Medication use in residential care facilities for the elderly

Temporal Trends in Analgesic Use in Long-Term Care Facilities: A Systematic Review of International Prescribing

OBJECTIVES

To explore global changes in the prescription of analgesic drugs over time in the international long-term care (LTC) population.

DESIGN

Systematic review.

SETTING

We included original research articles in English, published and unpublished, that included number of participants, country and year(s) of data collection, and prescription of analgesics (analgesics not otherwise specified, opioids, acetaminophen; scheduled only, or scheduled plus as needed (PRN)).

PARTICIPANTS

LTC residents.

MEASUREMENTS

We searched PubMed, EMBASE, CINAHL, International Pharmaceutical Abstracts, PsycINFO, Cochrane, Web of Science, Google Scholar, using keywords for LTC facilities and analgesic medication; hand-searched references of eligible papers; correspondence. Studies were quality rated using an adapted Newcastle-Ottawa scale. Pearson correlation coefficients were generated between percentage of residents prescribed an analgesic and year of data collection. If available, we investigated changes in acetaminophen and opioid prescriptions.

RESULTS

Forty studies met inclusion criteria. A moderate correlation (0.59) suggested that scheduled prescription rates for analgesics have increased over time. Similar findings were reflected in scheduled prescriptions for acetaminophen and opioids. No increase was seen when analyzing scheduled plus PRN analgesics. Use of opioids (scheduled plus PRN) appears to have increased over time.

CONCLUSION

Worldwide, use of opioids and acetaminophen has increased in LTC residents. Research is needed to explore whether this reflects appropriate pain management for LTC residents and if PRN medication is used effectively.

Facility characteristics associated with the use of electronic health records in residential care facilities

The integration of electronic health records (EHRs) across care settings including residential care facilities (RCFs) promises to reduce medical errors and improve coordination of services. Using data from the 2010 National Survey of Residential Care Facilities (n=2302), this study examines the association between facility structural characteristics and the use of EHRs in RCFs. Findings indicate that in 2010, only 3% of RCFs nationwide were using an EHR. However, 55% of RCFs reported using a computerized system for one or more (but not all) of the functionalities defined by a basic EHR. Ownership, chain membership, staffing levels, and facility size were significantly associated with the use of one or more core EHR functionalities. These findings suggest that facility characteristics may play an important role in the adoption of EHRs in RCFs.

[Prevalence and main characteristics of urinary incontinence among institutionalized older people in Madrid (Spain)]

INTRODUCTION

Urinary incontinence (UI) has been poorly studied in Spanish nursing homes. The objective is to determine the prevalence and related factors of UI in institutionalized older people in Madrid, Spain.

METHODS

A probabilistic sample of 754 subjects 65 years of age and older living in public and private institutions in Madrid was randomly selected through stratified cluster sampling. Residents, caregivers and physicians were interviewed. UI was defined as any leakage in the previous 14 days. We asked about the frequency (occasional, nocturnal, frequent and total), quantity (drops or small quantities, very much), and types (urge, stress, due to cognitive impairment, and due to walking difficulty). To determine the factors associated with UI, we built logistic regression models that adjusted for age, sex, functional dependency (Barthel index) and cognitive status (Pfeiffer's test).

RESULTS

The prevalence of UI was 53.6%. Of all residents 35.8% had frequent or total UI. Among those incontinent 60.1% had a very large quantity of urine loss and the most common presentation was mixed (54.1%). The most frequent type in the population was urgent UI (26.8%) followed by UI due to walking difficulty (21.4%). UI was associated (odds ratios [95% CI]) with moderate (3.51 [1.56-7.89]) and severe functional disability (44.71 [10.99-181.94]), faecal incontinence (4.97 [2.04-12.16]), stroke (4.59 [1.06-19.87]), physical restraints (4.03 [1.02-17.87]), and falls (2.10 [1.16-3.81]). The mean (95% CI) number of pads used per person per day was 3.0 (2.4-3.6).

CONCLUSIONS

The prevalence of UI was somewhat higher than that of other comparable populations. Mixed forms, including functional types, were common.

An Examination of the Health Profile, Service Use and Care Needs of Older Adults in Residential Care Facilities

Private, unregulated residential care facilities have become an increasingly important component of the continuum of housing and care for frail older adults in Canada. To date, this growing segment of the older population has received very little research attention. This study involved an in-depth examination of the functional/health profile, patterns of service use, and medical/care needs of a representative sample of 178 older adults in residential care facilities in the City of Ottawa. The results indicate great diversity in resident and facility profiles in this setting and confirm earlier impressions that special care units in the residential care sector have become increasingly close to being unlicensedpseudo-nursing homes. Despite the heavy burden of care, the evidence suggests that the care needs of the majority of residents are adequately met in the residential care environment. The results can inform future research, case finding, educational, and policy planning initiatives in this setting.

