
As a mother of two young girls, Ms Phillips describes herself as ‘incredibly time poor and forever on the go,’ with HMRs often scheduled on her ‘days off’.
Ms Stephenson transitioned into HMR work as her sole form of employment to provide a sense of flexibility as a single mum with chronic health issues. And since becoming a credentialed diabetes educator, she is ‘busier than ever’.
When asked what would make HMRs more sustainable, Ms Phillips suggested telehealth as a pivotal follow-up method.
[caption id="attachment_32040" align="alignright" width="300"] Katie Phillip MPS with her two daughters[/caption]
‘There is so much value in a follow-up call to close the loop of care,’ she said.
‘I have had a patient’s daughter text me almost daily, waiting out the month before [an HMR] follow-up, as various dose changes were made by the GP with not so great results.
‘I happily responded to all her texts, but I didn’t really need to see the patient in person again to be able to advise on what should be next, and there is no recognition or remuneration for this time,’ Ms Stephenson said.
The employment model piles on further strain. Most credentialed pharmacists are self-employed practitioners, so there is limited security – ranging from no superannuation, sick leave or annual leave – and time off is typically unpaid.
Ms Stephenson works 50 weeks of the year, taking time off only over Christmas as the backlog of referrals grows exponentially.
‘I joke that sometimes I'm on negative $5 an hour because I'm just so buried in admin. It's a full-time job just keeping on top of the admin, which is, of course, unpaid,’ Ms Stephenson said.
‘I don't really have any disposable income. I just pay my bills, and that's it. Which is unfair on my kids who are very independent and have their own jobs, but that’s just the way it is.’
These pressures are compounded by irregular referral patterns, which take a sense of financial stability out of the question. The Australian Health and Medical Research Workforce Audit shows that a lack of funding, job security and work-life balance are the main reasons individuals consider leaving the field.
Ms Stephenson urged younger mums looking to broaden their scope that HMRs are maybe not as clear cut as they seem as ‘You’re actually on the job 24/7 almost’.
Structural barriers
[caption id="attachment_32041" align="alignright" width="300"] Deborah Hawthorne FPS with her two daughters[/caption]
HMR remuneration has not been indexed since 2019 and remains at $222.77 per review, raising consistent concerns regarding long-term sustainability of the practice.
Funded by the Australian Government under the Community Pharmacy Agreements, an increase in the cost of living has not been met with an increase in fees, meaning that each pharmacist is essentially taking a pay cut each year.
‘Once you take out tax, provisions for personal leave/annual leave etc., the hourly rate is pitiful. And when appointments are cancelled due to the clinician or patient, it can leave you high and dry financially,’ Ms Phillips said.
Ms Stephenson, a single mum of two teenagers, called for an ‘essential’ increase to remuneration. ‘For every $222, I take $26 out for superannuation, $55 for tax, and $10 if I want to treat myself to catch up with friends. That leaves me with $130 to run my car and pay subscriptions, household bills and mortgage,’ she said.
‘There is a reluctance for people to give up permanent employment for a career pathway which is not assured.'
katie phillips MPS
’[The] 200 km limit for travel is too high. I can drive for an hour to see somebody and still not be eligible for the rural travel allowance.’
The lack of employment entitlements further exacerbates the issue. ‘As a young mum, if I have to cancel HMRs because my kids are sick, I don’t get paid,’ she said.
‘[And I] might miss special moments like a bedtime story because [I’m] frantically trying to finish something that the doctor's waiting on urgently.’
Despite these mounting challenges, many pharmacists remain committed to delivering HMRs, driven by the impact they have on patient care – particularly for elderly Australians and those with chronic and complex conditions.
Sustainable HMR practice, Ms Phillips said, depends on ‘Being paid appropriately, with appropriately indexed remuneration reflecting the level of skills and experience required, travel costs, and allowances for lack of entitlements’.
With demand for medication reviews projected to grow, driven by an aging population, rising rates of polypharmacy and a need to manage preventable, medication-related hospital admissions, there are increasing calls to address indexation and structural barriers – ensuring the workforce remains viable and patients continue to receive the care they need.
PSA’s 2026–27 Federal Budget Submission advocates for the government to lift the indexation freeze on the management of medications to ensure the longevity of patient care.
[post_title] => This Mother’s Day, let’s spotlight mums delivering HMR care
[post_excerpt] => Behind the flexible appeal of Home Medicines Reviews (HMRs) is a primarily female workforce – many of them mothers.
