Prescribing for older people in nursing homes: a review of the key issues

Delayed Epithelial Healing with Corneal Edema and Haze After Photorefractive Keratectomy Using Intraoperative Mitomycin C

We report an unusual presentation of presumed mitomycin C toxicity with possible subsequent hypersensitization to other medication toxicities. A 50-year-old female presented three months after photorefractive keratectomy with intraoperative mitomycin C for the management of persistent epithelial defects, corneal haze, and edema. She was found to have used an expansive and rapidly changing medical regimen which may have caused additional toxicity. These medications included besifloxacin, bromfenac, and ketotifen. Additives such as benzalkonium chloride and DuraSite^® may have also contributed. Intraoperative mitomycin C can result in longstanding corneal haze, edema, and delayed epithelial healing in the setting of corneal refractive surgery. These may leave the cornea more susceptible to additional subsequent medication toxicities during the postoperative period. This report describes a case of mitomycin C exposure leading to a prolonged sensitivity to other medication toxicities, which has not been discussed elsewhere in the literature.

To crush, or not to crush? Unauthorised covert administration of medication in nursing homes

BACKGROUND AND OBJECTIVES

This study aimed to explore the experiences and perceptions of nursing home staff and residents of unauthorised covert administration of medication. Prior studies identify that covert medication administration (crushing medication to administer in food or drink) is common in nursing home settings. Still, few recognise that this practice may occur without consultation or clinical authorisation.

DESIGN

An exploratory qualitative study was conducted with nursing home staff and residents as part of a more extensive mixed-methods study on medication omissions and clinical decision-making.

METHODS

We conducted a qualitative study using focus groups and semi-structured interviews across four geographical areas in New Zealand to better understand nursing home staff and residents' experiences and perspectives on covert administration. Semi-structured interviews took place with 11 Clinical managers/leads and one senior Registered Nurse; role specific focus groups were held with Registered Nurses (n = 6), Health Care Assistants (n = 14), and Residents (n = 12). Data were analysed using thematic analysis.

FINDINGS

Participants described covert administration as a practical option if a nursing home resident refused medication but recognised it was a deception that carried ethical and clinical risks, particularly when unauthorised. Participants felt that unauthorised covert administration stemmed from doubts about residents' competence and the competing demands staff face during medication administration. Staff, who typically relied on advice from their pharmacies around which medications were safe to crush, expressed a need for more education.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study provides evidence that unauthorised covert administration of medications is an ongoing practice, using New Zealand nursing homes as an example. The results emphasise that nursing home staff and residents are aware that this practice carries ethical and clinical risks and requires a certified process to legitimise its authorised form.

Antimuscarinic Discontinuation in Patients with Overactive Bladder in Nursing Homes: A Retrospective Study of Medicare Beneficiaries

Introduction

Although antimuscarinics form the first-line therapy in overactive bladder (OAB), little is known regarding antimuscarinic discontinuation among OAB patients in nursing homes. This study examined treatment patterns and predictors of antimuscarinic discontinuation among long-term nursing home (LTNH) residents with OAB.

Methods

The study cohort included LTNH residents (defined as residents staying ≥ 101 consecutive days) from the Minimum Data Set linked 2013–2015 Medicare claims data. Patients with OAB were defined by OAB-related claims and medication codes. Treatment patterns and discontinuation (medication gap ≥ 30 days) were characterized by examining OAB-specific antimuscarinics prescribed during LTNH stays. The Andersen Behavioral Model was used to identify predisposing, enabling and need factors that predict discontinuation. Kaplan-Meier curves and multivariable Cox proportional hazards regression model were used to assess the unadjusted and adjusted times to discontinuation, respectively, among different antimuscarinics.

Results

The mean age of the study cohort (n = 11,012) was 81.6 years (± 8.5), 74.6% were female, and 89.8% were non-Hispanic White. The mean duration of nursing home stay was 530.1 (± 268.4) days. The most commonly prescribed OAB-specific antimuscarinic was oxybutynin (69.8%). Overall, 66.5% of the study cohort discontinued the index antimuscarinic. Multivariable Cox PH regression analysis revealed that compared to LTNH residents who initiated treatment with oxybutynin, treatment discontinuation was lower with solifenacin or fesoterodin and discontinuation was more frequent when treatment was initiated with tolterodine, darifenacin or trospium compared with oxybutynin. In addition, several need factors (comorbidities, medication use and anticholinergic burden, etc.) were associated with antimuscarinic discontinuation.

Conclusion

About  two-thirds of LTNH residents with OAB discontinued their index antimuscarinic during their nursing home stay. There was significant variation in discontinuation based on the index antimuscarinic agent with lowest risk of discontiuation with solifenacin and fesoterodin. Concerted efforts to optimize antimuscarinic use are needed to improve the management of OAB in nursing homes.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-020-01412-z) contains supplementary material, which is available to authorized users.