[Association between anxiolytic and antidepressant consumption and psychiatric symptoms in the elderly]

INTRODUCTION

Many studies have reported excessive consumption of psychotropic drugs in the elderly but none have related psychotropic drug use to psychiatric symptoms and sleep disorders in community-dwelling patients aged more than 65 years old in Spain.

MATERIAL AND METHODS

We performed a cross sectional study in a representative sample (9,739 persons) from the population aged more than 55 years old in the city of Zaragoza in 2001. A total of 3,714 persons aged more than 65 years old were interviewed. The data belonged to the ZARADEMP project.

RESULTS

The mean age of the sample was 76.9 years (59.2% women and 40.8% men). Anxiolytics or antidepressants were consumed by 22.6% of the sample. A diagnosis of depression was made in 12.9%, anxiety in 1.6% and insomnia in 36%. We found high consumption of anxiolytics, especially in persons with depression (42.2%) and low consumption of antidepressants, especially in persons with a diagnosis of depression (15.4%) and in those with depressive symptoms (8.2%).

CONCLUSIONS

A correct psychiatric diagnosis is essential before psychotropic drugs are used to ensure appropriate treatment of the elderly with psychiatric symptoms.

A structured questionnaire to assess patient compliance and beliefs about medicines taking into account the ordered categorical structure of data

RATIONALE, AIMS AND OBJECTIVE

The objectives were to describe and evaluate the structured medication questionnaire and to improve data handling of results from the Morisky four-item scale for patient compliance and Beliefs about Medicines Questionnaire-specific (BMQ-specific).

METHODS

A questionnaire was developed with the purpose of being used when identifying medication errors and assessing patient compliance to and beliefs about medicines.

RESULTS

A majority of the respondents (62%; CI 45-77%) had at least one medication error. Assuming that all items are equally important in the Morisky four-item scale we presented four alternative ways to create a unidimensional global scale. A two-dimensional global scale was also constructed. The results from the BMQ-specific were presented in different ways, all taking into account that the scale has ordered verbal categories: at the level addressing each specific question, at the sub-scales 'concern' and 'necessity' level and at the global level.

CONCLUSIONS

The structured medication questionnaire can be used in daily practice as a tool to identify drug-related problems. The choice of how to use and present data from those scales in research depends on patient characteristics and how discriminating one would like the scales to be.

Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review

BACKGROUND

Clinically significant pharmacokinetic and pharmacodynamic changes occurring with age make older patients more prone to the consequences of inappropriate prescribing. The combination of higher use of medicines resulting from a higher disease burden with suboptimal treatment monitoring results in a higher risk of unwanted drug effects from sometimes inappropriate choice of drugs, doses and durations of treatment. Pharmacy services are increasingly being targeted to minimize the overall number of unnecessary and potential harmful medicines.

OBJECTIVE

To investigate the impact of a pharmacist-led medication review on quality of prescribing by a healthcare professional team consisting of a general practitioner (GP), care home staff and a pharmacist.

METHODS

This observational study compared outcome measurements before and after a pharmacist-led review of medications for patients under the care of a healthcare professional team consisting of a GP, care home staff and pharmacist. The procedure for conducting and recording the medication review consisted of the preparation of a patient medication profile, which combined the patient's medical records with his or her complete prescription record (current and previous [last 3 years] medication history) and pharmaceutical record (electronic journal entries for the patient over the same period). Laboratory values were evaluated in clinical context. Recommendations for the pharmaceutical plan were discussed at a conference involving the clinical pharmacist and other healthcare team members. Patients were recruited for medication review over the 12-month period 1 April 2003 to 1 April 2004. Medication appropriateness was assessed by an independent panel of clinical pharmacists using the Medication Appropriateness Index (MAI).

RESULTS

A total of 54 patients were eligible according to the inclusion criteria, of whom 24 were subsequently excluded for various reasons; thus, 30 patients were eligible for assessment on the MAI. There was a statistically significant difference between overall pre- and post-intervention summed MAI scores (p=0.013). The pharmacist identified 115 drug-related problems, and the total number of accepted recommendations was 78 (67.8%). Use of a medication review as an intervention by a clinical pharmacist was associated with an improvement in appropriateness of prescribing.

CONCLUSION

This study provides evidence supporting the formal integration of a clinical pharmacist into the healthcare team with the aim of improving prescribing appropriateness for institutionalized elderly Dutch patients. Overall MAI scores for all long-term medications used by a group of elderly patients improved significantly after a pharmacist-led medication review. This is an important finding because quality of prescribing is assuming increasing importance as a means of preventing avoidable medication-related harm.