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Case scenarioJoe, a 76-year-old man, visits the pharmacy accompanied by his daughter, who expresses concern about his increasing forgetfulness and confusion over the past year. Joe has begun misplacing items, repeating questions and occasionally getting lost in familiar places. You ask Joe and his daughter about the progression of symptoms, daily functioning and any changes in mood or behaviour. He denies feeling depressed but expresses frustration with his poor memory. He is currently taking medicines for hypertension and type 2 diabetes. |
Dementia was the leading cause of death in 2024, with deaths from dementia increasing by 39% over the past decade.1 It is a progressive, life-limiting syndrome characterised by a decline in cognition and functional abilities.2 The most common cause of dementia is Alzheimer’s disease (50–75% of cases), followed by vascular dementia (20–30%), frontotemporal dementias (up to 10%), and dementia with Lewy bodies and Parkinson’s disease dementia (up to 10%).2
Learning outcomesAfter reading this article, pharmacists should be able to:
|
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD[/caption]
Table 1 (page 44) summarises the common causes of dementia and the current understanding of their pathogenesis.
| Causes of dementia | Descriptions |
| Alzheimer’s disease | The amyloid cascade hypothesis suggests that the deposition of amyloid-β (Aβ) plaques leads to neurofibrillary tangles, cell loss, vascular damage and dementia.3 For decades, this hypothesis has been the primary target for developing therapies for Alzheimer’s disease. In light of new evidence, several iterations of the theory have been proposed, highlighting a more complex aetiology involving polygenic, epigenetic, environmental, vascular, neuroinflammatory and metabolic factors.4 Today, the aetiological complexity surrounding the pathogenesis of Alzheimer’s disease has not been fully established. |
| Vascular dementia | Vascular dementia results from impaired blood supply to the brain, which damages brain tissue and subsequently leads to cognitive decline.5 Common neuropathological findings include multiple infarcts or single strategic infarcts caused by atherothromboembolic events or small vessel disease.5 |
| Mixed dementia | It is common for individuals to present with more than one type of dementia. The term ‘mixed dementia’ refers to the co-occurrence of more than one subtype of dementia, most commonly Alzheimer’s disease and vascular dementia. However, the use of this term is increasingly discouraged due to its ambiguity.6 |
| Lewy body dementia | Lewy body dementia is an umbrella term describing two forms of dementia: dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). DLB is characterised by the accumulation of α-synuclein in Lewy bodies and Lewy neurites in the brain, as well as neuronal loss in the substantia nigra, although typically less severe than that observed in Parkinson’s disease.6 PDD and DLB are both α-synucleinopathies.6 There is considerable clinical overlap between DLB and PDD.6 Generally, DLB presents at an older age, while PDD is preceded by a long period of motor symptoms.6 The arbitrary ‘1-year rule’ is commonly applied in clinical practice, whereby DLB is diagnosed when cognitive symptoms appear before or within 1 year of motor symptoms, whereas PDD is diagnosed when cognitive decline occurs in the context of established Parkinson’s disease.6 |
| Frontotemporal dementia | Frontotemporal dementia (FTD) is a common cause of early-onset dementia, typically affecting individuals aged 45–65 years.7 FTD is categorised as three variants: 1) behavioural-variant FTD (associated with behavioural and executive deficits), 2) non-fluent variant primary progressive aphasia (progressive deficits in speech, grammar and word output), and 3) semantic-variant primary progressive aphasia (impaired naming and single-word comprehension).8 As the name suggests, FTD involves progressive degeneration of the frontal and/or temporal lobes associated with characteristic protein inclusions.6 Genetic mutations and family history of dementia play an important role in its pathogenesis.6 |
| Other causes of dementia |
|
Clinical features
Dementia symptoms vary between individuals, with common symptoms outlined in Box 1.11 Early dementia symptoms are often subtle and easily overlooked, and dementia is still commonly perceived as a normal part of ageing.12 To address this, initiatives such as the National Dementia Action Plan 2024–2034 have been introduced to raise awareness, reduce risks and improve access to services across Australia.13
Box 1 – Common symptoms of dementia
|
As dementia progresses, individuals may also experience changes in behaviour or emotional state, such as14:
Collectively, these symptoms used to be clinically referred to as behavioural and psychological symptoms of dementia (BPSD). However, this terminology is increasingly being discouraged as it does not reflect the lived experience of people with dementia.15
Some alternative terms include changed behaviours or responsive behaviours.14 However, these terms are not universally preferred among all people living with dementia and their carers.
Changed behaviours typically intensify with disease progression and are often triggered by underlying factors such as unmet needs (e.g. hunger, thirst, toileting), physical illness, pain, psychiatric conditions, constipation, fatigue, loneliness and environmental stressors.14 A comprehensive assessment is essential for identifying and addressing these contributing factors.
Changed behaviours can be distressing for both the individual and their carers, and person-centred care approaches are critical to managing these challenges effectively to minimise harm.
