Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway

The impact of a multidisciplinary team intervention on medication prescription in nursing homes in Catalonia

Background

In response to the rising population of nursing home residents with frailty and multimorbidity, optimizing medication safety through drug utilization review and addressing medication-related problems (MRPs) is imperative. Clinical decision support systems help reduce medication errors and detect potential MRPs, as well as medication reviews performed by a multidisciplinary team, but these combined assessments are not commonly performed. The objective of this study was to evaluate the impact on medication plans of a multidisciplinary team intervention in nursing homes, by analyzing the medication plan before and after the intervention and assessing whether the recommendations given had been implemented.

Methods

A multicenter before-after study, involving five nursing homes, assessed the impact of a multidisciplinary team intervention, to estimate effectiveness related to the review of the prescribed medications. The follow-up period for each patient was 12 months or until death if prior, from July 2020 to February 2022, and involved 483 patients. The clinical pharmacologist coordinated the intervention and reviewed all the prescribed medications to make recommendations, focused on the completion of absent data, withdrawal of a drug, verification of whether a drug was adequate, the substitution of a drug, and the addition of drugs. Since the intervention was performed during the COVID-19 pandemic, optimization of psychotropic drugs and absorbent pads were limited.

Results

The intervention had an impact with recommendations given for 398 (82.4%) of the patients and which were followed by 58.5% of them. At least one drug was withdrawn in 293 (60.7%) of the patients, with a mean of 2.3 (SD 1.7). As for the total of 1,097 recommendations given, 355 (32.4%) were followed. From the intervention, antipsychotics, antidepressants, benzodiazepines, statins, and diuretics were the most frequently withdrawn.

Conclusion

The findings underscore the impact of targeted interventions to reduce inappropriate medications and enhance medication safety in nursing homes. The proposed recommendations given and followed show the importance of a multidisciplinary team, coordinated by a clinical pharmacologist, for a patient-centered approach to make medication reviews regularly, with the help of clinical decision support systems, to help reduce potential MRPs and polypharmacy.

National Trends in Antidepressant Use in Australian Residential Aged Care Facilities (2006-2019)

OBJECTIVES

Antipsychotics have been the focus of reforms for improving the appropriateness of psychotropic medicine use in residential aged care facilities (RACFs). Comprehensive evaluation of antidepressant use in RACFs is required to inform policy and practice initiatives targeting psychotropic medicines. This study examined national trends in antidepressant use among older people living in RACFs from 2006 to 2019.

DESIGN

National repeated cross-sectional study.

SETTING AND PARTICIPANTS

Individuals aged 65 to 105 years who were permanent, long-term (≥100 days) residents of Australian RACFs between January 2006 and December 2019 were included.

METHODS

Annual age- and sex-adjusted antidepressant prevalence rates and defined daily doses (DDDs) supplied per 1000 resident-days from 2006 to 2019 were determined. Age- and sex-adjusted prevalence rate ratios (aRRs) and 95% confidence intervals (CIs) were estimated using Poisson and negative binomial regression models.

RESULTS

A total of 779,659 residents of 3371 RACFs were included (786,227,380 resident-days). Overall, antidepressant use increased from 46.1% (95% CI, 45.9-46.4) in 2006 to 58.5% (95% CI, 58.3-58.8) of residents in 2019 (aRR, 1.02; 95% CI, 1.02-1.02). Mirtazapine use increased from 8.4% (95% CI, 8.2-8.5) to 20.9% (95% CI, 20.7-21.1) from 2006 to 2019 (aRR, 1.07; 95% CI, 1.07-1.07). Antidepressant use increased from 350.3 (95% CI, 347.6-353.1) to 506.0 (95% CI, 502.8-509.3) DDDs/1000 resident-days (aRR, 1.03; 95% CI, 1.03-1.03), with mirtazapine utilization increasing by 6% annually (aRR, 1.06; 95% CI, 1.06-1.06).

CONCLUSIONS AND IMPLICATIONS

This nationwide study identified a substantial increase in antidepressant use among residents of Australian RACFs, largely driven by mirtazapine. With nearly 3 in every 5 residents treated with an antidepressant in 2019, findings highlight potential off-label use and suggest that interventions to optimize care are urgently needed.

Mortality and health-related quality of life in older adults with long-term use of opioids, z-hypnotics or benzodiazepines: a prospective observational study at 5 years follow-up

OBJECTIVES

Disease and medication use in older age is a consequence of age-related declining health. Multimorbidity followed by polypharmacy is common. Central nervous system depressing (CNSD) drugs such as opioids, benzodiazepines and z-hypnotics are not recommended for long-term use in older adults but are in use by many. We aimed to assess mortality and change in health-related quality of life (HRQoL) in older adults with long-term use of CNSDs.