Chronic systolic heart failure, guideline-directed medical therapy, and systemic hypotension-less pressure but maybe more risk (does this clinical scenario need more discussion?)

Many clinical trials have demonstrated the survival benefit of medication regimens that modulate the neurohormonal activation that occurs with chronic heart failure (HF). These medications, however, also commonly lower systemic blood pressure (BP). Low arterial BP in patients with chronic HF has been shown to be an independent predictor of increased mortality. Given this apparent paradox in therapeutic goals (treat aggressively but keep BP from going too low), how low should we allow systemic BP to go as a result of our medication regimens before we compromise the proven benefits of such drug therapy? Or is the association between the BP-lowering effects of standard therapy and outcomes in HF even meaningful clinically? It is from this perspective that the merits, potential clinical implications, and the relevant published literature pertaining to this patient and practice management issue will be discussed.

[Primary care in homes for the elderly]

Dutch GP's (General Practitioners) take care of people living in homes for the elderly. The population of these homes is selected on the basis of poor functioning on ADL (activities of daily living). We expected to find a group of elderly people within these homes that need more complex primary care. We describe the characteristics of care for an institutionalized elderly population and compare these to the care provided to their independently living peers. The design of this study is a matched case-control study in a Dutch General Practice in the study period 1/1/1998 to 1/7/2004. Our main results show that the rate of cognitive problems is two times, the prevalence of depression even three times higher in older people living in a home for the elderly than in those who live independently. Locomotory problems are a frequent problem in homes for the elderly. Rates of chronic pulmonary problems, atherosclerosis-related diseases and urinary tract infection are higher, whereas no significant differences for CVA, diabetes and cancer were found. Institutionalized older patients use more different types of medication. GP's do not have more contacts with people living in a home for the elderly than with older people living independently. We conclude that people living in homes for the elderly have complex problems, and need special attention for their specific vulnerability. Differences in care are not primarily explained by chronic disease but by problems with mobility, confusion, depression and cognition.

Analysis of drug–drug interactions (DDIs) in nursing homes in Central Taiwan

With the progressive aging of the population, the long-term nursing care and drug safety for the elderly are gradually gaining attention. In Taiwan, nursing homes are the main institutes helping society or families take care of elderly people suffering from diseases. The aim of this study was to assess the prescribed medications of nursing home residents, the occurrence of DDIs and the association between the number of drugs and DDIs with a view to reinforce drug safety for the elderly. The findings of this study showed that the mean number of medications per resident was 5.74+/-2.4. Of the 323 samples, 81 (25.1%) had experienced DDIs, 63 (64.95%) were of moderate and 7 (7.2%) of major severity. The findings also showed that the number of potential DDIs increased as the number of medications used per residents increased. The residents with nine or more medications tended to have more DDIs, in comparison to those with one or two medications. The odds ratio (OR) was 11.389, which had reached statistical significance in difference. Therefore, to reduce potential DDIs, the number of medications for the senior people with chronic diseases should be properly controlled.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Psychotropic use in community residential care facilities: A prospective cohort study

BACKGROUND

Psychotropic medication use in community residential care (CRC) facilities has been reported to be similar to that found in nursing homes before the implementation of the Omnibus Budget Reconciliation Act of 1987.

OBJECTIVES

The objectives of this study were to (1) describe patterns of psychotropic medication use at baseline and after 1 year of follow-up in adult residents aged > or =65 years supported by Medicaid in CRC facilities, (2) describe the quality of psychotropic use, and (3) examine the relationship between psychotropic use and resident and facility characteristics.

METHODS

This was a planned analysis of a larger prospective cohort study conducted in CRC facilities (assisted living, adult family home, adult residential care) in a 3-county area in the state of Washington. Interviews and state Medicaid databases were used to collect resident characteristics (demographic data, medication use, activities of daily living, self-reported health, and frequency of memory and behavior problems) and facility characteristics (type, staffing, and occupancy rates). Residents were classified as users or nonusers of psychotropic medications. Suboptimal psychotropic use was defined as use of agents with a higher side-effect profile (tertiary amine tricyclic antidepressants, long-acting benzodiazepines, and low-potency conventional antipsychotics). Logistic regression was used to examine characteristics associated with any psychotropic use at baseline.

