Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes

Pro re nata prescribing and administration for neuropsychiatric symptoms and pain in long-term care residents with dementia and memory problems: a cross-sectional study

Background Prescribing, dispensing and administering pro re nata (PRN; as needed or necessary, as determined by an individual) medicines to people with intermittent or short-term conditions is a potential area for medication errors and inappropriate prescribing and administration. In people with dementia, regular PRN medicines use can demonstrate good practice when appropriate or poor in situations where their use is not recommended. However, the frequency of PRN prescription and administration within long-term care settings (care homes) for people with dementia is largely unknown. A limited number of studies worldwide suggest variation between countries. Objective To describe the prescription and administration rates of PRN medicines for people with dementia in UK care homes. Setting Fifty UK care homes. Method Medication details were collected from review of residents’ medicines records within the care home for the previous month. Main outcome measure Prescription and administration of PRN medicines for the treatment of behaviours associated with neuropsychiatric symptoms and pain. Results The most commonly prescribed PRN medicines were analgesics (35.3%), although lower levels of PRN prescription were observed compared to recent studies. The percentage of residents receiving PRN administrations varied, with 20% for antipsychotics, 50% for benzodiazepines, 59% for analgesics, and 85.7% for nonbenzodiazepine hypnotics being administered. Conclusion Further research is needed to understand the decision making in PRN prescription and administration within long-term care. The prescribing of potentially inappropriate medicines remains a problem in long-term care settings and pharmacists have a key role in reducing inappropriate polypharmacy by undertaking medication reviews that consider both regular and PRN medicines.

Combined use of drugs inhibiting the renin-angiotensin system: prescribing patterns and risk of acute kidney injury in German nursing home residents

Background/aims

In 2012, the European Medicines Agency reviewed the safety of dual renin-angiotensin system (RAS) blockade because of potentially increased risks for inter alia acute kidney injury (AKI). Since residents of nursing homes are particularly vulnerable to adverse drug outcomes, the aims of our study were to describe RAS-inhibiting drug use in German nursing home residents and examine the risk of AKI associated with dual RAS blockade.

Methods

Based on claims data, a nested case-control study within a cohort of RAS-inhibiting drug users was conducted. Using conditional logistic regression, confounder-adjusted odds ratios (aORs) and 95% confidence intervals (CI) were obtained for the risk of AKI associated with dual RAS blockade. Subgroup analyses were performed in patients with diabetes or chronic kidney disease and both comorbidities.

Results

Of all 127,227 nursing home residents, the study cohort included 64,567 (50.7%) who were treated with at least one RAS-inhibiting drug. More than three quarters of the study population were female (77.1%). Mean age was 86.0 ± 6.8 years. Most residents were treated with angiotensin-converting enzyme inhibitors (77.8%), followed by angiotensin II receptor blockers (21.6%) and aliskiren (0.2%). Annual prevalence of dual RAS blockade declined from 9.6 (95% CI 7.8-11.8) in 2010 to 4.7 (95% CI 4.0-5.4) per 1,000 users in 2014. In the overall cohort, AKI was not significantly associated with dual RAS blockade (aOR 1.99; 0.77-5.17). However, significantly increased aORs were observed when considering patients with diabetes (3.47; 1.27-9.47), chronic kidney disease (4.74; 1.24-18.13) or both (11.17; 2.65-47.15).

Conclusions

Prescribing of drugs inhibiting the RAS is common in German nursing homes. Though the prevalence of dual RAS blockade declined, our study showed an increased risk of AKI in patients with diabetes and/or chronic kidney disease. Therefore, cautious use is warranted in these vulnerable patients.

Associations between conflictual relationships, psychopathology, and the use of psychotropic drugs among older people living in residential facilities

BACKGROUND

Psychiatric symptoms and conflictual relationships (CR) may negatively affect the delivery of care in residential facilities (RF). This study aims to analyze neuropsychiatric symptoms, their correlations with CR among older people living in RF, and their associations with the prescription of psychotropic drugs.

METHODS

A total of 1215 RF residents in five Italian regions were selected for this cross-sectional study. Psychiatric symptoms and CR were assessed with the Neuropsychiatric Inventory and the Resident Assessment Instrument, respectively. Associations between Neuropsychiatric Inventory items, CR, and the use of psychotropic drugs were tested via multiple logistic regressions.