METHOD

A prospective observational study was conducted at Akershus University Hospital, Norway, 2017-2019, with follow-up in 2021-2022, including 246 participants aged 65-90. At 5-year follow-up, 78 (32%) participants had passed away. Mortality data were collected from patient electronic health records. Of the surviving 168 (68%), we collected further follow-up data from 38 (16%) participants. Follow-up included demographic and clinical data. The EuroQuol Group EQ-5D-5L questionnaire was used to measure HRQoL. Analysis include Cox regression model for survival data and linear mixed model for change in HRQoL over time.

RESULTS

At follow-up, 78 (31.7%) were deceased. Mean survival time was 3.3 years. Total time for survival data was 4.7 years. Mortality was higher among participants with long-term use of CNSD (HR 1.9 95% CI (1.2 to 3.2), p=0.01). The multivariable analysis found being older (HR 1.1 95% CI (1.0 to 1.1), p=0.020) and male sex (HR 2.1 95% CI (1.2 to 3.5), p=0.008) to be associated with increased risk of mortality. According to the linear mixed model (n=38), there was no significant difference between surviving users and non-users in change in HRQoL EQ-5D-5L index from baseline to follow-up.

CONCLUSION

Mortality was higher for long-term users of CNSDs at 5-year follow-up. Being older and male sex were associated with mortality. Among survivors, there was no significant difference between the groups in change of HRQoL over time.

TRIAL REGISTRATION NUMBER

NCT03162081; 22 May 2017.

Terms used to describe and define activities undertaken as a result of the medication review process: Do they require standardisation? A systematic review

BACKGROUND

Medication review (MR) is the systematic assessment of a patient's medications by a healthcare practitioner. It is necessary to compare such MR interventions to rationalise differences between them and assess their impact. The development of an international taxonomy for terms used to describe activities undertaken within the MR process would facilitate quality of reporting, and the comparison of different interventions.

AIM

To identify overarching and individual MR activity terms and definitions reported within studies where MR was the main intervention.

METHOD

A systematic review of the literature was performed using search terms for 'Intervention' and 'Outcome'. Papers with empirical data reporting and describing MR activities in English were included. The Mixed Method Appraisal Tool was used to assess research quality. Two researchers reviewed all included literature independently. Data extraction was performed using Cochrane Effective Practice and Organisation of Care to report study characteristics, and terms and definitions used to describe MR activities.

RESULTS

Twenty-one papers were included: eight quantitative non-randomised trials (38%), eight randomised controlled trials (38%), and five quantitative descriptive studies (24%). Overarching interventions such as 'Clinical', 'Education' and 'Technical' were identified with no standardised definitions. Terms used to describe the medication review activities, such as stop, start and change, varied with significant potential for ambiguity.

CONCLUSION

The literature reports a variety of overlapping, ambiguous and undefined MR terms. As a result, comparing process evaluations from MR interventions may be difficult. A standardised taxonomy to describe, define and report MR activities is required.

The effect of educational intervention on use of psychotropics in defined daily doses and related costs - a randomized controlled trial

OBJECTIVE

To investigate the effect of an educational intervention of nursing staff on change in psychotropic use and related costs among older long-term care residents.

DESIGN

A secondary analysis of a randomized controlled intervention study with 12 months of follow-up.

SETTING

Assisted living facilities in Helsinki, Finland.

SUBJECTS

Older (≥65 years) residents (N = 227) living in assisted living facility wards (N = 20) in Helsinki in 2011.

INTERVENTION

The wards were randomized into two groups. In one group, the nursing staff received training on appropriate medication therapy and guidance to recognize potentially harmful medications and adverse effects (intervention group); in the other group, the nursing staff did not receive any additional training (control group).

MAIN OUTCOME MEASURES

Change of psychotropic use counted as relative proportions of WHO ATC-defined daily doses (rDDDs) among older long-term care residents. In addition, the change in drug costs was considered. Comparable assessments were performed at 0, 6, and 12 months.

RESULTS

A significant decrease in both rDDDs and the cost of psychotropics was observed in the intervention group at 6 months follow-up. However, at 12 months, the difference between the intervention and control group had diminished.

CONCLUSIONS

Educational training can be effective in reducing the doses and costs of psychotropics. Further studies are warranted to investigate whether long-term effects can also be achieved by various educational interventions.

REGISTRATION NUMBER

ACTRN 12611001078943 KEY POINTSWe explored the effect of staff training on psychotropic use and associated costs among older long-term care residents.Educational training of nursing staff was beneficial as regards the actual drug doses of psychotropics, and cost savings in psychotropic medication were achieved.Educational training was efficient in the short-term, but further research is warranted to achieve long-term effects.

Barriers and facilitators of appropriate antibiotic use in primary care institutions after an antibiotic quality improvement program - a nested qualitative study

BACKGROUND

Antibiotic prescribing by physicians in primary care institutions is common and affected by several factors. Diagnosis and treatment of infections in a nursing home (NH) resident is challenging, with the risk of both under- and overtreatment. Identifying barriers and facilitators of appropriate antibiotic prescribing in NHs and municipal acute care units (MACUs) is essential to ensure the most adequate antibiotic treatment possible and develop future antibiotic stewardship programs.

