Prescribing quality for older people in Norwegian nursing homes and home nursing services using multidose dispensed drugs

Assessment of the potential of drug-drug interactions among population-based oldest-old people in Turkiye

Background

The risk of potential drug‒drug interactions is highest in oldest-old people. Thus, the aim of this study was to investigate the frequency and type of potential drug‒drug interactions in population-based oldest-old people.

Methods

The type of study was descriptive. Ethical permission was obtained (13.04.2022/153). All participants were informed, and their written consent was obtained. The "oldest-old" were defined as those who were ≥85 years of age during the study period and living in Turkiye. These people were reached from every region of Turkiye via the snowball method and were visited at their homes. Data were collected via face-to-face interviews. Age, sex, city of residence, and generic names of regularly used medications were recorded. The medications used were analyzed according to the Beers 2019® Criteria and UpToDate® Lexicomp® drug interaction guides. SPSS was used for statistical analysis, and p < 0.05 was considered statistically significant.

Results

Data were collected from the 549 oldest-old people throughout Turkiye. Among the participants, 61.2% (n = 336) were women. The median age of the women was 88.00 years (minimum = 85, maximum = 101), and the median age of the men was 88.00 years (minimum = 85, maximum = 102). The distributions of men and women in the different age groups were similar (p = 0.341). The distributions of men and women across regions were similar (p = 0.826), most of whom (n = 300, 54.6%) had ≥1 potential drug‒drug interaction, according to the UpToDate analysis. The median number of medications used continuously was 4.0 (minimum = 0, maximum = 19). The median number of potential drug‒drug interactions was 1.0 (minimum = 0, maximum = 21). As the number of medications used increased, the number of potential drug‒drug interactions also increased (r = 0.737; p = 0.001). The number of potential drug‒drug interactions decreased with increasing age (r = -0.104; p = 0.015). According to the Beers 2019® Criteria, potential drug‒drug interactions were detected in only eight patients. The concordance between the Beers 2019® Criteria and the UpToDate®Lexicomb® drug interaction data was poor compared with the number of potential drug‒drug interactions (kappa = 0.024, p < 0.001). Central nervous system medications are a common group that can cause potential drug‒drug interactions according to both guidelines. Moreover, potentially inappropriate medications defined by the Beers 2019® Criteria were the most common causes of potential drug‒drug interactions, according to UpToDate®Lexicomb® drug interactions. The frequency of potential drug‒drug interactions was found to be high in the population-based oldest-old people interviewed in Turkiye. It has been determined that the use of more than one guide in the evaluation of potential drug‒drug interactions is safer.

Malnutrition and Polypharmacy in Older Adult Patients Receiving Home Care Nursing Services: A Cross-sectional Study

OBJECTIVE

We studied the nutritional status of older adult adults receiving home nursing care using demographic data, household category, polypharmacy, and potentially inappropriate medications (PIMs).

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Two Norwegian municipalities during 2017-2019; home nursing service clients aged ≥70 years.

METHODS

Inclusion of patients and data collection were done by nurses working in the home services. Recorded data were participants' age, sex, living alone or with others, nutritional status (Mini Nutritional Assessment-Short Form and body mass index), regular prescription drugs, and potentially inappropriate medications (PIMs) according to the Norwegian General Practice Nursing home (NORGEP-NH) criteria. Descriptive statistics and logistic regression were used.

RESULTS

Of the 270 patients (mean age 84.2 years; 64.8% females; 188 living alone), 25 (9.3%) were malnourished and 154 (57%) at risk of malnutrition; in addition, 14.8% had a BMI <21 and 27.8% had lost weight in the previous 3 months. The odds for being at malnutrition risk was higher if living with others vs living alone: adjusted odds ratio (OR) 2.23 (1.20-4.13). Female sex, older age, and better mobility was associated with living alone. The mean number of regular drugs was 7.3. Overall, 43.3% of the participants used at least 1 PIM. Using 0 to 5 drugs vs ≥6 drugs (polypharmacy) was associated with higher odds for malnutrition risk: adjusted OR 1.97 (1.04-3.75). Compared with well-nourished patients, those at risk for or who were malnourished used fewer cardiovascular and musculoskeletal drugs. Exposure to PIMs was not associated with nutritional status.

CONCLUSIONS AND IMPLICATIONS

Two-thirds of home nurse clients were either malnourished or at risk for malnutrition. Living with others or using fewer daily drugs implied increased risk for malnourishment, probably reflecting differences in morbidity and possible inappropriateness of medication use. Future research on nutritional status and medication use should aim for including more clinical data than simple drug counts.