RESULTS

The typical resident was a white woman, aged 83 years, receiving 7 medications. Nearly half (46.8%) of all residents used > or =1 psychotropic medication at baseline, whereas 16.7% used multiple agents. Antidepressants accounted for the greatest amount of psychotropic use (31.2%). Suboptimal antidepressants, sedative/anxiolytics, and antipsychotics were used by 19.3%, 16.7%, and 7.3% of medication users in each class, respectively. Only age (odds ratio [OR] = 0.97; 95% CI, 0.35-1.00), number of medications (OR = 1.06; 95% CI, 1.00-1.11), and the Revised Memory and Behavior Problems Checklist score (OR = 2.03; 95% CI, 1.28-3.23) were associated with psychotropic use at baseline.

CONCLUSIONS

Psychotropic medication use was high in CRC facilities (46.8%), with antidepressants being the most frequently used drugs. Use of suboptimal (19.3% of antidepressant users, 16.7% of sedative/anxiolytic users, 7.3% of antipsychotic users) and multiple psychotropics (16.7%) was low.

Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial

OBJECTIVE

to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.

DESIGN

randomised controlled trial of clinical medication review by a pharmacist against usual care.

SETTING

sixty-five care homes for the elderly in Leeds, UK.

PARTICIPANTS

a total of 661 residents aged 65+ years on one or more medicines.

INTERVENTION

clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care.

MAIN OUTCOME MEASURES

primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE).

RESULTS

the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (pounds sterling 42.24 and pounds sterling 42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented.

CONCLUSIONS

general practitioners do not review most care home patients' medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients' medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.

Factors related to medication adherence in memory disorder clinic patients

Medication adherence is a substantial problem in the elderly. It may be even more important among elderly persons with memory problems, since other factors that lead to non-adherence may be compounded with the memory problems themselves. The objective was to determine whether a model that integrates research on medication adherence from several research domains is useful in understanding adherence in elderly patients. The methodology involved a cross-sectional observational study using a convenience sample of 63 patients drawn from a university-affiliated outpatient memory disorders clinic. The primary measure of medication adherence was caregivers' reports of patients' medication adherence. Patients and their caregivers were asked questions assessing their beliefs about the seriousness of each condition for which a medication was prescribed and the likely outcome of that condition without treatment. Additional data collected included presence of side effects, total number of medications taken, and patients' mood and cognitive status. Multilevel path analysis confirmed several model-based predictions. Caregivers' reports of adherence were predicted by estimates of disease outcome, the presence of side effects, and patients' relying on themselves to remember to take medications. Results partially confirm the integrative model in understanding medication adherence in these patients. Patients' beliefs about the likely effect of medication treatment for their condition and the presence of side effects influence reported medication adherence. Results thus suggest that efforts to educate patients about the likely response of their medical condition to treatment and to assess and deal with medication side effects might improve patient adherence.

Medication utilization in an urban homebound population

BACKGROUND

The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population.

METHODS

We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction.

RESULTS

The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512).

CONCLUSIONS

For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Nurse delegation of medication administration for older adults in assisted living

Assisted living (AL) is a relatively new form of long-term care that offers residents personal care services and more independence in a home-like environment. Introduced to the United States in the 1980s, AL is changing the conventional thinking about how to care for frail older adults. One important issue to explore is registered nurse (RN) delegation to unlicensed assistive personnel (UAP), particularly for medication administration. This study provides a national perspective on medication delivery in AL settings from the perspectives of state Board of Nursing (BON) executives. Qualitative interviews using semi-structured interview guides were conducted with BON executives to validate a legal summary of AL regulations and nurse practice acts, and to identify nursing issues pertaining to medication management in AL across the United States. In this study, there was considerable variation across states regarding medication administration and the role of both the RN and the UAP. BON executives displayed a range of knowledge about nursing practice issues in AL, with many reporting low familiarity with this setting. Mechanisms for systematic review of quality of delegation were not in place. Medication administration and nurse delegation were dynamic issues, with practice and policy evolving concurrently. This study highlights the limited articulation of policies between agencies and across states in the important and growing setting of assisted living. Nurses have the opportunity to shape this evolving practice arena and to enhance awareness of the professional and clinical issues inherent in working with UAP in medication delivery.

Quality of Medication Records and Use of Pharmacy Resources in Community Residential Care Facilities

Background:

In community residential care (CRC) facilities, medication administration is often performed by unlicensed personnel with minimal knowledge in medication use. Medication management is one of the top 3 quality-of-care issues facing these facilities.

Objective:

To examine the type of medication assistance residents received, determine the proportion of facilities that used pharmacy resources, and examine the quality of facility medication records in CRC facilities (eg, adult family homes, adult residential care, assisted living facilities).

Methods:

Baseline in-person interviews were conducted with 349 residents and 299 facility providers in the Puget Sound region of Washington. Information was also obtained from facility medication records at enrollment and state databases. A pharmacist determined quality of the records using a standardized form.