RESULTS

About half (52.7%) of the RF residents experienced one or more clinically relevant neuropsychiatric symptoms. At least one category of CR was reported for 223 residents (19%). Although reciprocal associations were found between different categories of CR, only conflictuality with other residents was associated with the use of antipsychotics (odds ratio (OR) = 2.12). Significant associations were found with irritability (with staff: OR = 2.35; with relatives: OR = 3.09), aberrant motor behaviour (with staff: OR = 2.02), and elation (with relatives: OR = 10.55).

CONCLUSIONS

Neuropsychiatric symptoms and CR are common among RF residents and are reciprocally associated. Further research with longitudinal design is needed to better understand this relationship.

Pro re nata (as needed) medication in nursing homes: the longer you stay, the more you get?

PURPOSE

Injudicious pro re nata (PRN) or as needed prescribing can lead to polypharmacy, potentially harmful drug interactions and total drug doses exceeding the maximum recommended. Despite the known risks and the widespread administration, there is a paucity of current research examining the use of PRN drugs in nursing homes. Therefore, we examined characteristics of PRN drug use and potential predictors in nursing homes.

METHODS

The multicentre cross-sectional study included a heterogeneous sample of 21 nursing homes in Northwestern Germany comprising 852 residents. Descriptive statistics and multivariable regression models were used to analyse and present the collected data.

RESULTS

Nearly three quarters (74.9 %) of all residents were treated with at least one PRN medication. On average, each resident was prescribed 2.5 ± 2.3 PRN drugs. On average, residents with no PRN prescriptions stayed since 2.4 ± 2.9 years in the nursing home. Residents with five and more PRN prescriptions were on average since 4.8 ± 4.3 years in the nursing home. In a multivariable analysis, length of stay above the median of 2.1 years (OR 2.4; 95 % CI 1.8, 3.2) and polypharmacy with five or more long-term drugs (OR 2.1; 95 % CI 1.5, 2.9) were associated with a higher number of PRN prescriptions. Most commonly used PRN drug was acetaminophen, which was prescribed to 289 (33.9 %) residents.

CONCLUSIONS

The high prevalence of PRN medication should be taken into account when considering polypharmacy and inappropriate drug prescribing or using screening tools like the STOPP/START (screening tool of older persons' potentially inappropriate prescriptions/screening tool to alert doctors to right) criteria in nursing homes. Physicians should regularly reconsider the need of each PRN drug on the medication schedule. Moreover, the high prevalence of PRN medication and the association with length of stay highlights the importance of an accurate documentation.

A Review Exploring the Relationship Between Nursing Home Staffing and Antipsychotic Medication Use

Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.

Current knowledge and systematic review of viruses associated with Crohn's disease

The aetiology of Crohn's disease (CD) is currently unknown. A viral trigger was proposed more than 40 years ago and has been the focus of many investigations. We summarised the current literature surrounding the association between viruses and CD and conducted a systematic review of all studies investigating this association quantitatively. Studies were identified by searching for 13 specific virus names or the general term 'virus' and 'Crohn's disease' in search engines PubMed and OVID. A total of 1315 studies were identified, of which 78 studies had a laboratory result. Of the 78, 46 case-control studies met all the inclusion criteria for forest plot analysis. The most common viruses studied were EBV, CMV and measles virus (MV). Forest plot analysis for each virus was carried out (fitted using random effects) and identified evidence of an association between CD and CMV (risk ratio [RR] 1.602, 95% confidence interval [CI] 1.069 to 2.400) with some suggestion that EBV may also be associated with CD (RR 1.366, 95% CI 0.996 to 1.873). However, there was evidence of large heterogeneity in the results from the identified studies for EBV. There was little evidence of an association with CD for MV, human herpes virus 6, human herpes virus 8, human simplex virus, varicella-zoster virus, mumps virus, Rubella virus, rotavirus, norovirus and adenovirus. There is still some question around whether CD is associated with the presence of a currently known virus.

Nursing home research in Jinan, China: a focus group approach

This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.

Leadership, staffing and quality of care in nursing homes

Background

Leadership and staffing are recognised as important factors for quality of care. This study examines the effects of ward leaders' task- and relationship-oriented leadership styles, staffing levels, ratio of registered nurses and ratio of unlicensed staff on three independent measures of quality of care.