Multidose Drug Dispensing in Community Healthcare Settings for Patients With Multimorbidity and Polypharmacy

Multidose drug dispensing (MDD) is the dispensing of different drugs in dose bags containing one, some, or all units of medicine that a patient needs to take at specific times. The aim of this narrative review is to provide an overview of the literature describing the use of MDD systems in community healthcare settings in patients with multimorbidity and polypharmacy. A literature search identified 14 studies examining adherence, medication knowledge, quality of drug prescription (including inappropriate drug use, drug-drug interactions), medication incidents, and drug changes after MDD initiation, as well as healthcare professional (HCP) and patient perspectives. There are limited data on MDD in community healthcare settings, particularly on outcomes such as adherence. Studies are mostly from Northern Europe. Patients selected for MDD are more likely to be older, female, cognitively impaired, and have a higher number of disease diagnoses and drugs than those who do not receive drugs through MDD. MDD is generally initiated for patients who have decreased capacity for medication management. Several advantages of MDD have been reported by patients and HCPs, and studies indicate that MDD can be improved by medication review, defining clear roles and responsibilities of HCPs in the medication management chain, and comprehensive follow-up of patients. Future development, implementation, and assessment of MDD systems in community healthcare should be designed in collaboration with HCPs and patients, to identify ways to optimize the systems and improve patient outcomes.

Quality of Municipal Long-Term Care in Different Models of Care: A Cross-Sectional Study From Norway

The quality of care remains a critical concern for health systems around the globe, especially in an era of unprecedented financial challenges and rising demands. Previous research indicates large variation in several indicators of quality in the long-term care setting, highlighting the need for further investigation into the factors contributing to such disparities. As different ways of delivering long-term care services likely affect quality of care, the objectives of our study is to investigate (1) variation in structure, process and outcome quality between municipalities, and (2) to what extent variation in quality is associated with municipal models of care and structural characteristics. The study had a cross-sectional approach and we utilized data on the municipal level from 3 sources: (1) a survey for models of care (2) Statistics Norway for municipal structural characteristics and (3) the National Health Care Quality Indicator System. Descriptive statistics showed that the Norwegian long-term care sector performs better (measured as percentage or probability) on structure (85.53) and outcome (84.86) quality than process (37.85) quality. Hierarchical linear regressions indicated that municipal structural characteristics and model of care had very limited effect on the quality of long-term care. A deeper understanding of variation in service quality may be found at the micro level in healthcare workers' day-to-day practice.

Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study

PURPOSE

Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital.

METHODS

A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model.

RESULTS

In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs.

CONCLUSIONS

The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.

Weighted Blankets' Effect on the Health of Older People Living in Nursing Homes

Background: An increasingly aging population is a global phenomenon. While considered a positive step forward, vulnerability to age-related health problems increases along with the ageing population. The aim of the study was to investigate weighted blankets’ effect on health regarding quality of life (QoL), sleep, nutrition, cognition, activities of daily living ADL and medication in older people living in nursing homes. Methods: In total, 110 older people were involved in an intervention with weighted blankets, and 68 older people completed the intervention. Measures before and after were performed regarding quality of life; QoL-AD, EQ-VAS, sleep; MISS, nutrition; MNA, cognition; S -MMSE (ADL) and medication. Comparative statistical analyses were applied. Results: After intervention with weighted blankets, health in general, such as QoL, improved. Sleep also improved significantly, especially with respect to waking up during the night. Nutrition was enhanced, health as a cognitive ability improved, and medication in the psychoanaleptic group decreased. The effect size varied between small and large. Conclusions: A weighted blanket seems to be an effective and safe intervention for older people in nursing homes, as several improvements were made regarding the health of older people.

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.

Use of Benzodiazepines and Z-Drugs in Nursing Home Residents with Dementia: Prevalence and Appropriateness

Background:

Guidelines worldwide recommend restricted prescription of benzodiazepine receptor agonists (BZRAs), i.e., benzodiazepines and Z-drugs, for the treatment of dementia-associated behavioral and psychological symptoms and insomnia.

Objective:

To assess the prevalence and appropriateness of BZRA use among nursing home residents with dementia.

Methods:

This is a post-hoc analysis of BZRA prescriptions from two intervention studies on psychotropic drug use, conducted from 2016 to 2018. It includes 1,111 residents of dementia special care units from 24 Dutch long-term care organizations. We assessed the prevalence of use of continuous and as-needed BZRA prescriptions and their association with registered symptoms. Continuous BZRA prescriptions were evaluated for appropriateness, i.e., whether indication, dosage, duration, and evaluation accorded with guidelines for the treatment of challenging behavior in dementia and sleep disorders.