Are medications safely used by residents in elderly care homes? - A multi-centre observational study from Sri Lanka

BACKGROUND

Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services.

OBJECTIVE

To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka.

METHODOLOGY

This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications.

RESULTS

The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%).

CONCLUSION

Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.

Relationship between frailty, polypharmacy, and underprescription in older adults living in nursing homes

PURPOSE

Frailty, polypharmacy, and underprescription are considered a major matter of concern in nursing homes, but the possible relationships between them are not well known. The aim is to examine the possible association between medication underprescription, polypharmacy, and frailty in older people living in nursing homes.

METHODS

A cross-sectional analysis from a concurrent cohort study, including 110 subjects ≥ 65 years living in two nursing homes. Four frailty scales were applied; polypharmacy was defined as ≥ 5 medications and underprescription was measured with Screening Tool to Alert to Right Treatment (START) criteria. Logistic regression models were performed to assess the associations.

RESULTS

The mean age was 86.3 years (SD 7.3) and 71.8% were female. 73.6% of subjects took ≥ 5 chronic medications and 60.9% met one or more START criteria. The non-frail participants took more medications than the frail subjects according to the imputated frailty Fried criteria (8.1 vs 6.7, p = 0.042) and the FRAIL-NH scale (7.8 vs 6.8, p = 0.026). Multivariate analyses did not find an association between frailty and polypharmacy. Frail participants according to the Fried criteria met a higher number of START criteria (1.9 vs 1.0, p = 0.017), and had a higher prevalence of underprescription (87.5 vs 50.0%), reaching the limit of statistical significance in multivariate analysis.

CONCLUSION

The positive association found in previous studies between frailty and polypharmacy cannot be extrapolated to institutionalized populations. There is a trend towards higher rates of underprescription in frail subjects. Underprescription in frail older adults should be redefined and new strategies to measure it should be developed.

Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes

BACKGROUND

Prescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS).

METHODS

A long-list of outcomes was identified through a review of published literature and stakeholder input. Outcomes were reviewed and refined prior to entering a two-round online Delphi exercise and then distributed via a web link to the CHIPPS Management Team, a multidisciplinary team including pharmacists, doctors and Patient Public Involvement representatives (amongst others), who comprised the Delphi panel. The Delphi panellists (n = 19) rated the importance of outcomes on a 9-point Likert scale from 1 (not important) to 9 (critically important). Consensus for an outcome being included in the COS was defined as ≥70% participants scoring 7-9 and <15% scoring 1-3. Exclusion was defined as ≥70% scoring 1-3 and <15% 7-9. Individual and group scores were fed back to participants alongside the second questionnaire round, which included outcomes for which no consensus had been achieved.

RESULTS

A long-list of 63 potential outcomes was identified. Refinement of this long-list of outcomes resulted in 29 outcomes, which were included in the Delphi questionnaire (round 1). Following both rounds of the Delphi exercise, 13 outcomes (organised into seven overarching domains: medication appropriateness, adverse drug events, prescribing errors, falls, quality of life, all-cause mortality and admissions to hospital (and associated costs)) met the criteria for inclusion in the final COS.

CONCLUSIONS

We have developed a COS for effectiveness trials aimed at optimising prescribing in older adults in care homes using robust methodology. Widespread adoption of this COS will facilitate evidence synthesis between trials. Future work should focus on evaluating appropriate tools for these key outcomes to further reduce heterogeneity in outcome measurement in this context.

Screening Tool of Older Person's Prescriptions/Screening Tools to Alert Doctors to Right Treatment Medication Criteria Modified for U.S. Nursing Home Setting

OBJECTIVES

To develop a set of prescribing indicators measurable with available data from electronic nursing home (NH) databases by adapting the European-based 2014 Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tools to Alert Doctors to Right Treatment (START) criteria of potentially inappropriate and underused medications for the U.S.

SETTING

DESIGN

A two-stage expert panel process. In the first stage, the investigator team reviewed 114 criteria for compatibility and measurability. In the second stage, an online modified e-Delphi (OMD) panel was convened to rate the validity of criteria, and two webinars were held to identify criteria with highest relevance to U.S. NHs.

PARTICIPANTS

Seventeen experts with recognized reputations in NH care participated in the e-Delphi panel and 12 in the webinar.

MEASUREMENTS

Compatibility and measurability were assessed by comparing criteria with U.S. terminology and setting standards and data elements in NH databases. Validity was rated using a 9-point Likert-type scale (1 = not valid at all, 9 = highly valid). Mean, median, interpercentile ranges, and agreement were determined for each criterion score. Relevance was determined by ranking the mean panel ratings on criteria that reached agreement; the webinar participants reviewed and approved half of the criteria with the highest mean values.