Methods

A cross-sectional survey of forty nursing home wards throughout Norway was used to collect the data. Five sources of data were utilised: self-report questionnaires to 444 employees, interviews with and questionnaires to 13 nursing home directors and 40 ward managers, telephone interviews with 378 relatives and 900 hours of field observations. Separate multi-level analyses were conducted for quality of care assessed by relatives, staff and field observations respectively.

Results

Task-oriented leadership style had a significant positive relationship with two of the three quality of care indexes. In contrast, relationship-oriented leadership style was not significantly related to any of the indexes. The lack of significant effect for relationship-oriented leadership style was due to a strong correlation between the two leadership styles (r = 0.78). Staffing levels and ratio of registered nurses were not significantly related to any of the quality of care indexes. The ratio of unlicensed staff, however, showed a significant negative relationship to quality as assessed by relatives and field observations, but not to quality as assessed by staff.

Conclusions

Leaders in nursing homes should focus on active leadership and particularly task-oriented behaviour like structure, coordination, clarifying of staff roles and monitoring of operations to increase quality of care. Furthermore, nursing homes should minimize use of unlicensed staff and address factors related to high ratios of unlicensed staff, like low staff stability. The study indicates, however, that the relationship between staffing levels, ratio of registered nurses and quality of care is complex. Increasing staffing levels or the ratio of registered nurses alone is not likely sufficient for increasing quality of care.

Psychotropic drug use in relation to mental disorders and institutionalization among 95-year-olds: a population-based study

BACKGROUND

The prevalence of psychotropic drug use is high among the elderly, but research on how psychotropic drugs are used among individuals aged 90 years and older is limited. An increased knowledge on this topic may contribute to improved prescribing patterns in this vulnerable population. The aim of this study was to assess the use of psychotropic drugs in relation to mental disorders and institutionalization among 95-year-olds and to identify use of potentially inappropriate psychotropic drugs.

METHODS

All 95-year-olds born in 1901-1903 living in nursing homes or community settings in Gothenburg, Sweden were invited to participate. The response rate was 65% and 338 95-year-olds were examined (263 women, 75 men). Psychotropic drug use in relation to mental disorders and institutionalization was assessed. Information on drug use was collected primarily from multi-dose drug dispensing lists. Participants were examined by trained psychiatrists using the Comprehensive Psychopathological Rating Scale and a battery of cognitive tests. Dementia, depression, anxiety and psychotic disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R).

RESULTS

Sixty percent of the 95-year-old participants used psychotropic drugs; hypnotics were most common (44%). Potentially inappropriate psychotropics were observed in one third (33%). Antidepressants were used by 7% of the participants without dementia who fulfilled criteria for a depressive disorder, while 56% used hypnotics and 30% used anxiolytics.

CONCLUSIONS

The high prevalence of psychotropic drug use and the nonspecific nature of these treatments among 95-year-olds indicate a need for improvement in prescribing patterns.

Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications

BACKGROUND

Few studies have examined factors associated with antidepressant prescribing in older nursing home residents.

OBJECTIVE

The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort.

DESIGN

Longitudinal.

SETTINGS

Settings were 12,556 US nursing homes in 1996 and 2006.

DATA SOURCES

Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF).

MEASUREMENTS

Increasing prescribing of antidepressants analyzed using multivariable multinomial generalized estimating equations (GEE).

RESULTS

Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95% CI 0.53-0.69 and AOR 0.62; 95% CI 0.54-0.71, respectively), or coprescribing of antianxiety or antipsychotic agents (AOR 0.70; 95% CI 0.68-0.72 and AOR 0.74; 95% CI 0.72-0.77, respectively).

CONCLUSIONS

Prescribing of antidepressants has increased dramatically in the past decade in older nursing home residents and seems to be associated with certain staffing characteristics and the coprescribing of psychotropic medications. Further research is needed to determine if antidepressants are appropriately prescribed, and if overuse is determined, develop interventions to improve the quality of prescribing of these medications in older nursing home residents.