Results:

The prevalence of BZRA use is 39.2% (95% CI: 36.3%–42.0%): continuous 22.9%; only as-needed 16.3%. Combinations of preferred BZRAs and appropriate indications occur in 19.0% of continuous anxiolytic prescriptions and 44.8% of hypnotic prescriptions. Frequently registered inappropriate indications are aggression/agitation for anxiolytics (continuous: 75.7%; as-needed: 75.2%) and nighttime agitation for hypnotics (continuous: 40.3%; as-needed: 26.7%). None of the continuous prescriptions with appropriate indications were appropriate for all other items. For most of the prescriptions, duration and time to evaluation exceeded 4 weeks.

Conclusion:

BZRA use in nursing home residents with dementia is highly frequent. A large proportion of prescriptions do not follow the guidelines with regard to indication, exceed the recommended duration and are not evaluated in a timely manner. The discrepancy between evidence-based guidelines and daily practice calls for an exploration of factors maintaining inappropriate use.

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.

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.

Potentially inappropriate prescribing to older patients receiving multidose drug dispensing

Background

Multidose drug dispensing (MDD) is an adherence aid that provides patients with machine-dispensed medicines in disposable unit bags, usually for a 14 day period. Previous studies have suggested that the quality of prescribing, with time, is lower for MDD users, compared to patients receiving prescriptions dispensed as usual. This study aimed to examine the quality of prescribing to Norwegian elderly home care service patients receiving MDD.

Methods

A cross-sectional study comprising 45,593 MDD patients aged ≥70 years was performed. The proportion of potentially inappropriate medications (PIMs) was assessed using the Norwegian General Practice Criteria, and drug-drug interactions (DDI) were investigated using the Norwegian Medicines Agency database.

Results

On average, patients were prescribed 10.6 drugs (SD = 5.0), of which 6.1 were dispensed via MDD. Men used on average fewer drugs than women (10.7 vs 11.1), Twenty-seven percent of patients used at least one PIM. Concomitant use of three or more psychotropic drugs (10.8%), and prescribing of diazepam (6.4%) was the most commonly identified inappropriate prescribing. DDIs affected 59% of the patients, however, only 2.7% had serious interactions. Women were more frequently exposed to both PIMs and DDIs than men, with an odds ratio of 1.50 (95% CI: 1.43–1.58) and 1.43 (95% CI: 1.37–1.50), respectively.

Conclusions

Polypharmacy is common in elderly Norwegian patients using MDD. About one-fourth of the patients were exposed to PIMs, and over half were exposed to DDI.

Drug Burden Index and Cognitive and Physical Function in Aged Care Residents: A Longitudinal Study

OBJECTIVES

Anticholinergic/antimuscarinic and sedative medications (eg, benzodiazepines) have been found to be associated with poorer cognitive and physical function and mobility impairment in older age. However, previous studies were mostly conducted among community-dwelling older individuals and had often a cross-sectional design. Accordingly, our aim was to examine longitudinal associations between cumulative exposure to anticholinergic and sedative medications and cognitive and physical function among residents from aged care homes.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

A total of 4624 residents of Dutch aged care homes of whom data were collected between June 2005 and April 2014.

METHODS

Outcome measures were collected with the Long-Term Care Facilities assessment from the international Residential Assessment Instrument (interRAI-LTCF) and included the Cognitive Performance Scale, the Activities of Daily Living (ADL) Hierarchy scale, a timed 4-meter walk test, distance walked, hours of physical activity, and days being outside. Cumulative exposure to anticholinergic and sedative medications was calculated with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. Associations were examined with linear mixed models to take the potential dependence of observations into account (ie, data were collected at repeated assessment occasions of residents who were clustered in aged care homes). Analyses were adjusted for sex, age, dementia, comorbidity (neurological, psychiatric, cardiovascular, oncological, and pulmonary), fractures, depressive symptoms, and medications excluded from the DBI.

RESULTS

We observed significant longitudinal associations between a higher DBI and poorer ADLs, fewer hours of physical activity, and fewer days being outside. We found no significant longitudinal association between a higher DBI and poorer cognitive function.

CONCLUSIONS AND IMPLICATIONS

Over time, cumulative exposure to anticholinergic and sedative medications is associated with poorer physical but not cognitive function in aged care residents. Careful monitoring of aged care residents with high cumulative anticholinergic and sedative medication exposure is needed.