RESULTS

Fifty-three STOPP/START criteria were deemed to be compatible with the U.S. NH setting and measurable using data from electronic NH databases. E-Delphi panelists rated 48 criteria as valid for U.S. NHs. Twenty-four criteria were deemed to be most relevant, consisting of 22 measures of potentially inappropriate medications and two measures of underused medications.

CONCLUSION

This study created the first explicit criteria for assessing the quality of prescribing in U.S. NHs.

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study

OBJECTIVES

To identify system-related risk factors perceived to contribute to prescribing errors in Australian long-term care settings, that is, residential aged care facilities (RACFs).

DESIGN AND SETTING

The study used qualitative methods to explore factors that contribute to unsafe prescribing in RACFs. Data were collected at three RACFs in metropolitan Sydney, Australia between May and November 2011. Participants included RACF managers, doctors, pharmacists and RACF staff actively involved in prescribing-related processes. Methods included non-participant observations (74 h), in-depth semistructured interviews (n=25) and artefact analysis. Detailed process activity models were developed for observed prescribing episodes supplemented by triangulated analysis using content analysis methods.

RESULTS

System-related factors perceived to increase the risk of prescribing errors in RACFs were classified into three overarching themes: communication systems, team coordination and staff management. Factors associated with communication systems included limited point-of-care access to information, inadequate handovers, information storage across different media (paper, electronic and memory), poor legibility of charts, information double handling, multiple faxing of medication charts and reliance on manual chart reviews. Team factors included lack of established lines of responsibility, inadequate team communication and limited participation of doctors in multidisciplinary initiatives like medication advisory committee meetings. Factors related to staff management and workload included doctors' time constraints and their accessibility, lack of trained RACF staff and high RACF staff turnover.

CONCLUSIONS

The study highlights several system-related factors including laborious methods for exchanging medication information, which often act together to contribute to prescribing errors. Multiple interventions (eg, technology systems, team communication protocols) are required to support the collaborative nature of RACF prescribing.

Impact of prescribed medications on patient safety in older people

Appropriate prescribing for older adults presents unique challenges to the prescriber. An understanding of the scale of the problems and contributing factors is essential when designing interventions to improve patient safety. The altered pharmacology of ageing, the existence of multiple medical conditions and the exclusion of elderly patients from many trials render this subgroup of the population particularly vulnerable to underprescribing and overprescribing. Adverse drug events are common, causing significant morbidity and mortality as well as having economic implications. 'High-risk' medications such as opioids, anticoagulants and antipsychotics can have benefits in this group of patients but strategies to optimize their safety are required. Tools exist that help to identify those at risk of adverse drug reactions and to screen for inappropriate prescribing. Developments in information technology are ongoing, and it is hoped that these may enhance the process of medication reconciliation across healthcare transitions and alert the prescriber to potential adverse drug events. This review addresses commonly encountered issues when prescribing for older people, considers strategies to improve medication safety and offers a list of 'top tips' to aid the clinician.

[Recommendations on the safety of patients for socio-health centers: systematic review]

We did a systematic review to find recommendations on patient safety oriented toward improving the quality of care in nursing homes, residential facilities, housing for the elderly and long-term care facilities, among others. One hundred and thirty-four articles were selected in MEDLINE, EMBASE and CINAHL up to October 2012. Of these, 17 met inclusion criteria and 5 studies were added in the secondary search for further detailed analysis. Few studies with high or very high level of scientific evidence on the scale SIGN were identified. Analyzed studies focused primarily on nursing staff. Most of the recommendations are oriented toward medication-related issues, staff training, pressure ulcers or falls, adherence to guidelines and protocols and topics referred to organizational culture.

Knowledge and perspectives of Dutch home healthcare nurses regarding medication frequently used by older people

BACKGROUND

Home healthcare nurses in their roles as caregivers, educators and administrators of medications are particularly well positioned to act on a preventive way to be alert of adverse drug reactions. However, knowledge about medication and a professional attitude is required.

AIM

To describe medication-related knowledge and perspectives of Dutch home healthcare nurses regarding frequent used medication by older people.

METHOD

A cross-sectional study was conducted among home healthcare nurses (n=146) in the Netherlands based on the ten most frequently used drugs by older people.

FINDING

The mean score for total medication knowledge was 76.2% of the maximum score. Most home healthcare nurses (80.3%) felt responsible for improving older patients' medication use. Three-quarters of the home healthcare nurses agreed with the statement: "By taking appropriate action at the right time, I am able to prevent a medication-related hospital admission".

CONCLUSION

Although most home healthcare nurses felt responsible for their older patients' proper medication use and agreed with the statement that they played a role in preventing older patients' medication-related hospital admissions, their knowledge regarding medications could be improved.

IMPLICATIONS FOR PRACTICE

Home healthcare nurses should profit as a professional from gaining more knowledge of medication frequently used by older people.

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.