METHODS

After implementing a one-year antibiotic quality improvement program, we conducted six semi-structured focus group interviews with physicians (n = 11) and nurses (n = 14) in 10 NHs and 3 MACUs located in the county of Østfold, Norway. We used a semi-structured interview guide covering multiple areas influencing antibiotic use to identify persistent barriers and facilitators of appropriate antibiotic prescribing after the intervention. The interviews were audio-recorded and transcribed verbatim. The content analysis was performed following the six phases of thematic analysis developed by Braun and Clarke.

RESULTS

We identified thirteen themes containing barriers and facilitators of the appropriateness of antibiotic use in primary care institutions. The themes were grouped into four main levels: Barriers and facilitators 1) at the clinical level, 2) at the resident level, 3) at the next of kin level, and 4) at the organisational level. Unclear clinical presentation of symptoms and lack of diagnostic possibilities were described as essential barriers to appropriate antibiotic use. At the same time, increased availability of the permanent nursing home physician and early and frequent dialogue with the residents' next of kin were emphasized as facilitators of appropriate antibiotic use. The influence of nurses in the decision-making process regarding infection diagnostics and treatment was by both professions described as profound.

CONCLUSIONS

Our qualitative study identified four main levels containing several barriers and facilitators of appropriate antibiotic prescribing in Norwegian NHs and MACUs. Diagnostic uncertainty, frequent dialogue with next of kin and organisational factors should be targeted in future antibiotic stewardship programs in primary care institutions. In addition, for such programs to be as effective as possible, nurses should be included on equal terms with physicians.

Drug-Related Problems and Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

At present, 19.2% of the Spanish population is aged 65 or older. Polypharmacy is a frequent condition among the elderly, especially in those living in nursing homes, which is associated with adverse outcomes, such as adverse drug events or drug-drug interactions. This study aimed to assess the pattern of polypharmacy in a nursing home in Leon, one of Spain's most ageing regions, and its relationship with different drug-related problems. A descriptive, observational, and cross-sectional study design was used; 222 residents were involved in this study. Data on drug use were collected from medical charts. Information was screened with the software CheckTheMeds, BOT PLUS and Drug-Reax. Residents were on a median of 7 medicines. Polypharmacy and inappropriate medications were present in 78.8% and 96.8% of residents, respectively. Drug-related problems were present in almost all the populations evaluated. Drug-drug interactions were very common in participants (81.1%), being severe/moderate in 24.7%. A high prevalence of polypharmacy and drug-related problems in the nursing home population assessed has been observed. A significantly higher risk of suffering drug-drug interactions was revealed for increasing polypharmacy and anticholinergic risk. A regular evaluation of drug prescribing in nursing home residents is necessary to minimize drug-related problems risk.

Health professionals' experience of nursing home residents' consumption of alcohol and use of psychotropic drugs

Background:

Nursing home (NH) residents are in most cases in older ages and use prescription drugs. As alcohol interacts with many commonly prescribed drugs, NH residents may be more vulnerable to the effects of alcohol.

Aim:

To investigate the experiences of health professionals in Norwegian NHs when it comes to residents' alcohol consumption and use of psychotropic drugs, and the facilitation of such use in the NH.

Method:

Focus-groups and individual interviews with NH health professionals were performed in 2017 and 2018. The data were analysed using content analysis.

Findings:

Two main themes emerged: (1) the balancing of alcohol consumption, and (2) the use of psychotropic drugs. Each of these themes involved reasoning, which revealed that the informants in general had little attention regarding alcohol consumption among residents, and few institutions had policies regarding serving and consumption of alcohol. The informants reported an increased attention regarding use of psychotropic drugs and a tendency towards less use of psychotropic drugs among the residents than before, but few informants reported use of standardised observations tools of symptoms related to prescribing and discontinuation of drugs.

Conclusion:

Alcohol policies or procedures related to alcohol consumption were uncommon at the NH that the interviewees of this study represented, and the professionals regarded infrequent serving and consumption of alcohol among the residents as a part of everyday life. In cases when residents frequently consumed alcohol, the professionals used dialogue to underpin the adherent risks and they also tried to control the consumption of the resident in different ways. The interviewees were aware of various side-effects of psychotropic drugs; they were also aware of their effects in combination with alcohol.

Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review

BACKGROUND

Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps.

METHODS

We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively.

RESULTS

Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies.

CONCLUSIONS

Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

Background

Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.

Objectives

To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.

Design

A realist synthesis.

Setting

Primary care, hospital care and nursing homes.

Patients

Patients aged ≥ 65 years.

Interventions

Any intervention based on the use of the STOPP/START tools.

Review methods

Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.

Results

We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.