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.

A retrospective comparison of inappropriate prescribing of psychotropics in three Norwegian nursing homes in 2000 and 2016 with prescribing quality indicators

Background

Inappropriate prescribing of psychotropics is a persistent and prevalent problem in nursing homes. The present study compared inappropriate prescribing of psychotropics in nursing homes 16 years apart with prescribing quality indicators. The purpose was to identify any change in inappropriate prescribing of relevance for medical informatics.

Methods

Three Norwegian nursing homes were audited in 2000 and 2016 with regard to prescribing quality. Psychotropics among 386 patients in 2000, and 416 patients in 2016, included combinations of antidepressants, antipsychotics, anxiolytics-hypnotics, and antiepileptics. Prescribing quality indicators included psychotropic polypharmacy (defined as concurrent use of three or more psychotropics) and potential inappropriate psychotropic substances or combinations. Furthermore, potential clinically relevant psychotropic interactions were classified as pharmacodynamic or pharmacokinetic using an interaction database. The first ranked (most important) interaction in each patient was selected with the following importance of categories in the database; recommended action > documentation > severity. Three levels (from low to high) within each category were used for ranking.

Results

From 2000 to 2016, psychotropic polypharmacy increased from 6.2 to 29.6%, potential inappropriate psychotropic substances was reduced from 17.9 to 11.3% and potential inappropriate psychotropic combinations increased from 7.8 to 27.9%. Changes in polypharmacy and combinations were predominantly associated with prescribing of anxiolytics-hypnotics. Sixty-three patients (16.3%) had psychotropic interactions in 2000 increasing to 146 patients (35.1%) in 2016. The increase in interactions was associated with prescribing of antidepressants. First ranked interactions, more than 60% of all interactions in both years, were increasingly pharmacodynamic, from 69.9 to 91.0%. Interactions in 2016 were associated with a lower level of recommended action and documentation, but not severity compared to 2000. The inappropriate prescribing of antipsychotics and antiepileptics was reduced in 2016 compared to 2000.

Conclusions

Using prescribing quality indicators we observed the importance of antidepressants and anxiolytics-hypnotics for inappropriate prescribing in 2016 while the role of antipsychotics and antiepileptics were reduced compared to 2000. A change to mainly pharmacodynamic interactions that lack good documentation was also observed. The present findings can be used for medical informatics-based approaches to address specific problems with prescribing, and prescribing quality indicators, in Norwegian nursing homes.

Prevalence of cytochrome P450-mediated potential drug-drug interactions in residents of intermediate care facilities for older adults in Japan

AIM

Limited information is available on the prevalence of drug-drug interactions (DDI) in residents of long-term care facilities who often receive multiple drugs. This study aimed to evaluate the prevalence of clinically relevant cytochrome P450-mediated potential DDI in residents of intermediate care facilities for older adults (called Roken) in Japan.

METHODS

A nationwide drug utilization study was carried out for Roken residents in 2015 (up to five residents per facility). Potential DDI were identified with an explicit list of drugs that can be involved in clinically relevant cytochrome P450-mediated DDI in Japan. Logistic regression was used to evaluate the association of the number of drugs prescribed with the presence of potential DDI, adjusted for age, sex and long-term care needs level.

RESULTS

The study included 1222 residents of 348 Roken who were prescribed two or more active drug substances. The participants who received ≥6 and ≥10 drugs represented 49% and 10% of total participants, respectively. In total, 42 two-drug combinations involving potential DDI were identified in 33 participants (2.7%) - benzodiazepines, proton pump inhibitors, calcium channel blockers and anti-epileptic drugs were frequently involved. The adjusted odds ratios for potential DDI were 2.84 (95% confidence interval 1.15-7.02) or 7.82 (95% confidence interval 2.96-20.70) in residents receiving six to nine drugs or ≥10 drugs, compared with those receiving two to five drugs.

CONCLUSIONS

Approximately 3% of Roken residents were at risk for clinically relevant DDI. Reducing the number of drugs prescribed through medication reviews would mitigate the potential risk. Geriatr Gerontol Int 2019; 19: 513-517.

