Improving Medication Use in the Nursing Homes: A European Perspective

Geriatric Depression and Inappropriate Medication: Benefits of Interprofessional Team Cooperation in Nursing Homes

An investigation of inappropriate medication use in treatment of depressivity in institutionalized older adults, based on a nurse-led evaluation of functional status and depressive symptoms in nursing home residents. Methods: A cross-sectional multicenter study was performed using records from 1087 residents cared for in fifteen nursing homes (NHs) in the Czech Republic. Inclusion criteria were being a permanent resident of one of the facilities, being 60 years of age or older, having a Geriatric Depression Scale score of 6 or more, and having a Mini Mental State examination score 10 or more. The final sample for analysis included 317 depressed NH residents. Results: 52 percent of NH residents with depressivity had no antidepressant treatment. Benzodiazepines were the only medication in 16 percent of depressed residents, and were added to antidepressant treatment in 18 percent of residents. Benzodiazepine users had significantly higher GDS scores compared to non-users (p = 0.007). Conclusion: More than half of depressed NH residents remained without antidepressant treatment. Residents inappropriately treated with benzodiazepines were more depressed than residents treated with antidepressants only, or even not treated at all. Cooperation of the interprofessional team in the screening of depressive symptoms has the potential to improve the quality of care.

What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators

Background

Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood.

Objectives

The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents.

Methods

We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately.

Results

Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) ‘Operationality and routines’; (2) ‘Lack of resources and qualifications’; (3) ‘Patient-related outcomes’, which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) ‘Policies’, including support and buy-in from nursing home leadership; and (5) ‘Collaboration’ between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings.

Conclusions

Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00875-1.

Treatment of Osteoporosis in Australian Residential Aged Care Facilities: Update on Consensus Recommendations for Fracture Prevention

BACKGROUND

Older people living in residential aged care facilities (RACFs) are at a higher risk of suffering fractures than the community-dwelling older population. The first Consensus Conference on Treatment of Osteoporosis in RACFs in Australia, held in Sydney in July 2009, aimed to address some of the issues relating to the treatment of older residents with osteoporosis in RACFs. Considering that the field of osteoporosis diagnosis and management has significantly advanced in the last 5 years and that new evidence has been generated from studies performed within RACFs, a Second Consensus Conference was held in Sydney in November 2014.

METHODS

An expert panel met in November 2014 in Penrith, NSW, Australia in an attempt to reach a consensus on diverse issues related to the treatment of osteoporosis at RACFs. Participants were selected by the scientific committee on the basis of their practice in an RACF and/or major published articles. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short, evidence-based presentation, when possible.

RESULTS

This article provides an update on the most relevant evidence on osteoporosis in older people living in RACFs graded according to its level, quality, and relevance.

CONCLUSION

As with the first consensus, it is hoped that this statement will constitute an important guide to aid physicians in their decision making while practicing at RACFs.

An educational intervention on drug use in nursing homes improves health outcomes resource utilization and reduces inappropriate drug prescription

OBJECTIVE

Inappropriate drug prescription is a common problem in people living in nursing homes and is linked to adverse health outcomes. This study assessed the effect of an educational intervention directed to nursing home physicians in reducing inappropriate prescription and improving health outcomes and resource utilization.

DESIGN

Prospective, randomized, multicenter study.

SETTING

A private organization of nursing homes in Spain.

PARTICIPANTS

Sixty nursing home physicians caring for approximately 3900 nursing home residents in 37 centers were randomized to receive an educational intervention (30) or as a control group (30).

INTERVENTION

10 hours educational program, followed by on demand support by phone.

OUTCOME MEASUREMENTS

Outcomes were assessed in 1018 randomly selected nursing home residents. Appropriateness of drug use [measured by the Screening Tool of Older Persons Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) criteria], incidence of selected geriatric syndromes (falls, delirium) and health resource utilization (visits to physicians and nursing homes, visits to the emergency room, days of hospitalization) were recorded for 3 months before the intervention started and 3 months after the intervention finished.

RESULTS

O total of 716 residents finished the study (344 cared for by the intervention group physicians, 372 cared for by control physicians). Mean age was 84.4 ± 12.7 years; 73% were women. The mean number of inappropriate drugs (STOPP criteria) was higher at the end of the study in the control than in the intervention group (1.29 ± 1.56 vs 0.81 ± 1.13), as was the number of residents on 6 or more drugs (76.5% vs.67.0%), using antipsychotics (9.1% vs 3.2%) or duplicate medications (32.5% vs 9.2%). The number of fallers increased in the control group (from 19.3% to 28%) and did not significantly change in the intervention group (from 25.3% to 23.9%); the number of residents with delirium increased in the control group (from 3.8% to 9.1%) and decreased in the intervention group (from 6.1% to 3.2%). The number of visits to a physician did not change in the control group (-0.22, P = .3) but were significantly reduced in the intervention group (-0.76, P = .01), the same happened with the number of visits to a nurse (-0.38, P = .4 in controls, -1.43 in the intervention group, P < .001). Visits to the emergency room and days in hospital significantly increased in the control group (+0.12 and +0.38) but were unchanged in the intervention group (+0.03 and +0.01).

CONCLUSIONS

An educational intervention on drug use is feasible in nursing home physicians and improves the use of inappropriate drugs, use of antipsychotics, and drug duplications in their residents. It may also improve the risk of delirium and falls, and reduce the use of health care resources.