Limitations

None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.

Conclusions

No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.

Study registration

This study is registered as PROSPERO CRD42018110795.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.

A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities

OBJECTIVES

To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included.

METHODS

Screening, data extraction, and quality assessment were performed independently by 2 review authors.

RESULTS

Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2).

CONCLUSIONS AND IMPLICATIONS

Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.

The impact of electronic health record functions on patterns of depression treatment in primary care

BACKGROUND

Many individuals with depression are not being linked to treatment by their primary care providers. Electronic health records (EHRs) are common in medicine, but their impact on depression treatment is mixed. Because EHRs are diverse, differences may be attributable to differences in functionality. This study examines the relationship between EHR functions, and patterns of depression treatment in primary care.

METHODS

secondary analyses from the 2013-2016 National Ambulatory Medical Care Survey examined adult primary care patients with new or acute depression (n = 5,368). Bivariate comparisons examined patterns of depression treatment by general EHR use, and logistic regression examined the impact of individual EHR functions on treatment receipt.

RESULTS

Half the sample (57%; N = 3,034) was linked to depression treatment. Of this, 98.5% (n = 2,985) were prescribed antidepressants, while 4.3% (n = 130) were linked to mental health. EHR use did not impact mental health linkages, but EHR functions did affect antidepressant prescribing. Medication reconciliation decreased the odds of receiving an antidepressant (OR = .60, p < .05), while contraindication warnings increased the likelihood of an antidepressant prescription (OR = 1.91, p < .001).

CONCLUSIONS

EHR systems did not impact mental health linkages but improved rates of antidepressant prescribing. Optimizing the use of contraindication warnings may be a key mechanism to encourage antidepressant treatment.

Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors

BACKGROUND/AIMS

The aim was to explore the impact of sex on prevalence, patterns and trends in the prescription of psychotropics and analgesics in users of acetylcholinesterase inhibitors (AChEIs), before and after AChEI initiation, compared to the general population.

METHODS

A prospective study applying data from the Norwegian Prescription Database (NorPD) in the period 2004-2016. Prescription of antidepressants, antipsychotics, analgesics including opioids, benzodiazepines and z-hypnotics in persistent AChEI users was studied in a follow-up period from four years before to two years after AChEI initiation in men and women of four age groups: 37-64, 65-72, 73-80 and 81-88 years.

RESULTS

Use of antidepressants, antipsychotics and weaker analgesics increased in both sexes during the follow-up period in 11.764 persistent AChEI users. Women with pre-dementia and dementia stages of AD showed a prescription pattern with more use of psychotropics and opioids than men, except for antipsychotics.

CONCLUSION

Female sex showed to have a significant influence on the prescriptions of psychotropics and analgesics in AD patients in a pre-dementia and dementia stage. The exception is for antipsychotics, that men used more than women. The prescription pattern showed a higher extent of polypharmacy of psychotropics and/or opioids in women than in men. The total prescription pattern of analgesics could indicate an undertreatment of pain in pre-dementia and dementia stages, most pronounced in men.

Health Professionals' Experiences Regarding Alcohol Consumption and Its Relation to Older Care Recipient's Health and Well-Being

BACKGROUND

Alcohol consumption among older people is expected to increase in the years ahead. Health professionals' experiences of, and reflections on, alcohol consumption and its relation to well-being are thus important to the provision of adequate and high-quality treatment and care.

AIM

To investigate health professionals' experiences and reflections about alcohol consumption among older people and how it is related to their health and well-being.

METHODS

A case study design approach was adopted, incorporating three qualitative studies involving Norwegian health professionals. The health professionals interviewed included workers in nursing homes, home care professionals and general practitioners.

RESULTS

The study revealed a diversity of views and reflections on alcohol consumption, its facilitation, and the impact on the health and well-being of older patients and care recipients. Six themes were revealed by the three studies: (i) the facilitation of alcohol consumption to promote and normalize life in nursing homes, (ii) the restriction of unhealthy alcohol consumption, (iii) attempts to discuss alcohol consumption with care recipients, (iv) the initiation of collaboration with informal caregivers in restricting alcohol consumption, (v) minimalizing the dialogue regarding alcohol consumption to guard patient privacy and (vi) a desire for joint action and a national political strategy.

CONCLUSION

Health professionals working in NHs, in-home and GPs find it difficult to discuss the use and elevated use of alcohol with older people for whom they have care and treatment responsibilities. In general, they are concerned that such conversations infringe on the principles governing an individual's autonomy. However, because they are aware that elevated alcohol intake may have a negative impact on health and well-being, they also express a need for guidelines how they in a better and open minded way can discuss the use and elevated use of alcohol with the patients they care for.

Interventions to optimize medication use in nursing homes: a narrative review

PURPOSE

Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes.

METHODS

We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting.

RESULTS

Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels.

CONCLUSION

Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.