Results:

The average resident was a 78-year-old white female taking 7 drugs. Medication records that were computer generated were significantly less likely to have misspelled names of drugs and errors in or absence of dose, directions for use, and route of administration. Overall, 26.3% of facilities reported that a consultant pharmacist reviewed residents' medication lists, 52.0% reported the use of preprinted lists, and 75.6% received prepackaged medications from the pharmacy. Adult family homes, the smallest facility type, were the least likely to use pharmacy-related services.

Conclusions:

The quality of handwritten medication records was a concern in CRC facilities. These facilities may benefit from services offered by pharmacies that may enhance medication management, many of which were underutilized.

Orthostatic Hypotension in the Nursing Home Setting

Orthostatic hypotension is a common condition among nursing home (NH) residents. NH residents tend to have multiple disease processes and tend to be on multiple medications associated with orthostatic hypotension and are predisposed to a myriad of negative clinical consequences, most notably falls. This article discusses a commonsense approach to diagnosis, evaluation, and treatment of patients with this disorder, with an emphasis on nonpharmacological interventions, such as patient and staff education.

Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents

OBJECTIVE

Polypharmacy is a well-known risk factor for adverse drug reactions (ADRs). The objective of this study was to determine the relationship between the use of > or = 9 different scheduled medications and the occurrence of ADRs in geriatric nursing home residents.

METHODS

This was a retrospective cohort study conducted in a 1200-bed, county-owned and -operated, longterm care skilled nursing facility Participants were 335 subjects aged > or = 65 years who were present at the facility during the index month of October 1998. Hospice, respite care, and rehabilitation patients were excluded. Use of > or = 9 different scheduled medications was defined a priori as routinely administered medications, excluding as-needed agents, topical agents, 1-time administration, and vaccinations. ADRs were identified by voluntary reporting and by chart review during a 12-month period. ADRs were assessed individually by 2 clinical pharmacists applying the Naranjo ADR probability scale.

RESULTS

A total of 207 ADRs were identified. The cohort receiving > or = 9 scheduled medications (n = 43) experienced 53 ADRs, compared with 154 ADRs in the control group receiving <9 medications (n = 292). The demographic distribution was similar in both cohorts, with white as the dominant ethnicity; 45% were white in the control group and 51% were white in the cohort group receiving > or = 9 scheduled medications. The sex distribution was also similar, with women outnumbering men in both cohorts: 60% and 81% were women in the control and cohort groups, respectively. The mean age was 72 years (range, 65-100 years). After the data were adjusted for the number of days each subject was at risk for experiencing an ADR, subjects using > or = 9 different scheduled medications were 2.33 times more likely than controls to experience an ADR (95% CI, 1.54-3.52; P < 0.001).

CONCLUSION

A positive correlation between the use of >/=9 different scheduled medications and ADRs was found among these geriatric nursing home residents.

Medication use and prescribing considerations for elderly patients

Older adults consume more medications than any other segment of the population. Increasing lifespan means that more people will live into old age, frequently with disabilities and conditions man-aged by medications. Age-associated physiologic changes, medication use patterns, and adverse drug effects and interactions place the older adult at high risk for medication-related problems. Older adults living in institutions, those with complex medical problems,and those who do not adhere to medication regimens are at highest risk for negative health outcomes from medication mishaps. Dentists must be able to identify older adults who are susceptible to adverse drug events and to recognize which medications are most likely to precipitate problems.

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.

Factors influencing the implementation of quality use of medicines in residential aged care

BACKGROUND

In response to concerns about, and issues pertaining to, medication use practices in residential aged-care facilities (RACFs), the Australian Pharmaceutical Advisory Council (APAC) established a working party on quality use of medicines (QUM) in nursing homes and hostels. The APAC is a representative ministerial advisory forum bringing together key stakeholders from the medical, nursing and pharmacy professions, as well as pharmaceutical industry, consumer and government sectors. The working party developed the integrated best practice model for medication management in RACFs.

OBJECTIVES

This study arose from concerns that, despite the availability of such guidelines to inform best practice in RACFs, there remain barriers to its implementation. Thus, the focus of this research was to explore factors influencing the implementation of best practice with respect to QUM in RACFs.

METHODS

This multimethod, multidisciplinary study was conducted in a representative sample of 12 RACFs in one Australian state - South Australia. The methods used were Critical Incident Technique (CIT) interviews, focus groups, nominal groups and Participatory Action Research.