Assessing Potentially Inappropriate Medications in Nursing Home Residents by NORGEP-NH Criteria

Background: Nursing home residents often have several conditions that necessitate the use of multiple medicines. This study investigates the prevalence of potentially inappropriate medications (PIMs) and its associations with sex, age, number of medicines, and study location (rural/urban). Methods: A cross-sectional study of long-term care residents from six nursing homes. Data was collected from medical records. We identified PIMs by applying the NORGEP-NH criteria. We conducted a Poisson regression analysis to investigate the association between the number of PIMs and sex, age, number of medicines, and study location. Results: We included 103 (18.4%) of 559 residents (68.0% women; mean age 83.2 years, mean number of daily used medicines 7.2 (SD = 3.6)). We identified PIMs in 56% of the residents (mean number = 1.10, SD = 1.26). In adjusted analyses, residents ≥80 years had 0.43 fewer PIMs compared to residents <80 years (p < 0.05). Residents using 4–6, 7–9, and 10+ medicines had on average 0.73, 1.06, and 2.11 more PIMs compared to residents using 0–3 medicines (p < 0.001), respectively. Conclusion: PIM use is prevalent among nursing home residents and is significantly associated with age and number of medicines. Our findings suggest a modest decrease in residents using PIMs compared to previous studies. Nevertheless, prescribing quality in nursing home residents in both urban and rural areas is still of great concern.

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.

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.

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.

Polypharmacy and potentially inappropriate medications: a cross-sectional analysis among 451 nursing homes in France

PURPOSE

The quality of drug therapy is an important issue for nursing homes. This study aimed to assess the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a large sample of nursing home residents by using the data recorded during the preparation of pill dispensers.

METHODS

This is a cross-sectional study that included 451 nursing homes across France. Information about the medications received by the 30,702 residents (73.8% women) living in these nursing homes was extracted from the system that assists in the preparation of pill dispensers in pharmacies. The anonymized database included age, sex, and medications prescribed to residents, as well as nursing home characteristics (capacity, legal status). Factors associated with excessive polypharmacy (≥10 different drugs) and PIMs according to the Laroche list were studied using multilevel regression models.

RESULTS

The average number of drugs prescribed was 6.9 ± 3.3, and excessive polypharmacy concerned 21.1% of the residents (n = 6468). According to the Laroche list, 47.4% of residents (n = 14,547) received at least one PIM. Benzodiazepines (excessive doses, long-acting benzodiazepines, and combination of benzodiazepines) and anticholinergic medications (hydroxyzine, cyamemazine, alimemazine) accounted for a large part of PIMs. Individual characteristics (age, gender) influenced the risk of receiving PIMs whereas nursing home characteristics (capacity, legal status) influenced the risk of excessive polypharmacy.

CONCLUSIONS

This study shows that polypharmacy and PIMs remain highly prevalent among nursing home residents. Main PIMs concerned psychotropic and anticholinergic medications.

Drug-drug interactions and adverse drug reactions in polypharmacy among older adults: an integrative review

OBJECTIVE

to identify and summarize studies examining both drug-drug interactions (DDI) and adverse drug reactions (ADR) in older adults polymedicated.

METHODS

an integrative review of studies published from January 2008 to December 2013, according to inclusion and exclusion criteria, in MEDLINE and EMBASE electronic databases were performed.

RESULTS

forty-seven full-text studies including 14,624,492 older adults (≥ 60 years) were analyzed: 24 (51.1%) concerning ADR, 14 (29.8%) DDI, and 9 studies (19.1%) investigating both DDI and ADR. We found a variety of methodological designs. The reviewed studies reinforced that polypharmacy is a multifactorial process, and predictors and inappropriate prescribing are associated with negative health outcomes, as increasing the frequency and types of ADRs and DDIs involving different drug classes, moreover, some studies show the most successful interventions to optimize prescribing.

CONCLUSIONS

DDI and ADR among older adults continue to be a significant issue in the worldwide. The findings from the studies included in this integrative review, added to the previous reviews, can contribute to the improvement of advanced practices in geriatric nursing, to promote the safety of older patients in polypharmacy. However, more research is needed to elucidate gaps.

OBJETIVO

identificar e sintetizar estudos que examinam as interações medicamentosas (IM) e reações adversas a medicamentos (RAM) em idosos polimedicados.

MÉTODOS

revisão integrativa de estudos publicados de janeiro de 2008 a dezembro de 2013, de acordo com critérios de inclusão e exclusão, nas bases de dados eletrônicas MEDLINE e EMBASE.