[Clinical medication review in French community pharmacy: Interest of a new pharmaceutical service for detection of drug related problems]

OBJECTIVE

Using clinical medication reviews, analyze the most pharmaceuticals intervention generating treatments and the problems associated.

METHODS

Analysis of activity reports made by 6th year pharmaceutical students from the University of Bordeaux, class of 2017-2018.

RESULTS

76 % of clinical medication review have detected at least one drug related problem in the population of this study. Drug classes that most frequently lead to pharmaceutical interventions are nervous system drugs, alimentary tract and metabolisma drugs and cardiovascular system drugs. The most frequent drug related problems are an unjustified prescription, a contraindication or a non-compliance with the standards of care and posology issues.

CONCLUSIONS

The most at risk and pharmaceutical intervention generating drugs in this study are the same as described in the international literature. This shows that more precautions must be taken for their use in the elderly. Furthermore, this new pharmaceutical service is an efficient way to detect them.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

Trajectories of pro re nata (PRN) medication prescribing and administration in long-term care facilities

BACKGROUND

Little is known about changes in pro re nata (PRN) medication prescribing and administration in residential aged care facilities (RACFs) over time.

OBJECTIVE

To determine the prevalence and factors associated with PRN medication administration in RACFs and examine changes over 12-months.

METHODS

Secondary analyses utilizing data from the SIMPLER randomized controlled trial (n = 242 residents, 8 RACFs) was undertaken. PRN medication data were extracted from RACF medication charts. Factors associated with PRN medication administration in the preceding week were explored using multivariable logistic regression.

RESULTS

At baseline, 211 residents (87.2%) were prescribed ≥1 PRN medication, with 77 (36.5%) administered PRN medication in the preceding week. PRN administration was more likely in non-metropolitan areas, and less likely among residents with more severe dementia symptoms and greater dependence with activities of daily living. No significant differences in overall PRN prescribing or administration in 162 residents alive at 12-month follow-up were observed.

CONCLUSIONS

Despite being frequently prescribed, the contribution of PRNs to overall medication use in RACFs is small. PRN prescribing and administration was relatively static over 12-months despite likely changes in resident health status over this period, suggesting further exploration of PRN prescribing in relation to resident care needs may be warranted.

Considering additive effects of polypharmacy : Analysis of adverse events in geriatric patients in long-term care facilities

Background

Potential additive effects of polypharmacy are rarely considered in adverse events of geriatric patients living in long-term care facilities. Our aim, therefore, was to identify adverse events in this setting and to assess plausible concomitant drug causes.

Methods

A cross-sectional observational study was performed in three facilities as follows: (i) adverse event identification: we structurally identified adverse events using nurses’ interviews and chart review. (ii) Analysis of the concomitantly administered drugs per patient was performed in two ways: (ii.a) a review of summary of product characteristics for listed adverse drug reactions to identify possible causing drugs and (ii.b) a causality assessment according to Naranjo algorithm.

Results

(i) We found 424 adverse events with a median of 4 per patient (range 1–14) in 103 of the 104 enrolled patients (99%). (ii.a) We identified a median of 3 drugs (range 0–11) with actually occurring adverse events listed as an adverse drug reaction in the summary of product characteristics. (ii.b) Causality was classified in 198 (46.9%) of adverse events as “doubtful,” in 218 (51.2%) as “possible,” in 7 (1.7%) as “probable,” and in 1 (0.2%) adverse event as a “definitive” cause of the administered drugs. In 340 (80.2%) of all identified adverse events several drugs simultaneously reached the highest respective Naranjo score.

Conclusion

Patients in long-term facilities frequently suffer from many adverse events. Concomitantly administered drugs have to be frequently considered as plausible causes for adverse events. These additive effects of drugs should be more focused in patient care and research.

Variation between nursing homes in drug use and in drug-related problems

BACKGROUND

Residents at nursing homes (NHs) are at particular risk for drug related harm. Regular medication reviews using explicit criteria for pharmacological inappropriateness and classification of drug related problems (DRPs) have recently been introduced as measures to improve the quality of medication use and for making the treatment more uniform across different institutions. Knowledge about variation in DRPs between NHs is scarce. To explore if increased attention towards more appropriate drug treatment in NHs have led to more uniform treatment, we have analyzed variations between different nursing homes' drug use and DRPs.

METHODS

Cross-sectional medication review study including 2465 long-term care residents at 41 NHs in Oslo, Norway. Regular drug use was retrieved from the patients' medical records. DRPs were identified by using STOPP/START and NORGEP criteria and a drug-drug interactions database. NHs were grouped in quartiles based on average levels of drug use. The upper and lower quartiles were compared using independent samples t-test and associations between drug use and DRPs were tested by logistic regression.

