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      Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials

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          Abstract

          Background

          Studies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes.

          Methods

          We searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary).

          Results

          Due to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews.

          Conclusions

          Interventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes.

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          Most cited references 29

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          Appropriate prescribing in elderly people: how well can it be measured and optimised?

          Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.
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            Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine.

            Increasing attention is being paid to inappropriate medication use in nursing homes. However, criteria defining the appropriate or inappropriate use of medication in this setting are not readily available and are not uniform. We used a two-round survey, based on Delphi methods, with 13 nationally recognized experts to reach consensus on explicit criteria defining the inappropriate use of medications in a nursing home population. The criteria were designed to use pharmacy data with minimal additional clinical data so that they could be applied to chart review or computerized data sets. The 30 factors agreed on by this method identify inappropriate use of such commonly used categories of medications as sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, histamine2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, gastrointestinal antispasmodics, and antiemetics. These criteria may be useful for quality assurance review, health services research, and clinical practice guidelines. The method used to establish these criteria can be used to update and expand the guidelines in the future.
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              The prevalence of psychiatric symptoms and behavioural disturbances and the use of psychotropic drugs in Norwegian nursing homes.

              Psychiatric and behavioural symptoms in dementia are associated with a range of negative outcomes, including institutional placement and the widespread use of psychotropic drugs in spite of limited evidence for their efficacy. To determine the prevalence of psychiatric and behavioural symptoms and the pattern of psychotropic drug prescription in patients with various degrees of dementia. A sample of 1,163 non-selected nursing home patients were assessed by means of the Neuropsychiatric Inventory, the Clinical Dementia Rating scale and Lawton's activities of daily living scale. In addition, information was collected from the patients' records. Dementia was found in 81% of the patients and 72% of them had clinically significant psychiatric and behavioural symptoms. The frequencies of symptoms increased with the severity of the dementia. Psychotropic medication was being prescribed to 75% of patients with dementia. There was a significant relationship between the type of drug and the symptom for which it had been dispensed. Psychiatric and behavioural symptoms are frequent in nursing homes and the rate increases with the progression of the dementia. Systematic programmes are needed for disseminating skills and providing guidance regarding the evaluation and treatment of these symptoms in nursing homes.
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                Author and article information

                Journal
                BMC Geriatr
                BMC Geriatrics
                BioMed Central
                1471-2318
                2011
                17 April 2011
                : 11
                : 16
                Affiliations
                [1 ]Norwegian Knowledge Centre for the Health Services, PO Box 7004 St. Olavsplass, 0130 Oslo, Norway
                [2 ]Institute of Medical Genetics, University of Oslo, Oslo, Norway
                [3 ]Section for Medical Ethics, University of Oslo, Oslo, Norway
                Article
                1471-2318-11-16
                10.1186/1471-2318-11-16
                3108292
                21496345
                f1502f85-8f3c-4570-b58b-fa21f4f2d00d
                Copyright ©2011 Forsetlund et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Geriatric medicine

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