RESULTADOS

foram analisados 47 estudos de texto completo, incluindo 14,624,492 idosos (≥ 60 anos): 24 (51,1%) sobre RAM, 14 (29,8%) sobre IM e 9 estudos (19,1%) que investigaram tanto IM como RAM. Encontramos uma variedade de desenhos metodológicos. Os estudos revisados reforçaram que a polifarmácia é um processo multifatorial, e os preditores e a prescrição inadequada estão associados a resultados negativos de saúde, como aumento da frequência e tipos de RAM e IM envolvendo diferentes classes de drogas, além disso, alguns estudos mostram as intervenções mais bem-sucedidas para otimizar a prescrição.

CONCLUSÕES

IM e RAM entre idosos continuam a ser um problema significativo no mundo todo. Os resultados dos estudos incluídos nesta revisão integrativa, adicionado às revisões anteriores, podem contribuir para a melhoria das práticas avançadas de enfermagem geriátrica, para promover a segurança dos pacientes idosos em polifarmácia. No entanto, são necessárias mais pesquisas para elucidar lacunas.

OBJETIVO

identificar y resumir los estudios que analizan tanto las interacciones medicamentosas (IM) como las reacciones adversas a medicamentos (RAM) en los adultos mayores polimedicados.

MÉTODOS

revisión integradora de estudios publicados entre enero de 2008 a diciembre de 2013, siguiendo criterios de inclusión y exclusión, en las bases de datos electrónicas MEDLINE y EMBASE.

RESULTADOS

cuarenta y siete estudios de texto completo incluidos fueron analizados incluyendo 14,624,492 adultos mayores (≥ 60 años), de ellos 24 (51,1%) en relación con RAM, 14 (29,9%) con IM y 9 estudios (19,1%) que investigaron tanto IM como RAM. Encontramos una gran variedad de diseños metodológicos. Los estudios revisados reforzaron el concepto que la polifarmacia es un proceso multifactorial, y los predictores y la prescripción inadecuada se asocian con resultados negativos para la salud tales como el aumento de la frecuencia y tipos de RAM y IM implicando diferentes clases de fármacos, además que algunos estudios muestran cuales son las intervenciones más exitosas para optimizar la prescripción.

CONCLUSIONES

IM y RAM siguen siendo un problema importante en el mundo entero entre los adultos mayores. Los resultados de los estudios incluidos en esta revisión integradora, sumado a las revisiones previas, pueden contribuir a la mejora de las prácticas avanzadas de enfermería geriátrica, para promover la seguridad de los pacientes de mayor edad en la polifarmacia. Sin embargo, se necesita más investigación para esclarecer los vacíos de conocimiento.

Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review

IMPORTANCE

As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided.

OBJECTIVES

To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents.

EVIDENCE REVIEW

We searched in PubMed and EMBASE databases (1990-2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.

FINDINGS

A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%-49.1%], increasing from 30.3% in studies conducted during 1990-1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5-55.5) than those reported in North America (26.8%, 95% CI 16.5-37.1) or in other countries (29.8%, 95% CI 19.3-40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use.

CONCLUSIONS AND RELEVANCE

This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.

Prevalence of Different Combinations of Antiepileptic Drugs and CNS Drugs in Elderly Home Care Service and Nursing Home Patients in Norway

Introduction. Antiepileptic drugs (AEDs) are used to treat different conditions in elderly patients and are among the drug classes most susceptible to be involved in drug-drug interactions (DDI). The aim of the study was to describe and compare use of AEDs between home care service and nursing home patients, as these patients are not included in nationwide databases of drug utilization. In the combined population, we investigate DDI of AEDs with other central nervous system- (CNS-) active drugs and DDIs involving AEDs in general. Materials and Methods. Point-prevalence study of Norwegian patients in home care services and nursing homes in 2009. At the patient level, we screened for different DDIs involving AEDs. Results. In total, 882 patients (7.8%) of 11,254 patients used AEDs and number of users did not differ between home care services and nursing homes (8.2% versus 7.7%). In the combined population, we identified 436 potential DDIs in 45% of the patients. Conclusions. In a large population of elderly, home care service and nursing home patients do not differ with respect to exposure of AEDs but use more AEDs as compared to the general population of similar age. The risk of DDIs with AEDs and other CNS-active drugs should be taken into consideration and individual clinical evaluations are assessed in this population.

Differences in quality of life in home-dwelling persons and nursing home residents with dementia - a cross-sectional study

BACKGROUND

Dementia often eventually leads to dependency on others and finally to residential care. However, in Norway about half of the dementia population lives at home, due to individual and political wishes. There is scarce and inconclusive knowledge of how living in a nursing home differs from living at home for persons with dementia (PWDs) with regard to their quality of life (QoL). The first aim of the study was therefore to compare QoL, cognitive and physical functions, social contacts, sleep patterns, physical activity levels, exposure to light, and medication of PWDs in nursing homes and home-dwelling PWDs, and whether living in nursing homes was associated with a lower QoL than living at home for PWDs. A second aim was to examine if possible differences between residencies in QoL were consistent over time.

