Potentially inappropriate medication use in nursing homes: an observational study using the NORGEP-NH criteria

Background

Frail residents in the nursing home sector call for extra care in prescribing. The Norwegian General Practice Nursing Home (NORGEP-NH) list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed explicitly for this population. The aim of this study was to employ the NORGEP-NH Criteria to study the extent of potentially inappropriate medication use among nursing home residents and explore possible associated factors.

Methods

Cross-sectional observational pharmacoepidemiological study from residents in nursing homes in the county of Vestfold, Norway. Data collected 2009–11 included residents’ demographic and clinical status and all medications, regular and on demand.

Results

881 patients from 30 institutions (mean 85.9 years, 68.6% female), were included. According to NORGEP-NH, 43.8% were prescribed at least one potentially inappropriate regular medication, and 9.9% regularly received three or more potentially inappropriate medications. When also including a) the NORGEP-NH Deprescribing Criteria and b) including drugs prescribed for use as needed, 92.7% of all residents received medication that needs particular surveillance according to the NORGEP-NH. 69.7% of the nursing home residents used at least one psychotropic drug regularly. Female residents received more often than males at least one potentially inappropriate regular medication (OR 1.60, p=0.007). Regarding the prescription of three or more concomitant psychotropic medications, odds ratio for females was 1.79 (p=0.03) compared to males. Residents with the best performance in activities of daily living, and residents residing in long-term wards, had higher risk of using three or more psychotropic drugs. Use of multiple psychoactive drugs increased the risk of falls in the course of an acute episode of infection or dehydration (odds ratio 1.70, p=0.009).

Conclusions

Prevalence of potentially inappropriate medications in nursing homes according to the NORGEP-NH was extensive, and especially the use of multiple psychotropic drugs. The high prevalence found in this study shows that there is a need for higher awareness of medication use and side effects in the elderly population.

Trial registration

Retrospectively registered. Data obtained from clinical trial NCT01023763 registered with ClinicalTrials.gov 12/01/2009.

The Norwegian General Practice--Nursing Home criteria (NORGEP-NH) for potentially inappropriate medication use: A web-based Delphi study

OBJECTIVE

To develop a set of explicit criteria for pharmacologically inappropriate medication use in nursing homes.

DESIGN

In an expert panel, a three-round Delphi consensus process was conducted via survey software.

SETTING

Norway.

SUBJECTS

Altogether 80 participants - specialists in geriatrics or clinical pharmacology, physicians in nursing homes and experienced pharmacists - agreed to participate in the survey. Of these, 62 completed the first round, and 49 panellists completed all three rounds (75.4% of those ultimately entering the survey).

MAIN OUTCOME MEASURES

The authors developed a list of 27 criteria based on the Norwegian General Practice (NORGEP) criteria, literature, and clinical experience. The main outcome measure was the panellists' evaluation of the clinical relevance of each suggested criterion on a digital Likert scale from 1 (no clinical relevance) to 10. In the first round panellists could also suggest new criteria to be included in the process. For each criterion, degree of consensus was based on the average Likert score and corresponding standard deviation (SD).

RESULTS

A list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed through a three-round web-based Delphi consensus process. Degree of consensus increased with each round. No criterion was voted out. Suggestions from the panel led to the inclusion of seven additional criteria in round two.

IMPLICATIONS

The NORGEP-NH list may serve as a tool in the prescribing process and in medication list reviews and may also be used in quality assessment and for research purposes.

Inappropriate prescribing for the elderly--a modern epidemic?

PURPOSE

The elderly often use several drugs on a regular basis and are especially at risk for drug-related harm from side effects and interactions. The aim of this study was to explore the overall prevalence of and predictors for potentially inappropriate medication use among Norwegian elderly outpatients.

METHODS

A pharmaco-epidemiological retrospective cross-sectional survey was undertaken based on data from the Norwegian Prescription Database. Prescriptions from all doctors in Norway, dispensed by pharmacies to home-dwelling elderly ≥ 70 years in 2008, were included for a total of 11,491,065 prescriptions from 24,540 prescribers to 445,900 individuals (88.3% of the Norwegian population in this age group, 58.9% females). We applied a list of criteria for pharmacological inappropriateness for elderly people (the NORGEP criteria) to determine the prevalence of potentially inappropriate medications (PIMs) and applied a multiple logistic regression model to identify predictors.

RESULTS

According to our criteria, 34.8% of the study population (28.5% of the men, 39.3% of the women) was exposed to at least one PIM. Of these, 59.9% represented psychoactive substances. The odds of receiving potentially harmful prescriptions increased with the number of prescribers (OR 3.52, 99% CI 3.44-3.60 for those with ≥ 5 compared to those with 1 or 2 prescribers). Twenty percent were prescribed more than 10 medications; among these two-thirds had at least one PIM. Adjusted for differences in age distribution and the number of prescribers involved, women were more frequently exposed to PIMs than men, with an odds ratio of 1.60 (99% CI 1.58-1.64).

CONCLUSIONS

About one-third of the elderly Norwegian population is exposed to potentially inappropriate medications, and elderly females are at particular risk.

Occurrence of short chain aliphatic diols in human blood: identification by gas chromatography-mass spectrometry

Patients attending a general hospital for various reasons were screened for raised serum gamma glutamyltransferase (gamma-GT) and positive blood alcohol concentration (BAC). The results served as objective biochemical tests of heavy drinking. Among 419 individuals, 50 (11.9%) met these requirements and blood samples were used to determine the presence of low molecular mass aliphatic diols. 1,2-Propanediol, 2,3-butanediol and 2,2-dimethyl-1,3-propanediol were determined by gas liquid chromatography-mass spectrometry (GC-MS). In patients with blood ethanol concentration less than 2 mmol/l, 1,2-propanediol and 2,2-dimethyl-1, 3-propanediol mainly occurred together at median concentrations of about 200 mumol/l. When blood ethanol was 2-42 mmol/1,2,3-butanediol was also present covering a wide concentration range: three patients had concentrations between 6 and 10 mmol/l. There was no apparent correlation between the concentration of 2,3-butanediol and the concentration of blood ethanol. The diols were below the limits of detection in blood from nonintoxicated control individuals and hospital in-patients.