RESULTS

In stage one of the research the CIT interviews identified four major issues/factors influencing the implementation of best practice: contextual/structural, boundaries, day-to-day practices and keeping up. These themes were developed in the focus and nominal group sessions and the project team prepared a discussion paper summarising stage one results. In stage two participants were asked to use the discussion paper to develop a way forward. Medication Advisory Committees (MACs) emerged as a key strategy. Each participating RACF was then supported to establish and maintain a MAC. A second workshop heard feedback from the facilities on factors supporting the MACs and barriers to their functioning. Eleven of the 12 RACFs had a functioning MAC at the end of the project. Key support factors included: an external facilitator to help organise MAC meetings, provision of resources, such as terms of reference, agendas, policy statements and the sharing of information between MACs. In stage three a set of agreed recommendations was prepared and submitted to the funding body. The recommendations reported here informed the development of the peak guidelines for medication management and administration in Australia.

CONCLUSION

This project has been groundbreaking in its impact on Australian aged-care practice. A major outcome has been significantly improved communication and collaboration between industry organisations, academic disciplines, professional bodies and educators involved in the RACFs.

Repeat prescribing: scale, problems and quality management in ambulatory care patients

The reported scale of repeat prescriptions ranges from 29% to 75% of all items prescribed, depending on the definition of repeat prescribing and other variables. It is likely that a substantial part of repeat prescribing by general practitioners (GPs) occurs without direct doctor-patient contact. While this reduces the workload for the GP and is convenient for the patient, it does not provide the adequate control that is needed to ensure that every repeat prescription is still appropriate, effective and well tolerated, and that it is still being viewed upon and taken by the patient as intended. Infrequent therapy reviews may lead to failure to prevent, identify and solve drug-related problems and drug wastage, and may, thereby, have a negative impact on the effectiveness, safety or cost of the medications prescribed. Studies evaluating the repeat prescribing process have shown that GPs and medical practices vary widely in their degree of administrative and clinical control of repeat prescriptions. Contrary to the opinion that GPs cannot change prescribing behaviour when the prescription is initiated by a medical specialist, GPs have their own responsibility for controlling the repeats of such prescriptions. Intervention studies suggest that a medication review by a pharmacist can help to reduce drug-related problems with repeat prescriptions, and the effectiveness of the intervention may be increased by combining the medication review with a consultation of the patient's medical records and a patient interview. In several studies, such an intervention was relatively inexpensive and, therefore, feasible. However, these conclusions should be viewed with appropriate caution because a number of caveats pertain. There is still no evidence that these types of intervention improve health-related quality of life or reduce healthcare cost, and so far only a few trials have produced any evidence of clinical improvement. As implicit and explicit screening criteria have their own benefits and limitations, a combined application may offer a more thorough assessment but may also be more complex and time consuming. Further studies on the development and evaluation of repeat prescription management models are needed, preferably focussing on improving clinical, humanistic and economic outcomes. New studies should investigate the effects of: different types of interventions; different organisational models; different target populations; and selecting and training different types of healthcare professionals. Future studies should also assess whether results are sustained, the optimal time interval between reviews of repeat prescriptions, and the possibilities offered by new computerised support technologies.

The short-term effect of interdisciplinary medication review on function and cost in ambulatory elderly people

OBJECTIVES

To determine whether a medication review by a specialized team would promote regimen changes in elders taking multiple medications and to measure the effect of regimen changes on monthly cost and functioning.

DESIGN

A randomized-controlled trial.

SETTING

Health center ambulatory clinic.

PARTICIPANTS

Community-dwelling older adults taking five or more medications were assessed at baseline and 6 weeks. A medication-change intervention group of 57 elders was compared with a control group of 76 elder adults.

INTERVENTION

The primary intervention was a comprehensive review and recommended modification of a patient's medication regimen. Changes were endorsed by each patient's primary physician and discussed with each patient.

MEASUREMENTS

Measures were the Timed Manual Performance Test, Physical Performance Test, Functional Reach Assessment, subtests from the Wechsler Adult Intelligence Scale, a modified Randt Memory Test, the Center for Epidemiological Studies-Depression Scale, the Self-Rating Anxiety Scale, and the Rand 36-item Health Survey 1.0. Comorbidity was determined using the International Classification of Diseases, Ninth Revision, Clinical Modification. Medication usage was determined using brown bag review.

RESULTS

Intervention subjects decreased their medications by an average of 1.5 drugs. No differences in functioning were observed between groups. Intervention subjects saved an average $26.92 per month in wholesale medication costs; control subjects saved $6.75 per month (P<.006).

CONCLUSION

Although the intervention significantly reduced the medications taken and monthly cost, most patients were resistant to reducing medications to the recommended level. Further study is needed to understand patient resistance to reducing adverse polypharmacy and to devise better strategies for addressing this important problem in geriatric health. Greater focus on prescriber behavior is recommended.