METHODS

The cross-sectional study was based on baseline data from two RCT studies of PWDs. A total of 15 nursing homes with adapted units for PWDs and 23 adapted day care centres for home-dwelling PWDs recruited 78 and 115 participants respectively. Trained nurses scored sociodemographic data, level of dementia (on the Clinical Dementia Rating scale), amount of medication, and QoL (QUALID). Sleep patterns, physical activity levels, and light exposure were measured by actigraphy. A multiple regression analysis was used to test the association between residency and QoL. The association between residency and change in QoL over time was investigated by linear regression analysis of a subsample with follow-up data.

RESULTS

Home-dwelling PWDs showed significantly higher QoL than PWDs in nursing homes. This difference was maintained even after stratifying on the severity of dementia. Home-dwelling PWDs with moderate dementia showed significantly less use of walking aids, more social contact, higher levels of activity and exposure to daylight, and less use of psychotropic medications. The regression model explained 28 % of the variance in QoL in persons with moderate dementia. However, only residency contributed significantly in the model. Residency also significantly predicted negative change over time in QoL.

CONCLUSION

The study indicated that living at home as long as possible is not only desirable for economic or health political reasons but also is associated with higher QoL for persons with moderate dementia. More studies are needed to investigate how QoL could be increased for PWDs in nursing homes.

Analgesic prescribing in care home residents: how epidemiological studies may inform clinical practice

Care home residents are often frail with multiple comorbidities and cognitive impairment, most commonly caused by dementia. This population is under-represented in clinical trials, leading to a lack of valid and reliable evidence to inform clinicians' prescribing practice. This paper summarizes how epidemiological research conducted in similar populations can inform pain management by describing pain prevalence, risk factors, typical features and functional consequences. This evidence can help overcome the numerous barriers to optimal pain management in care home residents.

Multi-psychotropic drug prescription and the association to neuropsychiatric symptoms in three Norwegian nursing home cohorts between 2004 and 2011

BACKGROUND

Neuropsychiatric symptoms, such as affective symptoms, psychosis, agitation, and apathy are common among nursing home patients with and without dementia. Treatment with one or more psychotropic drug is often without explicit clinical indication, despite low treatment efficacy, and potential side effects. We aim to investigate the multi-psychotropic drug use to identify factors and patient characteristics associated with multi-use.

METHODS

We analysed three cohorts from 129 Norwegian nursing homes, collected between 2004 and 2011. Patients (N = 4739) were assessed with the Neuropsychiatric Inventory - Nursing Home version (NPI-NH), Clinical Dementia Rating scale, and Physical Self Maintenance Scale. We used ordinal logistic regression to analyse associations between psychotropics (antidepressants, antipsychotics, anxiolytics, hypnotics, and anti-dementia drugs), patient characteristics, and neuropsychiatric symptoms.

RESULTS

Patients used on average 6.6 drugs; 27 % used no psychotropics, 32 % one, and 41 % multiple psychotropic drugs (24 % two, 17 % ≥3). Thirty-nine percent were prescribed antidepressants, 30 % sedatives, 24 % anxiolytics, and 20 % antipsychotics. The total NPI-NH score was associated with multi-use (OR 1.02, 95 % CI 1.02-1.03), and increased from a mean of 13.5 (SD 16.3) for patients using none, to 25.5 (21.8) for patients using ≥3 psychotropics. Affective symptoms (depression and anxiety) were most strongly associated with multi-psychotropic drug use (OR 1.10, 95 % CI: 1.09-1.12). Female gender, independency in daily living, younger age, dementia, and many regular drugs were also associated with multi-use.

CONCLUSION

Forty-one percent were exposed to multi-psychotropic drug prescriptions. Contrary to current evidence and guidelines, there is an extensive use of multiple psychotropic drugs in patients with severe NPS and dementia.

Prevalence of statin-drug interactions in older people: a systematic review

PURPOSE

Statins are among the most frequently prescribed medications internationally. Older people are commonly prescribed multiple medications and are at an increased risk of drug-drug interactions, including statin-drug interactions. The aim of this study was to conduct a systematic review of current evidence on the prevalence of statin-drug interactions in older people.