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac[/caption]
Reversible causes of cognitive impairment should be excluded as part of the dementia assessment and treated as appropriate. Examples include9:
Some medicines adversely affect cognition. In individuals receiving cholinesterase inhibitors and medicines that have anticholinergic properties, clinicians should first consider deprescribing anticholinergics due to the potential adverse impact on cognitive function.16 Other medicines associated with cognitive impairment include psychotropics, GABAergic agents, opioids, corticosteroids and antibiotics.17
Dementia diagnosis requires a comprehensive physical examination and cognitive test using validated tools, such as the Mini-Mental State Examination (MMSE), General Practitioner Assessment of Cognition (GPCOG), and Montreal Cognitive Assessment (MoCA).9 For Aboriginal and Torres Strait Islander peoples, the Kimberley Indigenous Cognitive Assessment (KICA) is a culturally appropriate dementia screening tool that has been validated in this population in Australia.18
While challenging, identifying the specific type of dementia is crucial for guiding appropriate treatment and support. Input from specialists (e.g. neurologist, neuropsychologist or geriatrician) is often required, in collaboration with the individual and their family or support network.
Dementia risk factors are broadly categorised into potentially modifiable and non-modifiable.
Non-modifiable risk factors include age, parental family history of dementia and the possession of the APOE4 allele.19 Dementia incidence increases exponentially with age, doubling approximately every 5 years from 65 and 90 years.20 Despite age being a major risk factor, dementia can affect individuals of all ages.
Potentially modifiable risk factors include air pollution, smoking (including second-hand exposure), high alcohol intake, low education, head injuries, hearing impairment, hypertension, obesity, sedentary lifestyle and social isolation.9,19 Addressing modifiable risk factors is important for reducing dementia risk and preventing other chronic diseases.9 Key strategies include increasing physical activity, preventing head injury and hearing loss (e.g. wearing hearing protection when exposed to loud noise), quitting smoking, avoiding second-hand smoke exposure, maintaining a healthy and balanced diet, reducing or ceasing alcohol use, managing a normal weight and blood pressure, staying socially connected, engaging in cognitively stimulating activities, and promoting community inclusion.9
There is currently no cure for dementia. The primary goal of management is to support the individual’s quality of life, maintain independence for as long as possible, and provide holistic care throughout the disease trajectory.
A dementia care plan should aim to9:
Non-pharmacological approaches are the first-line treatment for managing changed behaviours in dementia and should be continued even when medicine is commenced. Non-pharmacological interventions are person-centred and aim to address unmet needs, environmental stressors and emotional distress.2 Evidence-based psychosocial interventions that can be delivered in both the community and facility settings include reminiscence therapy, validation therapy, cognitive stimulation therapies and reality orientation.21,22
Other non-pharmacological practices include structured care approaches (e.g. bathing, oral care routines), sensory interventions (e.g. aromatherapy, massage, multisensory stimulation, bright light therapy), psychosocial practices (music therapy, pet therapy, meaningful activities), and social engagement.21,22 Approaches for managing dementia should be tailored to the individual’s preferences, cultural background and life history – and involve carers in the planning and delivery.
Pharmacological interventions are not recommended as first-line treatments for changed behaviours due to limited efficacy and risk of serious harm.2,14,23 They were associated with increased risks of cardiovascular or cerebrovascular events (stroke, venous thromboembolism, myocardial infarction, heart failure), fracture, pneumonia and acute kidney injury.24
As such, psychotropic medicines should only be considered when acute behavioural disturbance is severe, posing an imminent risk of harm to the individual or others, and the required expertise is available.2
The two main classes of medicines used in the treatment of dementia are anticholinesterases (donepezil, galantamine and rivastigmine) and memantine (an N-methyl-D-aspartate receptor antagonist).25 They provide modest symptomatic relief and do not alter the course of the disease. 2,23
Anticholinesterases are indicated for mild to moderate Alzheimer’s disease,26 and may also be used off-label for Lewy body dementia, vascular dementia or mixed dementia. Common adverse effects include nausea, vomiting, diarrhoea and insomnia.25 Memantine is indicated for moderate to severe Alzheimer’s disease or when anticholinesterases are unsuitable and can sometimes be combined with an anticholinesterase, though benefits vary between individuals.23 Before initiating treatment, clinicians should perform an electrocardiogram, record baseline weight and assess fall risk.9 A review shortly after initiation (e.g. 1 month) is recommended to assess adverse events and dose titration, and within 6 months to determine responses on cognition, daily function and physical symptoms.9,23
Many people living with dementia are living with other comorbidities, and the cumulative burden of polypharmacy can present a great risk to their quality of life and health. Deprescribing should be considered and offered if the person16:
The MATCH-D (medication appropriateness tool for comorbid health conditions in dementia) criteria is a practical tool that allows pharmacists to optimise medicine use in people with dementia.27 The tool is freely available at www.match-d.com.au, and can be used by pharmacists to decide whether medicines are used appropriately for comorbidities during the different stages of dementia.
