Determinants of drug utilization in an elderly population in North and West Belfast

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We included original research articles in English, published and unpublished, that included number of participants, country and year(s) of data collection, and prescription of analgesics (analgesics not otherwise specified, opioids,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.

Use of medicines in nursing homes for older people

The National Health Service (NHS) spent £10 billion (40%) of its total budget on people aged 65 and over in 1998/1999. The profile of the health and social care of older people has been raised recently by the publication of the National Service Framework (NSF) for Older People (Department of Health, 2001). The NSF contains standards that older people can expect when they receive health and social care (Box 1). The document also discusses in detail medication management issues in older people. Its two aims in this area are to ensure that older people gain the maximum benefit from their medication in order to maintain or improve quality and duration of life, and do not suffer unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicines.

Factors influencing prescription of CNS medications in different elderly populations

Factors influencing the use of neuroleptic and other CNS-acting medications ('antidepressants' and 'hypnotics/anxiolytics') were examined in different elderly populations (> 65 years): long-stay care hospital subjects (n = 381), nursing home subjects (n = 1247), private residential home subjects (n = 321), statutory residential home subjects (n = 525), old age psychiatry facility subjects (n = 48), community dwellers (n = 97), in different geographical areas (urban n = 1223 and rural n = 1396). Neuroleptics were prescribed in 28% of the individuals, hypnotics/anxiolytics in 33% and antidepressants in 12%. Prescription of neuroleptics was significantly predicted by institutional placement (other than long-stay care hospital facility), lower cognitive function and rural geographical area. Age greater than 75 years and lower functional score (lower dependency) significantly decreased the likelihood of receipt of neuroleptics. Antidepressant use was significantly less likely in male subjects, patients with cognitive impairment and patients greater than 85 years. Institutional placement (other than long-stay care hospital facility and old age psychiatry facility) and rural locality predicted increased likelihood of antidepressant prescription. Institutional placement (other than long-stay care hospital facility) and geographical (rural) location were significant independent predictors of hypnotic/anxiolytic use. Prescription of hypnotic/anxiolytic drug class was significantly less likely in those individuals with lower cognitive status. In this representative elderly cohort, patient characteristics: age, sex, cognitive score, functional score, place of residence and geographical location markedly influenced drug utilisation.

Factors associated with antipsychotic drug use in residential care: changes between 1990 and 1997

BACKGROUND

There is limited information from population-based studies about the rates of antipsychotic drug use in residential and nursing homes in the UK, and associated adverse effects.

OBJECTIVES

To examine the relationship between antipsychotic drug prescription, cognitive impairment and disturbed behaviour in this population over time, and to identify possible adverse consequences of their use.

METHODS

Two censuses of the residential and nursing home population aged 65 years and older in Leicestershire, carried out in 1990 and 1997. A questionnaire was completed by care staff for each resident, including information on demographic details, physical functioning, cognitive impairment, behaviour disturbance, urinary incontinence, falls, mobility, daytime alertness (1997 only), and prescribed medication.

RESULTS

The prevalence of staff-rated moderate or severe cognitive impairment increased from 38.0% in 1990 to 44.3% in 1997. The prevalence of staff-rated disturbed behaviour decreased from 11.8% in 1990 to 10.4% in 1997. Cognitive impairment was strongly associated with disturbed behaviour in both years. The prescription rate of antipsychotic drugs increased from 17.8% in 1990 to 21.9% in 1997. There was no significant change in the prescription rates to cognitively impaired residents between 1990 and 1997 (29.1% vs 30.7%). In residents without cognitive impairment, the prescription rate rose from 10.7% to 15.0%. Antipsychotic drug use was independently associated with: younger age, type of home (1990 only), cognitive impairment, offensive behaviour, lower ADL dependency (1990 only), antidepressant drug use, reported urinary incontinence and greater mobility. There was no association with increased liability to falls or drowsiness. In the cognitively unimpaired residents, antipsychotic drug use was not associated with urinary incontinence in 1997, and there was an association with increased drowsiness in that year.