METHODS

A systematic search of observational studies in Embase, Medline, and PubMed was conducted. Articles were included if they were published in English during the period July 2000-July 2014 and reported on the prevalence of statin-drug interactions in people over 65 years of age. Two reviewers independently assessed the articles for eligibility and extracted the data.

RESULTS

The search returned 1556 eligible articles. A total of 19 articles met the inclusion criteria. In studies (n = 7) that focused on statin users only, the prevalence of potential statin-drug interactions assessed using different measures ranged from 0.19 to 33.0 %. In studies that examined drug interactions across a population of both statin users and non-users (n = 12), the prevalence of potential statin-drug interactions ranged from 0.1 to 7.1 % (n = 8), and the prevalence of clinically relevant statin-drug interactions ranged from 1.5 to 4 % (n = 4).

CONCLUSIONS

Current published evidence suggests substantial variations in the prevalence of statin-drug interactions and their clinical relevance. Further studies are necessary to provide a better understanding of the prevalence of clinically significant statin-drug interactions, the medications most frequently contributing to statin-drug interactions, and impact on relevant clinical outcomes in older people.

Social Pharmacy and Clinical Pharmacy-Joining Forces

This commentary seeks to define the areas of social pharmacy and clinical pharmacy to uncover what they have in common and what still sets them apart. Common threats and challenges of the two areas are reviewed in order to understand the forces in play. Forces that still keep clinical and social pharmacy apart are university structures, research traditions, and the management of pharmacy services. There are key (but shrinking) differences between clinical and social pharmacy which entail the levels of study within pharmaceutical sciences, the location in which the research is carried out, the choice of research designs and methods, and the theoretical foundations. Common strengths and opportunities are important to know in order to join forces. Finding common ground can be developed in two areas: participating together in multi-disciplinary research, and uniting in a dialogue with internal and external key players in putting forth what is needed for the profession of pharmacy. At the end the question is posed, "What's in a name?" and we argue that it is important to emphasize what unifies the families of clinical pharmacy and social pharmacy for the benefit of both fields, pharmacy in general, and society at large.

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.

Drug treatment at the end of life: an epidemiologic study in nursing homes

OBJECTIVE

To examine drug treatment in nursing home patients at the end of life, and identify predictors of palliative drug therapy.

DESIGN

A historical cohort study.

SETTING

Three urban nursing homes in Norway.

SUBJECTS

All patients admitted from January 2008 and deceased before February 2013.

MAIN OUTCOME MEASURES

Drug prescriptions, diagnoses, and demographic data were collected from electronic patient records. Palliative end-of-life drug treatment was defined on the basis of indication, drug, and formulation.

RESULTS

524 patients were included, median (range) age at death 86 (19-104) years, 59% women. On the day of death, 99.4% of the study population had active prescriptions; 74.2% had palliative drugs either alone (26.9%) or concomitantly with curative/preventive drugs (47.3%). Palliative drugs were associated with nursing home, length of stay > 16 months (AOR 2.10, 95% CI 1.12-3.94), age (1.03, 1.005-1.05), and a diagnosis of cancer (2.12, 1.19-3.76). Most initiations of palliative drugs and withdrawals of curative/preventive drugs took place on the day of death.

CONCLUSION

Palliative drug therapy and drug therapy changes are common for nursing home patients on the last day of life. Improvements in end-of-life care in nursing homes imply addressing prognostication and earlier response to palliative needs.

Medication adherence and knowledge of older patients with and without multidose drug dispensing

OBJECTIVE

we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD users) with patients receiving manually dispensed drugs (non-MDD users).

METHODS

MDD users (≥ 65 years, ≥ 5 oral chronic drugs) were randomly selected from eight Dutch community pharmacies. Non-MDD users (≥ 5 oral chronic drugs) were matched on age and gender. Medication adherence was assessed by using the Medication Adherence Reporting Scale (MARS) and medication knowledge by asking the indication of drugs. Cognitive function was measured with Mini-Mental State Examination (MMSE) for a sub selection of patients.

RESULTS

the percentage of patients being adherent to all drugs was higher for MDD users (n = 119, 81%) compared with non-MDD users (n = 96, 58%, P < 0.001).The percentage of patients with adequate knowledge was lower for MDD users (40%) compared with non-MDD users (79%, P < 0.001). The differences in adherence were independent of knowledge and MMSE scores.

CONCLUSION

this study shows that older patients receiving their drugs via MDD reported a higher medication adherence compared with patients receiving manually dispensed drugs, despite a lower knowledge and lower cognitive function among patients receiving MDD.