An assessment of pharmaceutical inspection reports from nursing and residential homes for the elderly in Northern Ireland

Objectives

To highlight issues currently being inspected in nursing, residential and dual-registered homes (care homes) for the elderly in Northern Ireland as part of a pharmaceutical inspection. Methods A cross-sectional survey and analysis of reports from pharmaceutical inspections in Northern Ireland care homes between January 1999 and December 2000 was undertaken, using reports provided by the four Registration and Inspection Units (R & I Units 1–4) within the region. Reports were reviewed and all recommendations made by inspectors were classified into 11 main categories. Binary logistic regression was used to examine possible relationships between the type of home (nursing, residential or dual-registered) or the R & I unit and the recommendations made by the inspectors, with corresponding odds ratios and 95% confidence intervals.

Key findings

Reports from 415 homes (one report per home) formed the final sample for analysis. Each R & I unit used different documentation to conduct a pharmaceutical inspection. Homes received the majority of recommendations from inspectors in the categories ‘Records’ (66.7% of all homes), ‘Policies and protocols’ (39.3%) and ‘Medication’ (31.8%). More recommendations in a number of categories emanated from R & I unit 4 compared with R & I unit 1 (referent). Dual-registered homes (those registered as a nursing and residential facility) were more likely to receive a recommendation in the categories ‘Storage of medicine’, ‘Order and receipt of medication’ and ‘Equipment’ than nursing or residential homes.

Conclusion

Inspections of care homes should be standardised in terms of documentation used and facilities should be given guidance on issues that are likely to result in recommendations from inspectors. In the longer-term, pharmaceutical inspections should move from a focus on structure/process measures to those that emphasise quality in prescribing.

Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study

OBJECTIVES

This study compares inter- and intra-country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments.

METHODS

Population-based, cross-sectional data were collected using a standardized Resident Assessment Instrument (RAI) from 14,504 long-term care facilities providing nursing home level services in five countries participating in the interRAI consortium, including Canada, Finland, Hong Kong (Special Administrative Region, China), Switzerland, and the United States. Facility-level prevalence rates of physical restraints and antipsychotic use were examined both between and within the study countries.

RESULTS

The prevalence of physical restraint use varied more than five-fold across the study countries, from an average 6% in Switzerland, 9% in the US, 20% in Hong Kong, 28% in Finland, and over 31% in Canada. The prevalence of antipsychotic use ranged from 11% in Hong Kong, between 26-27% in Canada and the US, 34% in Switzerland, and nearly 38% in Finland. Within each country, substantial variations existed across facilities in both physical restraint and antipsychotic use rates. In all countries, neither facility case mix nor organizational characteristics were particularly predictive of the prevalence of either treatment.

CONCLUSIONS

There exists large, unexplained variability in the prevalence of physical restraint and antipsychotic use in nursing home facilities both between and within countries. Since restraints and antipsychotics are associated with adverse outcomes, it is important to understand the idiosyncratic factors specific to each country that contribute to variation in use rates.

Psychotropic medication use among nursing home residents in Austria: a cross-sectional study

Background

The use of psychotropic medications and their adverse effects in frail elderly has been debated extensively. However, recent data from European studies show that these drugs are still frequently prescribed in nursing home residents. In Austria, prevalence data are lacking. We aimed to determine the prevalence of psychotropic medication prescription in Austrian nursing homes and to explore characteristics associated with their prescription.

Methods

Cross-sectional study and association analysis in forty-eight out of 50 nursing homes with 1844 out of a total of 2005 residents in a defined urban-rural region in Austria. Prescribed medication was retrieved from residents' charts. Psychotropic medications were coded according to the Anatomical Therapeutic Chemical Classification 2005. Cluster-adjusted multiple logistic regression analysis was performed to investigate institutional and residents' characteristics associated with prescription.

Results

Residents' mean age was 81; 73% of residents were female. Mean cluster-adjusted prevalence of residents with at least one psychotropic medication was 74.6% (95% confidence interval, CI, 72.0–77.2). A total of 45.9% (95% CI 42.7–49.1) had at least one prescription of an antipsychotic medication. Two third of all antipsychotic medications were prescribed for bedtime use only. Anxiolytics were prescribed in 22.2% (95% CI 20.0–24.5), hypnotics in 13.3% (95% CI 11.3–15.4), and antidepressants in 36.8% (95% CI 34.1–39.6) of residents. None of the institutional characteristics and only few residents' characteristics were significantly associated with psychotropic medication prescription. Permanent restlessness was positively associated with psychotropic medication prescription (AOR 1.54, 95% CI 1.32–1.79) whereas cognitive impairment was inversely associated (AOR 0.70, 95% CI 0.56–0.88).