Other tools for optimising medicine regimens include the Clinical Practice Guidelines for Deprescribing in Older People (available at deprescribing.com)16 and the Drug Burden Index tool for calculating the cumulative exposure to anticholinergic and sedative medicines (available at www.gmedss.com/about).28
New and emerging therapies
Research into disease-modifying treatments for dementia is ongoing. Recent developments have focused on monoclonal antibodies that target Aβ plaques, a hallmark of Alzheimer’s disease pathology.26 Donanemab and lecanemab are newly approved monoclonal antibody therapies for adults with early symptomatic Alzheimer’s disease who have a specific genetic profile and confirmed Aβ plaque presence.26 These medicines are administered by intravenous infusion every 2–4 weeks, and can cause brain oedema and microhaemorrhages, necessitating regular MRI monitoring.
They are not subsidised by the Pharmaceutical Benefits Scheme at the time of writing, and their high cost may further limit uptake. While anti-amyloid therapies have demonstrated a significant reduction in brain amyloid in people with early Alzheimer’s disease,26 clinically meaningful cognitive and functional improvements are modest.29
In addition to monoclonal antibodies, there are over 100 compounds currently in the pharmaceutical research pipeline.30 These include potential peptide-based vaccines aimed at prevention,31 as well as biomarker-driven screening tools to identify individuals at risk earlier in the disease process.32
Most people with dementia live in the community1 and are often supported by family members. Families should be encouraged to apply for aged care support and request an assessment through My Aged Care. Legal arrangements such as enduring power of attorney, wills, property management and advance care planning should be discussed early. A wide range of resources is available to support carers and families, including those provided by Dementia Australia, the Wicking Dementia Research and Education Centre, Services Australia, Carers Australia, Carer Gateway (1800 422 737), the National Dementia Helpline (1800 100 500), and the Dementia Behaviour Management Advisory Service (1800 699 799).
A national survey revealed gaps in community awareness of dementia, finding that Australians hold diverse and often stigmatising views about dementia.12 Such stigma may deter individuals experiencing cognitive changes from seeking medical advice due to fears of unfair treatment.33
Aboriginal and Torres Strait Islander peoples are disproportionately affected by dementia and may face additional barriers to accessing services.15 Dementia Australia offers culturally appropriate resources, including materials for people with dementia, families and carers, communication cards, and language guidelines.34,35 Pharmacists play a vital role in reducing these barriers and supporting ongoing culturally safe care.
Pharmacists are trusted professionals with the knowledge to support people living with dementia through safe, person-centred medicines management. Pharmacists are key members of the broader healthcare team. Our roles include reconciling medicines aligned with individuals’ goals of care, early identification of adverse effects, recognising potentially inappropriate medicines and suggesting deprescribing where appropriate. Having a comprehensive understanding of the condition and its impact on individuals is essential for delivering person-centred care. Pharmacists can contribute by identifying early signs of cognitive decline – facilitating referrals to appropriate support services and assisting with symptoms and medicines management.
Clinical pharmacists also have the potential to extend their scope beyond medicines management, contributing to proactive, multidisciplinary dementia care in primary care settings.36 Dementia-specific training and a supportive workplace environment are essential for pharmacists to effectively fulfil these roles. Dementia support pharmacists have demonstrated the great value of this role.37
Dementia is a debilitating condition with high morbidity and mortality. Pharmacists play a vital role in reducing stigma by deepening their understanding of dementia – improving access to support and services, and ensuring safe, person-centred medicines management. By identifying inappropriate medicines and supporting optimal treatment outcomes, pharmacists help individuals maintain independence and quality of life.
Case scenario continuedBased on the conversation, you provide information about cognitive screening tools such as the Mini-Cog and refer Joe to a GP for further assessments. You explain that the GP may refer Joe to a neurologist or geriatrician for a comprehensive evaluation, which could include neuropsychological testing and brain imaging. You also discuss lifestyle strategies that may support cognitive health, including regular exercise, mental stimulation, social interaction and a balanced diet. Joe and his daughter appreciate the guidance and feel reassured about the next steps. |
Amanda Quek (she/her) BPharm(Hons), GradCertAppPharmPrac is supported by an Australian Government Research Training Program Scholarship at the University of Western Australia.
Dr Amy Page (she/her) PhD, MClinPharm, GradDipBiostat, GradCertHProfEd, GradCertDMED, GAICD has received multiple grants through the Medical Research Future Fund (MRFF) and the Western Australian Future Health Research and Innovation Fund/WA Department of Health. She is an employee of the University of Western Australia.
Our reviewer
Morna Falkland BPharm
Conflict of interest declaration None declared.
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Australian Pharmacist is the official journal for Pharmaceutical Society of Australia Ltd.