RESULTS

Patients' mean age was 85.9 years, 74.2% were women. Mean numbers of regular drugs per patient was 6.8 and varied between NHs from 4.8 to 9.3. The proportion of patients within each NH using psychotropic and analgesic drugs varied largely: antipsychotics from three to 50%, benzodiazepines from 24 to 99%, antidepressants from nine to 75%, anti-dementia drugs from no use to 42%, opioids from no use to 65% and paracetamol from 16 to 74%. Mean DRPs per patient was 2.0 and varied between NHs from 0.5 to 3.4. The quartiles of NHs with highest and lowest mean drugs per patient (7.7 vs. 5.7, p < 0.001) had comparable mean number of DRPs per patient (2.2 vs. 1.8, p = 0.2). Using more drugs and the use of opioids, antipsychotics, benzodiazepines and antidepressants were associated with more DRPs.

CONCLUSIONS

The use of psychotropic and analgesic drugs was high and varied substantially between different NHs. Even if the use of more drugs, opioids and psychotropic drugs was associated with DRPs, no difference was found in DRPs between the NHs with highest vs. lowest drug use.

Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki

Background

The use of drugs with anticholinergic properties (DAPs) is common among older adults despite their known adverse effects, such as cognitive decline. Professionals should pay attention to DAPs, since evidence on their adverse effects has been accumulating during the last decade. However, to our knowledge previous studies exploring temporal trends in the use of DAPs are scarce.

Objective

The aim of this study was to assess temporal trends in the use of DAPs from 2003 to 2017 in long-term care facilities in Helsinki.

Methods

Four cross-sectional studies were conducted in 2003, 2007, 2011, and 2017. Participants included older people (≥ 65 years) living in nursing homes (NHs) in 2003 (n = 1979), 2011 (n = 1568), and 2017 (n = 750), and in assisted living facilities (ALFs) in 2007 (n = 1336), 2011 (n = 1556), and 2017 (n = 1673) in Helsinki, Finland. Data on demographics, medication use, and diagnoses were collected by structured questionnaires. The assessments were conducted as a point prevalence over 1 day. The use of DAPs and the total anticholinergic burden were defined by the Anticholinergic Risk Scale (ARS).

Results

In ALFs, there has been an increasing trend in the use of DAPs over a 10-year period (41.2% in 2007 and 53.7% in 2017). In NHs, by contrast, the use of DAPs remained quite stable (52.3% in 2003 and 52.4% in 2017). The burden of DAPs measured by ARS score decreased in NHs and remained stable in ALFs. Marked changes occurred in the DAPs used; antidepressants, especially mirtazapine, increased in both settings, whereas the use of hydroxyzine and urinary antispasmodics nearly disappeared. The proportion of users of DAP antipsychotics increased in ALFs. Participants with dementia had a lower anticholinergic burden than those without dementia, in both settings.

Conclusions

Despite increased knowledge of the harms of DAPs, they remain widely used. Physicians seem to be aware of the harms of DAPs among people with dementia, and some other favorable trends in prescribing were also observed. Clinicians should especially consider the indications behind the use of DAP antidepressants and antipsychotics, and carefully weigh their potential benefits and harms.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Interdisciplinary medication review to improve pharmacotherapy for patients with intellectual disabilities

Background Patients with intellectual disabilities is an underserved patient group that have poor abilities to express their health complaints. Objective The aim of this study was to improve pharmacotherapy in patients with intellectual disability, by the use of medication reviews and interdisciplinary case conferences. Setting Patients with intellectual disabilities receiving home care services in Oslo, Norway. Method Patients receiving home care services were recruited by a nurse. A clinical pharmacist conducted medication reviews, and thereafter, the patients' general practitioner, nurse/social educator and clinical pharmacist discussed the pharmacotherapy at an interdisciplinary case conference. Patient demographics, prescribed drugs (strength, dose, indication) and drug-related problems (DRPs) were recorded. Main outcome measure Patient outcomes and actions taken to resolve DRPs 6 weeks after the case conference. Results Forty patients (34-77 years) with intellectual disabilities consented to medication reviews. They used on average 12 different drugs (range 5-23). The most commonly prescribed drugs were CNS-active drugs: analgesics (25 patients), antiepileptics (23 patients) and anxiolytics (21 patients). In total, 27 patients used between 3 and 7 different CNS-active drugs. The clinical pharmacist identified 178 DRPs in 39/40 patients (average 4.5 DRPs, range 0-13). DRPs for 30% of all prescribed drugs were resolved (145/481). Overall, 11% of drugs were deprescribed, 8% required therapeutic monitoring/follow-up, and either the dosage, formulation or route of administration were changed for 7% of the drugs. Conclusions Patients with intellectual disabilities receiving home care services were prescribed many unnecessary drugs and needed adjustment of pharmacotherapy for about one third of their prescribed drugs. The interdisciplinary case conferences improved pharmacotherapy for this vulnerable patient group.