Conclusion

Frequency of psychotropic medication prescription is high in Austrian nursing homes compared to recent published data from other countries. Interventions should aim at reduction and optimisation of prescriptions.

[Psychopharmacological drug treatment in Munich nursing homes]

The survey of Munich nursing homes with 888 residents showed that 56.4% received psychotropic drugs and a twice as frequent prescription of antipsychotics to residents of double rooms than of single rooms. In a subsample of 397 residents the last review of the prescriptions of 17.5% of the psychotropic drugs was at least 3 months to partly years ago. Based on the American Beers-criteria 13.6% of the consumers of psychotropic drugs received psychotropic drugs, which preferably should not be taken by older people.

Does Organisational Culture Influence Prescribing in Care Homes for Older People?

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.

Factors Associated With Psychotropic Drug Usage Among Nursing Home Residents With Dementia

BACKGROUND

Although federal regulations hold nursing homes responsible for monitoring psychotropic drug (PD) usage, there is a high prevalence of PD usage and significant variation in use across nursing homes.

OBJECTIVES

The aims of study were to (a) describe current PD usage in nursing homes and (b) examine resident and nursing home factors associated with PD usage in nursing home residents with dementia.

METHODS

A multivariate, multisite, cross-sectional descriptive study was used on data from 107 dementia patients residing in nine randomly selected nursing homes in southeastern Michigan. The PD usage of interest included antipsychotics, antidepressants, anxiolytics or sedatives, and mood stabilizers. Regression analysis tested resident factors, including cognitive ability, functional ability, presence of depressive symptoms, and demographic characteristics, and three facility factors (nursing home size, type of ownership, and level of registered nurse [RN] staffing) in comparison with PD usage.

RESULTS

In this study, 67.3% of the participants received at least one PD. The most frequently prescribed PDs were antidepressants (41.1%) and antipsychotics (37.4%). Newly developed antipsychotics such as risperidone were given more frequently to residents than were conventional drugs such as haloperidol. Regression analysis suggests that the presence of depressive symptoms (odds ratio [OR]= 3.5, p < .01) and low levels of RN staffing (OR = 1.0, p < .01) were associated with the use of PD.

DISCUSSION

Psychotropic drugs are prescribed frequently for nursing home residents, although such usage is variable. Behavioral symptoms were not an independent predictive factor for PD use. Rather, combined resident and facility characteristics best predicted the use of PDs in nursing home residents. The evaluation of nursing home systems for these characteristics as predictive factors for PD usage in nursing home patients with dementia is suggested by the results. Likewise, attention to new drugs such as selective serotonin reuptake inhibitors and their appropriate use is recommended.

Types of medication errors in north carolina nursing homes: A target for quality improvement

BACKGROUND

Medication errors are an important problem in nursing homes, but little is known about the types of medications involved in errors in this setting. Gaining a better understanding of the types of medications commonly involved in medication errors in nursing homes would be an important step toward quality improvement.

OBJECTIVES

This study sought to describe the types of medication errors most frequently reported to a statewide repository by North Carolina nursing homes. We also examined whether nursing homes reporting an error involving a drug on the updated Beers list of medications considered potentially inappropriate for use in the elderly were likely to report a greater number of medication errors or more harmful medication errors compared with nursing homes that did not report such an error.

METHODS

Medication errors were defined as preventable events that had the potential to cause/lead to or actually caused/led to inappropriate medication use or patient harm. We analyzed summary reports of medication errors submitted to the State of North Carolina by licensed nursing homes for the 9-month period from January 1, 2004, to September 30, 2004, using a Web-based reporting system. Drugs commonly involved in medication errors were summarized for all nursing homes in the state. Errors involving medications on the updated Beers list also were identified. Nursing homes were profiled and compared according to the type of medication error and whether the error reached the patient and/or caused harm.

