Home and Community Care Digest
Methods: Survey data collected in 1996 from a representative sample of nursing homes and residents were analyzed (Medical Expenditure Panel Survey, Nursing Home Component). Residents over the age of 65 who had resided in a nursing home for at least three months were included, for a sample of 3,372. Information on all medications prescribed to residents over a period was recorded, including the drug name, form, strength, dosage, and administration procedures.
Using consensus guidelines developed in the US in the 1990s to help clinicians avoid prescribing potentially inappropriate medications to the elderly, the study examined three types of inappropriate prescriptions: inappropriate drug choice, excess dosage, and drug-disease interactions. Inappropriate drug choice includes medications that are contra-indicated for elderly patients. Excess dosage includes medications prescribed for a dose or duration that should not be exceeded among the elderly. Drugdisease interaction medications constitute those that should be avoided among elderly patients with specified co-morbid conditions. The study design controlled for a number of resident characteristics including various demographics, functional, and communicative abilities. Facility characteristics examined included facility type; nursing certification status; accreditation status; and RN-to-non-RN and RN-toresident ratios.
Finding: Approximately half of all residents received at least one potentially inappropriate medication during the study period. The vast majority were for inappropriate drug choice, placing up to one-third at risk of severe harm. The majority of potentially inappropriate prescriptions involved narcotics, antihistamines, and sedatives/hypnotics. Resident characteristics associated with potentially inappropriate prescriptions included having Medicaid coverage, having a mental disorder such as dementia, and taking many different drugs (more than 9). Being older and having communication problems appeared to reduce the risk of receiving an inappropriate prescription. Facility characteristics associated with potentially inappropriate prescriptions included not being accredited, being a large facility (200+ beds), and having less than one RN per 20 residents.
Conclusions: While many of the inappropriate prescriptions in this study would not likely have resulted in dangerous outcomes for patients, they also lacked efficacy compared to alternative agents. The authors concluded that polypharmacy (taking more than 9 drugs) is of serious concern among the elderly due to their increased susceptibility to side effects and toxicity. They also echoed concern for ensuring adequate nurse staffing levels to ensure quality of care.
Readers are cautioned that the authors' findings relate to potentially inappropriate prescriptions. Specific clinical situations may have warranted use of a contra-indicated drug or excess dosage. Similar to many models designed for screening purposes, the only way to assess actual appropriateness would be to conduct full medical chart audits and/or interview physicians about prescribing practises.
Reference: Lau, Denys T., Kasper, Judith D. , Potter, D. E. B., Lyles, Alan. "Potentially Inappropriate Medication Prescriptions among Elderly Nursing Home Residents: Their Scope and Associated Resident and Facility Characteristics". Health Services Research, 2004; 39(5), 1257-1276.
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