A Stepwise Pharmacist-Led Medication Review Service in Interdisciplinary Teams in Rural Nursing Homes

Background: The provision of responsible medication therapy to old nursing home residents with comorbidities is a difficult task and requires extensive knowledge about optimal pharmacotherapy for different conditions. We describe a stepwise pharmacist-led medication review service in combination with an interdisciplinary team collaboration in order to identify, resolve, and prevent medication related problems (MRPs). Methods: The service included residents from four rural Norwegian nursing homes during August 2016–January 2017. All residents were eligible if they (or next of kin) supplied oral consent. The interdisciplinary medication review service comprised four steps: (1) patient and medication history taking; (2) systematic medication review; (3) interdisciplinary case conference; and (4) follow-up of pharmaceutical care plan. The pharmacist collected information about previous and present medication use, and clinical and laboratory values necessary for the medication review. The nurses collected information about possible symptoms related to adverse drug reactions. The pharmacist conducted the medication reviews, identified medication-related problems (MRPs) which were discussed at case conferences with the responsible physician and the responsible nurses. The main outcome measures were number and types of MRPs, percentage agreement between pharmacists and physicians and factors associated with MRPs. Results: The service was delivered for 151 (94%) nursing home residents. The pharmacist identified 675 MRPs in 146 (97%) medication lists (mean 4.0, SD 2.6, range 0–13). The MRPs most frequently identified concerned ‘unnecessary drug’ (22%), ‘too high dosage’ (17%) and ‘drug interactions’ (16%). The physicians agreed upon 64% of the pharmacist recommendations, and action was taken immediately for 32% of these. We identified no association between the number of MRPs and sex (p = 0.485), but between the number of MRPs, and the number of medications and the individual nursing homes. Conclusion: The pharmacist-led medication review service in the nursing homes was highly successfully piloted with many solved and prevented MRPs in interdisciplinary collaboration between the pharmacist, physicians, and nurses. Implementation of this service as a standard in all four nursing homes seems necessary and feasible. If such a service is implemented, effects related to patient outcomes, interdisciplinary collaboration, and health economy should be studied.

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.

Drug Use before and after Initiating Treatment with Acetylcholinesterase Inhibitors

Background/Aims

The aim was to study the prevalence of use of different drugs prescribed for behavioral and psychological symptoms of dementia in persistent users of acetylcholinesterase inhibitors (AChEIs) before and after AChEI initiation, and to compare with the use in the general population.

Methods

Use of antidepressants, antipsychotics, and analgesics in the 4 years before and 2 years after AChEI initiation was studied based on data from the Norwegian Prescription Database 2004–2016.

Results

The prevalence of use of antidepressants and antipsychotics the year before AChEI initiation was twice the prevalence in the age-adjusted general population and continued to rise in the first 2 years after initiation of AChEIs. The prevalence of weak analgesics and antipsychotics increased strongly in the last year before AChEI initiation. The increase in the use of antidepressants started at least 4 years before initiation of AChEIs. Opioid use was generally lower than in the general population and was not influenced by AChEI initiation.

Conclusion

Increased use of antidepressants and antipsychotics was observed both before and after initiation of AChEIs and may indicate that behavioral symptoms occur in a preclinical or early phase of Alzheimer's disease. The prescription pattern of analgesics with a low use of opioids may indicate an undertreatment of pain in people with dementia.

Prevalence of potentially inappropriate medications among geriatric residents in nursing care homes in Malaysia: a cross-sectional study

Background Polypharmacy has been associated with an increased risk of morbidity and mortality among older adults especially those living in nursing homes. Explicit criteria to evaluate the appropriateness of medications have recently been updated. Objective To estimate and compare the prevalence of potentially inappropriate medications (PIMs) among older adults in nursing homes using screening tool for older people's prescription (STOPP-2) and the 2015 Beers criteria. Setting Nursing care homes in the Klang Valley, Malaysia. Method A cross-sectional survey of medications used among residents living in nursing homes was performed. The 2015 Beers criteria and STOPP-2 criteria were used to evaluate the use of PIMs among this population. These PIMs were subsequently classified using the Pharmaceutical Network Europe classification (PCNE). Main outcome measure Number of PIMs among residents using both criteria. Results A total of 155 residents were recruited into the study. The prevalence of PIMs was 9.7% using the STOPP-2 criteria, 17.6% using the 2015 Beers criteria and 21.3% when both tools were used in combination. The PCNE criteria identified a total of 198 drug related issues, with an average of 1.27 issue per resident. Factors associated with higher risk of having PIM include multiple medication use and history of psychiatric disorder. Conclusion The 2015 Beers criteria was able to identify more PIM's compared to STOPP-2 criteria. The findings also support the expansion of pharmacists' services in nursing homes in Malaysia.

Drug use differs by care level. A cross-sectional comparison between older people living at home or in a nursing home in Oslo, Norway

Background

Drug consumption increases with age, but there are few comparisons of drug use between old people living at home or in a nursing home. To identify areas of concern as well as in need for quality improvement in the two settings, we compared drug use among people aged ≥70 years living at home or in a nursing home.