RESULTS

Among the 384 licensed nursing homes included in our analysis, 9272 medication errors were reported. The specific medication involved was documented for 5986 of these errors. The medications most commonly involved in an error were lorazepam (457 errors [8%]), warfarin (349 [6%]), insulin (332 [6%]), hydrocodone and hydrocodone combinations (233 [4%]), furosemide (173 [3%]), and the fentanyl patch (150 [3%]). The medication errors disproportionately included central nervous system agents (16%) and analgesics (11%). Medications considered potentially inappropriate in the elderly were frequently involved in the reported errors (10% of all reported errors), with the greatest number of such errors associated with lorazepam (457 [8%]), alprazolam (130 [2%]), and digoxin (74 [1%]). Nursing homes reporting potentially inappropriate drugs among their 10 most common medication errors also reported a significantly greater mean number of errors compared with nursing homes that did not report such errors (26.9 vs 17.6, respectively; P < 0.001), as well as a significantly greater number of errors that reached the patient (6148 vs 1393; P < 0.001).

CONCLUSION

Based on the experience in North Carolina, quality improvement efforts in nursing homes should focus on the medications commonly involved in errors and should continue to discourage or closely monitor the use of medications considered potentially inappropriate in the elderly.

Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland

BACKGROUND

The use of psychotropic drugs is high in institutionalised elderly, which raises the question of its appropriateness. This study aimed to: (1) estimate the use of psychotropics, for each family, in terms of the prevalence and dosage among the elderly in nursing homes in French-speaking Switzerland and Quebec; and (2) assess, for each family of psychotropic drugs and for each care facility, the prevalence of use and departure from average prescription (ratio of observed-to-expected prevalence).

METHOD

An administrative database was used for this cross-sectional analysis. The sample included 8183 Quebec and 7592 Swiss long-term care residents. Three classes of psychotropics (antipsychotics, antidepressants, hypnotics-anxiolytics) were defined as dichotomous variables. Logistic regressions were conducted to identify residents characteristics associated with the use of each psychotropic type and to compute expected prevalence.

RESULTS

Swiss residents were slightly older and less dependent than Quebec residents. Use of psychotropic drugs was higher in Swiss than in Quebec residents, on the whole as well as for each family of drug. A total of 78.1% of Swiss residents used at least one drug as compared to 66.9% in Quebec. Ninety percent of residents were given less than 7 defined daily doses per week, irrespective of the drug family. According to Beer's criteria, only 4.9% of prescriptions were inadequate. In Quebec and in Switzerland, the prevalence of antidepressant use was associated with the prevalence of hypnotic-anxiolytic use. No ratios of observed-to-expected reached statistical significance.

INTERPRETATION

There was a considerable use of psychotropics in Quebec and Switzerland with, seemingly, no dramatic departure from the average practice. Our data cannot tell if there is a global overuse of psychotropics, but indicated that dosage and medication selection seem adequate. Physicians should critically reassess the necessity of prescribed medications for their patients.

Perceived anxiety, depression, and sleeping problems in relation to psychotropic drug use among elderly in assisted-living facilities

OBJECTIVE

The aim of the present study was to investigate the perceived anxiety, depression, sleeping habits, and participation in social activities in relation to psychotropic drug use among elderly in assisted-living facilities and to identify factors of importance for the use of these drugs.

METHOD

The study had a cross-sectional design and included 93 residents living in old-age homes or in nursing homes in a municipality in southern Sweden. Data regarding medication was obtained from medical records and included all psychoactive drugs. The perceived anxiety, depression and sleeping habits of the residents were assessed using a structured interview questionnaire.

RESULTS

Many of the residents had sleeping problems and also reported problems concerning anxiety and depression. Of the study population, 65 (70%) used one or more psychoactive drug; 9 were prescribed neuroleptics (10%), 29 anxiolytics (31%), 43 hypnotics (43%) and 31 were prescribed anti-depressants (33%). The most commonly used psychotropic drugs as it related to the residents' problems were: benzodiazepines (oxazepam) against anxiety, benzodiazepine-related agents (zoldipem and zopiclon) against insomnia and serotonin reuptake inhibitors (SSRI; citalopram) against depression. The residents who had been treated with psychotropic drugs at home continued this treatment after moving to assisted-living facilities and approximately 30% of the residents were prescribed new psychotropic drugs. Of those that perceived anxiety, insomnia or felt depressed, between 58% and 69%, respectively, had spoken to neither a nurse nor a physician about these problems. Of those that had talked to a nurse/physician about these problems, a majority had been prescribed psychotropic drugs. Factors of importance for treatment with psychotropic drugs against anxiety, insomnia and depression were: prior treatment with these drugs at home and discussing their problems with a physician.