Pharmacotherapeutic interventions by a multi-specialty team: opinions of the general practitioners and nurses

OBJECTIVES

The objective of this study was to assess the opinions of the general practitioners (GPs) and nurses towards a previous pharmacotherapeutic intervention and their opinions towards future alternative or complementary methods to improve nursing-home patients' drug treatments.

METHODS

Sixty-six GPs and forty-five nursing-home nurses, working at nursing homes in southern Sweden, were sent a questionnaire to assess their opinions towards a pharmacotherapeutic intervention conducted by a multi-specialty team and their opinions on alternative or complementary future methods potentially improving patient treatment.

RESULTS

The response rate was 62% for the GPs and 69% for the nurses. Both GPs and nurses were positive towards further co-operation regarding pharmacotherapeutic interventions. All nurses that were positive to further co-operation wished to do it in a multidisciplinary team, whereas some GPs wished to do this in a multi-specialty team.

CONCLUSION

The opinions of GPs and nurses towards the pharmacotherapeutic intervention indicate that this or similar methods may successfully be used in clinical practice for improving drug therapy.

Pattern of prescriptions issued by nursing home-based physicians versus office-based physicians for frail elderly patients in German nursing homes

PURPOSE

The purpose of this study was to describe the physician prescription pattern for frail elderly patients in German nursing homes and to identify differences, if any, between that of physicians based in the nursing homes (A) and those with office-based practices (B).

METHODS

Retrospective, longitudinal study of medication prescriptions on the basis of the database of a health insurance (Betriebskrankenkasse) in Berlin, Germany. We assessed the medication prescriptions for all 996 unselected insured individuals aged > or = 60 years who were insured throughout 1999 and lived in nursing homes. We analyzed selected patient characteristics and prescription data. Drugs were classified according to the WHO ATC code and were assigned a mean daily defined dose (DDD).

RESULTS

816 individuals were women and 180 were men. A total of 78% of women and 43% of men were aged 80 years or older. Two hundred sixty three patients were seen by nursing home-based physicians (A) and 733 by office-based physicians (B). The median of prescriptions per patient and year was 31 (A) and 37 (B) (p between groups < 0.001). Patients in Group A also received a lower number of DDDs in comparison to Group B (1109 vs 1250; p < 0.01). Costs were substantially higher in group B, and in both groups higher in the 60-69 years old in comparison to the more senior patients. The prescription pattern suggested a considerable frequency of inappropriate drug use in both groups in the following classes: psychopharmacological agents (neuroleptics, antidepressants, hypnotics), pain medication, digitalis glycosides, laxants and loop diuretics. On an average, office-based physicians (B) prescribed relatively more medications in all major classes with the exception of non-opiate analgesics, laxants and anxiolytics.

CONCLUSIONS

These data are indicative of a considerable use of inappropriate medication for frail geriatric patients. Differences between the prescribing pattern among nursing home-based and office-based physicians were not substantial, however, the latter group prescribed relatively more drugs.

Medication decisions--right and wrong

This paper reviews the recent literature on problems associated with prescription drug use in older adults. The authors address four major issues: Why giving patients the wrong drug is so common; how taking the wrong amount is an even larger problem; why good drugs may be wrong for particular patients; and how high out-of-pocket spending and inadequate insurance coverage may disrupt otherwise sound drug regimens. The organizing theme of this review is the right drug for the right patient, taken in the right way at the right price. Despite significant gaps in the research record the evidence leaves no doubt that elderly individuals are at significant risk for inappropriate medication use. The paper concludes with an agenda for future studies: the need to validate standards for geriatric drug use, assess inappropriate drug use at the national level, establish population-based risk factors, and target research to the most significant adverse outcomes.

Efficacy, safety, and tolerability of extended-release once-daily tolterodine treatment for overactive bladder in older versus younger patients

OBJECTIVES

To evaluate the efficacy, safety, and tolerability of a new, once-daily extended-release (ER) formulation of tolterodine in treating overactive bladder in older (> or =65) and younger (<65) patients.

DESIGN

A 12-week double-blind, placebo-controlled clinical trial.

SETTING

An international study conducted at 167 medical centers.

PARTICIPANTS

One thousand fifteen patients (43.1% aged > or =65) with urge incontinence and urinary frequency.

INTERVENTION

Patients were randomized to treatment with tolterodine ER 4 mg once daily (qd) (n = 507) or placebo (n = 508) for 12 weeks.

MEASUREMENTS

Efficacy, measured with micturition charts (incontinence episodes, micturitions, volume voided per micturition) and subjective patient assessments, safety, and tolerability endpoints were evaluated, relative to placebo, according to two age cohorts: younger than 65 and 65 and older.

