Drug prescribing in residential homes for elderly people in the United Kingdom

Drugs prescribed for people aged 85 and over living in their own homes in an area of inner London

This study investigated drugs prescribed for people aged 85 and over and living in their own homes in an area of inner London, and explored associations between drug use and other factors including use of general medical practitioner (GP) services, mobility, mortality and self-perceived health. Data were collected by structured interview of 630 participants in their own homes, with a follow-up interview of survivors three years later.

Respondents were taking a mean of 2.2 different drugs; 23 per cent were taking no prescribed drugs and 11 per cent were taking five or more. Of those on two or more drugs, 45 per cent were taking potentially interacting combinations. Although respondents on more drugs were more likely to have seen their GP recently, some on many different drugs had not. Nearly 15 per cent reported some sort of difficulty with their medication.

There was no significant difference between the mean number of drugs prescribed, at the begining of the study, for survivors and for non-survivors. However, there was an inverse relationship between prescribed medication and mobility, self-perceived health and satisfaction with other aspects of life. Very elderly people living in their own homes, like those in institutions, will frequently be on drug regimens that should be monitored regularly for drug-related problems. Because of rising numbers, the provision of a cost-effective service would require the identification of those most likely to experience problems with their medication.

Use of medicines that influence falls or fractures in a residential home setting

OBJECTIVE

To study the pattern of use of medicines that may contribute to, or protect against, falls and fractures in the setting of a UK residential home population, and to compare the results with a similar study conducted in 2001.

SETTING AND METHOD

A cross-sectional survey was conducted in 2003 in 18 residential homes. A trained community pharmacist visited the homes to retrieve information about use of medicines whilst demographic details were provided by the residential home staff.

MAIN OUTCOME MEASURE

The proportion of patients who were prescribed medicines with a potential positive benefit in preventing fractures, and medicines that may cause elderly people to fall.

RESULTS

The study population consisted of 581 residents. Compared to the 2001 study, the use of both calcium and vitamin D had increased significantly (8.3% versus 2.1%). Although, the overall prescribing of psychotropics in 2003 was relatively low, there was a trend for increased prescribing of these medicines which have been identified as risk factors for falling.

CONCLUSION

In a residential home setting in the UK, the use of psychotropic drugs is not uncommon, whereas there is limited use of drugs that have the potential for preventing morbidity associated with falls.

Diuretic therapy in elderly heart failure patients with and without left ventricular systolic dysfunction

Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. Studies on diuretic withdrawal in elderly patients with heart failure are discussed, with emphasis on issues involved in decision making such as diuretic dose reduction and withdrawal in elderly patients and factors that have been established to predict successful withdrawal. Existing guidelines on the prescription of diuretics in elderly patients with heart failure with normal and decreased left ventricular systolic function and in those with diastolic heart failure are also discussed. By reducing intravascular volume, diuretics may further impair ventricular diastolic filling in patients with diastolic heart failure and thus reduce stroke volume. Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.

Drug therapy and the older person: role of the pharmacist

Older people in the UK receive a disproportionate amount of medication. They comprise 18% of the population but receive 45% of all prescription items. Not surprisingly they experience drug-related illnesses - in 1980, 1 in 10 admissions to acute geriatric units were wholly or partly due to adverse drug reactions. Drugs which should be used with particular care or even avoided in older people include benzodiazepines, warfarin, digoxin, aminoglycosides, tricylic antidepressants, antipsychotics and long-acting oral hypoglycaemic agents. Pharmacists can promote safer prescribing practices by advising both patients and doctors. The community pharmacist can assist in drug compliance by providing patients with additional information about individual drugs, identifying potential adverse drug reactions and interactions, supplying appropriate drug containers or compliance aids, and even arranging home visits for patients unable to visit the pharmacist. Some community pharmacists provide pharmaceutical advice and services to residential and nursing homes. Pharmacists' advice to doctors can include one to one discussions in either primary or secondary care, assisting in medication review, providing information to prescribing committees, compiling drug formularies, assisting in auditing of prescribing practices and organising disposal of unwanted medicines and poisons campaigns.

Self-reported sleep disturbance among African-American elderly: the effects of depression, health status, exercise, and social support

The prevalence and correlates of self-reported difficulties in initiating and maintaining sleep were investigated for a sample of 998 Black elderly. In terms of prevalence, only 68.3 percent of this sample had no trouble falling asleep. Over 14.5 percent of men and 23.6 percent of women participants in this study reported sleep latencies exceeding thirty minutes. Almost 13 percent reported getting less than four hours of sleep at night. Moreover, 14.5 percent of participants wake up at least three times during a typical night's sleep other than to use the bathroom and 45.3 percent said when they wake up during the night, they remain awake at least thirty minutes before falling back to sleep. Compared to men, women reported longer sleep latency, waking up more frequently at night, and were more likely to visit a health practitioner for sleeping problems. Multivariate analysis indicates that self-reported sleep problems were significantly greater among Black elderly who were women, with a higher level of depression/anxiety, those with a higher number of chronic illnesses, those who did not exercise, and those who reported lower levels of emotional social support.

Promoting rational prescribing: an international perspective

Irrational prescribing is a global problem. Rational prescribing cannot be defined without a method of measurement and a reference standard. The former is now available but the latter needs further development. Proven effective interventions to promote rational prescribing in developed countries are treatment protocols based on wide consultation and consensus, properly introduced and with a possibility of feedback; face-to-face education focussed on a particular prescribing problem in selected individuals; structured order forms; and focussed educational campaigns. Essential drugs lists are probably effective when based on consensus and used within a comprehensive educational programme. Printed materials alone are not effective. In most cases the usefulness of such strategies in developing countries has not been proven and should be studied. Medical education in clinical pharmacology and pharmacotherapy should be based on the practical needs of future prescribes, should include the principles of rational therapeutics and problem solving, and should immunize the students against the influences they are likely to encounter in their professional life, such as patient pressure, drug promotion and irrational prescribing by peers. Within the scope of a national formulary, specialist departments in teaching hospitals should define prescribing policies as the basis for prescribing, teaching, examinations and medical audit.