CONCLUSION

The communication between the residents and the nurses/physicians appears to be insufficient as the residents state that they have not discussed their problems with a nurse or a physician and that the prescription of psychotropic drugs does not seem to be in proportion to the residents' perceived problems.

Which organizational characteristics are associated with increased management of depression using antidepressants in US nursing homes?

BACKGROUND

There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes.

OBJECTIVE

This study evaluated the relation between organizational characteristics and management of depression using antidepressants.

RESEARCH DESIGN

This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000.

SUBJECTS

We studied 87,907 residents with depression in 2,128 facilities.

MEASURES

Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations.

RESULTS

Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents.

CONCLUSIONS

Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing.

Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics

OBJECTIVE

To estimate the scope of potentially inappropriate medication prescriptions (PIRx) among elderly residents in U.S. nursing homes (NHs), and to examine associated resident and facility characteristics.

DATA SOURCES

The 1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC), a survey of a nationally representative sample of NHs and residents.

STUDY DESIGN

The PIRx, defined by Beers's consensus criteria (1991, 1997), was identified using up to a year's worth of NH prescribed medicine data for each resident. The study sample represented 1.6 million NH residents (n=3,372).

RESULTS

At a minimum, 50 percent of all residents aged 65 or older, with an NH stay of three months or longer received at least one PIRx in 1996. The most common PIRx involved propoxyphene, diphenhydramine, hydroxyzine, oxybutynin, amitriptyline, cyproheptadine, iron supplements, and ranitidine. Resident factors associated with greater odds of PIRx were Medicaid coverage, no high school diploma, and nondementia mental disorders. Facility factors were more beds and lower RN-to-resident ratio. Factors associated with lower odds of PIRx were fewer medications, residents with communication problems, and being in an accredited NH. Onsite availability of pharmacists or mental health providers was not related.

IMPLICATIONS

With quality of care and patient safety as major public health concerns, effective policies are needed to avoid PIRx occurrences and improve the quality of prescribing among elderly residents in NHs. Additional studies are needed to determine the impact of PIRx on this NH population.

A systems framework for evaluating nursing care quality in nursing homes

Given the ongoing concerns about the quality of care in nursing homes, a theoretical framework to guide a systems approach to quality is important. Existing frameworks either do not model causality, or do so in a linear fashion in which the actual linkages between components of quality may not be well specified. Through a review of frameworks for nursing home quality, and empirical studies on the subject, the authors construct a framework for nursing home quality that links contextual components of quality with structure, structure with process, and process with outcomes, focusing on nursing care quality. Intrastructural relationships and feedback mechanisms are also modeled. The framework is matched with a discussion of multilevel structural equation analysis for statistical application. Future research should expand the framework to include non-nursing components of quality.

Prescribing indicators for evaluating drug use in nursing homes

OBJECTIVE

To evaluate drug use in 2 Dutch nursing homes (254 residents) by developing and evaluating prescribing indicators based on pharmacy prescription data.

METHODS

We evaluated the prescribing of benzodiazepines, nonsteroidal antiinflammatory drugs (NSAIDs), ulcer-healing drugs, and diuretics. Prescribing indicators were used to identify prescribing that was potentially not in line with recommendations in national and regional prescribing guidelines. We used both descriptive indicators, such as the number and percentage of users, and indicators reflecting potentially suboptimal prescribing, such as use of drugs outside the regional drug formulary, use of >1 drug from the same drug class, and prescription of drug dosages above recommended values. When potentially suboptimal prescribing was found, we verified the findings by means of an interview with 1 of the prescribers.

RESULTS

The prescribing indicators we assessed were generally in agreement with national and regional guidelines. However, prescribing of NSAIDs without concomitant prescribing of gastroprotective drugs was found in a relatively high number of patients. After prescriber interview and patient chart review, it was found that some prescribing indicators, such as dosages above recommended values, were not always indicative for suboptimal prescribing.