RESULTS

Mean age in the older and younger patient cohorts was 74 (range 65-93) and 51 (range 20-64), respectively. Compared with placebo, significant improvements in micturition chart variables with tolterodine ER showed no age-related differences. Irrespective of age, significantly more tolterodine ER recipients than placebo recipients reported an improvement in urgency symptoms. After 12 weeks of treatment with tolterodine ER, a fivefold increase in the percentage of patients able to finish tasks before voiding in response to urgency was noted in both age groups (<65: from 6.5-32.8%, > or =65: from 5.1-26.2%). Tolterodine ER recipients, irrespective of age, also had significant improvements in their bladder condition than did placebo recipients. Overall, a greater percentage of patients, irrespective of age, perceived any benefit with tolterodine ER than with placebo (P <.001). Dry mouth (of any severity) was the most common adverse event in both the tolterodine ER and placebo treatment arms, irrespective of age (<65: ER 22.7%, placebo 8.1%; > or =65: ER 24.3%, placebo 7.2%). Few patients (<2%) experienced severe dry mouth. No central nervous system, visual, cardiac (per electrocardiogram), or laboratory safety concerns were noted. Withdrawal rates due to adverse events on tolterodine ER 4 mg qd were comparable in the two age cohorts (<65: 5.5%; > or =65: 5.1%; P =.87).

CONCLUSIONS

The new, once-daily ER formulation of tolterodine is efficacious, safe, and well tolerated in the treatment of patients with symptoms of overactive bladder, irrespective of age.

Once-daily, extended-release formulations of antimuscarinic agents in the treatment of overactive bladder: a review

Overactive bladder (OAB) is a chronic condition that often requires long-term treatment to maintain control of symptoms. A range of therapeutic options are available; however, antimuscarinic agents form the mainstay of treatment. Of these agents, tolterodine and oxybutynin are the most widely used. It is well documented that the immediate-release (IR) formulations of these agents have equivalent efficacy in relieving OAB symptoms. However, tolterodine demonstrates a more favorable tolerability profile, particularly in terms of the frequency and severity of dry mouth. Due to the development of novel drug delivery systems, extended-release (ER) formulations of both oxybutynin and tolterodine are now available, permitting once-daily dosing. The convenience of once-daily dosing of antimuscarinic agents would be expected to improve patient compliance and further relieve the symptoms of OAB. Clinical studies with the ER formulations of tolterodine and oxybutynin demonstrate potential clinical advantages over their respective IR forms in terms of either efficacy or tolerability or both, although the therapeutic index of tolterodine ER appears to show a greater advantage over its IR counterpart compared with oxybutynin ER and its IR form. Importantly, the two ER agents have not been compared directly in a head-to-head clinical study. Overall, available clinical data suggest that the newly developed ER formulation of tolterodine represents a significant therapeutic advancement in the treatment of OAB.

The safety of low-dose Larrea tridentata (DC) Coville (creosote bush or chaparral): a retrospective clinical study

OBJECTIVE

To determine whether internal use of low doses of Larrea tridentata tincture or topical applications of this traditional herbal medicine are safe.

DESIGN

Retrospective review of all people prescribed Larrea for internal or for topical use over a 22-month period.

SETTING/LOCATION

A general naturopathic practice in Sedona, Arizona.

SUBJECTS

Thirteen patients were identified for whom Larrea tincture for internal use was prescribed. An additional 20 female and 3 male patients were identified for whom an extract of Larrea in Ricinus communis (castor) oil for topical use was prescribed. No patient had any history of liver disease.

INTERVENTIONS

Larrea was prescribed as part of the usual care of each patient. In all cases it was given as either part of a complex herbal formula individualized for each patient containing less than 10% Larrea tincture or as an extract in Ricinus oil for topical use.

OUTCOME MEASURES

Serum liver enzyme levels as well as blood urea nitrogen and creatinine levels, glucose levels, electrolytes, bilirubin levels, iron levels, ferritin levels, lipid levels, and complete blood count (CBC) were available for analysis in four patients; general clinical history and physical examination findings were relied on in all other cases.

RESULTS

The four patients with complete before and after blood chemistry panels and CBC had no indication of liver damage from use of Larrea. This included one patient who was taking medications with significant potential for hepatotoxicity. No patient in the study, whether using Larrea for short term or long, internally or externally, showed any sign of organ damage during the period of follow-up.

CONCLUSIONS

Relatively small intakes of Larrea tincture, or topical application of extracts in Ricinus oil, are safe when prescribed by a clinically trained botanical prescriber. Larrea should be used with caution in persons with a history of previous, or current, liver disease. It may be preferable to avoid the use of Larrea capsules because they have been associated with potentially dangerous overdosing.