CONCLUSIONS

The only significant change in antipsychotic drug prescribing practice in this population over the period covered by this study was an increase in the prescription rate in cognitively unimpaired residents in 1997, possibly related to mental hospital closures. Urinary incontinence was the principal adverse effect of antipsychotic drug use observed in the group as a whole. Changes in the adverse effects associated with antipsychotic drug use may be a function of the increasing frailty.

Construction of the Korea Elderly Pharmacoepidemiologic Cohort: drug utilization review of cephalosporins in geriatric inpatients

We performed a cohort-based pharmacoepidemiologic study in order to evaluate the pattern of cephalosporin prescriptions in elderly inpatients in Korea. The Korea Elderly Pharmacoepidemiologic Cohort was composed of a geriatric population of beneficiaries of the Korea Medical Insurance Corporation residing in Busan in 1993. The cohort consisted of 23,649 members, comprising 15,221 women (64.4%) and 8428 men (35.6%). The study population for drug utilization review consisted of those cohort members who were admitted into hospitals during the period January 1993 through December 1994. The number of hospitalized patients was 4262, comprising 2631 women (61.7%) and 1681 men (38.3%). The trend of cephalosporin prescriptions over the 2-year period showed that the use of second and third generation cephalosporins increased relative to the use of first generation. The use of cephalosporins combined with other antibiotics was found to occur in 22.8% aminoglycosides (76.7%) and quinolones (17.1%) being the most common antibiotics combined with cephalosporins. Our result demonstrates an increase in the prescription of second and third generation cephalosporins in Korea, which has implications not only for the elderly population but also for the total population because of the impact on health care costs and the potential for the emergence of antimicrobial resistance.

Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments

BACKGROUND

Behavioural and psychological symptoms in dementia (BPSD) are a common reason for placement in long term care and are often associated with indiscriminate prescription of psychotropic medication.

AIMS

To determine the prevalence of BPSD in care environments, their relationship with severity of dementia and the pattern of psychotropic medication.

METHODS

Two hundred and thirty-one elderly residents (39% living in social care facilities and 61% in nursing home care) were assessed using a range of standardised psychiatric schedules. Additional information about the residents and medication was obtained from professional carers.

RESULTS

Overall 90% of residents had dementia, 79% of whom had clinically significant BPSD with 58% receiving psychotropic medication. There was no difference in the prevalence of BPSD between social and nursing care. Depression was most common in people with mild dementia, whilst delusions arose most frequently in those with moderate dementia and aberrant motor behaviour had a high prevalence in people with severe dementia.

CONCLUSION

BPSD are common in elderly people with dementia living in care environments. More rigorous guidelines are needed pertaining to the prescription and monitoring of medication and the need to disseminate skills regarding psychosocial management approaches to care staff.

Differential pharmacokinetics of digoxin in elderly patients

Digoxin remains one of the most commonly prescribed of all cardiac medications. The main indications for digoxin usage include atrial fibrillation and heart failure; both these conditions are more prevalent in older patients. Given the aging population and the increasing incidence of heart failure we would expect prescribing of digoxin to remain as frequent or to even increase in older patients. Older patients are also more likely to develop toxicity and diagnosis of digoxin toxicity can be difficult in this group. Numerous components contribute to the development of toxicity in older patients, ranging from aging-related changes in renal function or body mass to polypharmacy and possible interactions with digoxin. It is therefore important to understand how the pharmacokinetics of digoxin may be altered in the older population. Application of basic pharmacological principles may be helpful in anticipating these problems. This review describes the pharmacokinetics of digoxin, the changes in pharmacokinetics with increasing age and how concomitant disease states or drug interactions may affect the pharmacokinetics of digoxin. Greater knowledge about the causes and prevention of digoxin toxicity should further reduce the morbidity and mortality arising from digoxin toxicity, especially in the elderly population.

Medication use in nursing homes for elderly people

Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions for the treatment of behavioural disturbances have been significantly reduced and non-pharmacists have a role to play in the appropriate management of medicines in elderly residents; they can improve patient care and be cost-effective. Identification of methods by which to improve awareness of inappropriate medication prescription and to avoid certain types of drugs is required. This review critically evaluates medication use in this population with specific reference to psychotropics and aims to raise awareness of the issue.