CONCLUSIONS

This pilot study showed that prescribing indicators based solely on pharmacy prescription data can be a useful tool to evaluate drug prescribing. With some of these prescribing indicators, we identified cases of potentially suboptimal prescribing. However, with other indicators such as those based on drug dosages, we could not identify suboptimal prescribing, and clinical information from the prescriber was necessary to get insight into the appropriateness of prescribing.

[Prevalence, associated factors, and misuse of medication in the elderly: a review]

Most elderly people use at least one medication, and about one-third use more than five drugs simultaneously. Many patients have no access to the drugs they most need, and others use unnecessary or dangerous drugs. The mean number of drugs used by the elderly, as quoted in different studies, varies from 2 to 5. Significant predictors for such misuse of medication are older age, female gender, precarious health conditions, and depression. Cardiovascular drugs, anti-rheumatics, and analgesics are the most frequently consumed therapeutic classes. Multiple use, prescription of contraindicated drugs, redundant use, and inadequate training of the health care team are associated with adverse drug effects and interactions. Better quality of prescriptions and research on drug use can bring benefits to people aged 60 years or older.

Nurse-physician communication and quality of drug use in Swedish nursing homes

The objective was to explore the impact of the quality of nurse-physician communication on the quality of psychotropic drug use in Swedish nursing homes, while controlling for resident mix and other nursing home characteristics. Data were collected from a sample of 36 Swedish nursing homes providing care for 1645 residents. Drug use data, along with residents' demographic characteristics, were obtained from residents' medication administration lists. Ward nurses reported other residents' characteristics (e.g. diagnosis and frequency of behavioral problems), and facility characteristics were obtained from head nurses. The quality of drug use was assessed and cross-sectional relationships among study variables were compared. Outcome measures included two drug use quality scores reflecting selection of drug and polymedicine. To assess behavioral problems, a list of the most commonly observed problems was created through a number of steps, including focus groups in the target population. Furthermore, a valid and reliable scale for assessing communication quality was developed. This measure was included in a survey administrated to nurses in the 36 facilities. There was a remarkable variation in the quality of drug use according to the two drug measures. As predicted, the quality of drug use was positively associated with the quality of nurse-physician communication and with regular multidisciplinary team discussions addressing drug therapy and negatively associated with prevalence of behavioral disturbances among residents. Facility size, level of staffing, resident's diagnostic mix, and demographic mix were unrelated to the two drug quality measures. Future efforts to improve the quality of drug use in long term facilities should consider ways of improving communication skills and communication routines among health care professionals.

Influence of facility characteristics on use of antipsychotic medications in nursing homes

OBJECTIVES

This study investigated the effect of facility and resident characteristics on the use of antipsychotic medications in the long-term care setting.

RESEARCH DESIGN

This research used data available from the On-Line Survey and Certification of Automated Records (OSCAR) for all Medicare/Medicaid-certified nursing homes in the contiguous United States in 1997. The data consisted of 14,631 facilities.

MEASURES

A multiple linear regression model was used to determine the effects of selected facility and resident characteristics on antipsychotic drug use while simultaneously controlling for the effects of resident characteristics and stratifying by ownership type. beta-Coefficients provided measures of effect and represented the per-unit change in the prevalence of antipsychotic use corresponding to the per-unit change in each independent variable.

RESULTS

In for-profit facilities, both the presence of special care units and mental health professionals were associated with increased antipsychotic use (beta = 1.70, SE = 0.23; beta = 0.24, SE = 0.17, respectively), while other facility factors such as increasing size, being part of a chain, and higher occupancy rate were associated with decreased antipsychotic drug use. In the nonprofit environment, facility characteristics (eg, increasing occupancy rate, certified nurses' aides per 100 beds) were associated with decreasing antipsychotic use. Increasing percentages of residents covered by Medicare, those with dementia, and residents with mental retardation (beta = 0.05, SE = 0.01; beta = 0.03, SE = 0.01; beta = 0.08, SE = 0.08, respectively) were predictive of increased drug use.

CONCLUSIONS

Facility and resident characteristics are associated with use of antipsychotic medications, although the extent to which these factors explain variability in use of anti-psychotics may vary on the basis of the underlying financial incentives of the institution.