Methods

Cross-sectional observational study from Oslo, Norway. Information about drug use by people living at home in 2012 was retrieved from the Norwegian Prescription Database. Drug use in nursing homes was recorded within a comprehensive medication review during November 2011–February 2014. Prevalence rates and relative risk (RR) with 95% confidence intervals were compared between uses of therapeutic groups with prevalence rates of ≥5%. Drug use was compared for the total population and by gender and age group.

Results

Older people (both genders) in nursing homes (n = 2313) were more likely than people living at home (n = 48,944) to use antidementia drugs (RR = 5.7), antipsychotics (RR = 4.0), paracetamol (RR = 4.0), anxiolytics (RR = 3.0), antidepressants (RR = 2.8), dopaminergic drugs (RR = 2.7), antiepileptic drugs (RR = 2.4), loop diuretics (RR = 2.3), cardiac nitrates (RR = 2.1) or opioids (RR = 2.0). By contrast, people living in a nursing home were less commonly prescribed statins (RR = 0.2), nonsteroidal antiinflammatory drugs (NSAIDs) (RR = 0.3), osteoporosis drugs (RR = 0.3), thiazide diuretics (RR = 0.4), calcium channel blockers (RR = 0.5) or renin–angiotensin inhibitors (RR = 0.5). Each of the populations had only minor differences in drug use by gender and a trend towards less drug use with increasing age (p <  0.01).

Conclusions

Drug use by older people differs according to care level, and so do areas probably in need for quality improvement and further research. In nursing home residents, this relates to a probable overuse of psychotropic drugs and opioids. Among older people living at home, the probable overuse of NSAIDs and a possible underuse of cholinesterase inhibitors and osteoporosis drugs should be addressed.

Assessment of drug related problems among type 2 diabetes mellitus patients with hypertension in Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia

Objective

This study was conducted to assess magnitude and pattern of drug related problems among patients with type 2 diabetes mellitus (T2DM) and hypertension.

Results

This study identified 364 drug related problems (DRPs) across the three categories of drug related problems, giving an average of 1.8 DRPs per patient. The effect of drug treatment being not optimal 179 (49.2%), untreated indication and symptoms 77 (21.1%), unnecessary drug-treatment 39 (10.7%) and adverse drug reactions 69 (19%) were the most frequent categories of DRPs identified. In general, high prevalence of drug-related problems was identified among patients with T2DM hypertension. The effect of drug treatment being not optimal, untreated indication and symptoms, unnecessary drug-treatment and adverse drug reactions were the most frequent categories of drug related problems identified. Therefore, the clinicians should work to improve patient care through prevention and resolving drug related problems since it can affect the quality of the care significantly.

Variations in drug-related problems detected by multidisciplinary teams in Norwegian nursing homes and home nursing care

OBJECTIVE

Traditionally, nursing homes have been associated with suboptimal drug therapy and drug-related problems (DRPs). In contrast, less is known about drug safety in homecare. The aim of this study was to describe and compare DRPs in older persons across two care settings: nursing homes and home nursing care.

DESIGN

Cross-sectional study using descriptive and inferential statistics.

SETTING

Nursing homes (n = 5) and home nursing care units (n = 8) across nine municipalities in the middle of Norway.

PARTICIPANTS

Multidisciplinary medication reviews for 61 nursing home residents and 93 patients receiving home nursing care performed over the 2013-2014 period, were mapped and examined (N = 154).

MAIN OUTCOME MEASURES

DRPs classified by a Norwegian Classification Tool.

RESULTS

In all, 740 DRPs were detected in the total sample, 227 in nursing homes and 513 in home nursing care. DRPs were significantly higher among patients receiving home-based care (Mean =5.5) compared to patients in nursing homes (Mean =3.7, p = 0.002). Among the problem categories, the need for additional drug was most frequent in nursing homes (p = 0.001), while documentation discrepancies reached the highest numbers in patients receiving home nursing care (p = 0.000). Additionally, patients in home nursing care had more problems concerning adverse reactions (p = 0.060); however, this was not statistically significant. Differences in DRP categories leading to changes in the patients' medication lists were also discovered.

CONCLUSIONS

The frequency of unclear documentation and adverse reactions found in the homecare setting is alarming. This is an important issue given the trend in aged care towards caring people in their own homes. Further research is warranted to explore how different care settings may influence the safety of pharmacotherapy for older persons. Key Points Drug related problems are a significant cause of concern among patients receiving home nursing care as well as for patients living in nursing homes. The findings of this study showed that: •Significantly more DRPs were detected among patients receiving home nursing care than patients living in nursing homes. •While patients living in nursing homes were often undermedicated, documentation discrepancies were more frequent in home nursing care. •DRP categories leading to changes on the medication lists differed between the settings.