Medication-Related Acute Care Admission and Inappropriate Polypharmacy of Nursing Home Residents

ObjectivesTo evaluate the prevalence of medication-related admissions (MRAs) and their association with potentially inappropriate medications (PIMs) used by nursing home residents admitted to the geriatric center of a tertiary hospital.DesignCross-sectional study.Setting and ParticipantsOlder patients admitted from nursing homes to the geriatric center of the Seoul National University Bundang Hospital who had undergone comprehensive geriatric assessment from January 1, 2016, to December 31, 2020.MethodsMRAs were determined and verified using a previously described MRA adjudication guide. The PIMs in the preadmission medication lists were identified according to each of the following criteria (as well as the combined criteria), the Beers, NORGEP-NH, STOPP/START-NH, and STOPPFrail criteria. Medication use factors associated with MRAs were analyzed using multivariate logistic regression.ResultsAmong the 304 acute care admissions, 32.2% were MRAs. The main cause of MRAs was acute kidney injury related with use of renin-angiotensin system inhibitors. Approximately 81% of the patients used at least 1 PIM according to the combined criteria. The use of 1 or more PIMs, renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, and benzodiazepines was significantly associated with MRAs. The combined criteria were able to predict MRAs better than the individual criteria.Conclusions and ImplicationsApproximately one-third of acute admissions of nursing home residents may be MRAs. Interventions for the optimal use of medication among nursing home residents are needed.     

Interprofessional Medication Assessment has Effects on the Quality of Medication Among Home Care Patients: Randomized Controlled Intervention Study

ObjectiveMultimorbidity and complex medications increase the risk of medication-related problems, especially in vulnerable home care patients. The objective of this study was to examine whether interprofessional medication assessment has an effect on medication quality among home care patients.DesignThe FIMA (Finnish Interprofessional Medication Assessment) study was a randomized, controlled study comparing physician-led interprofessional medication assessment and usual care.Setting and ParticipantsThe FIMA study was conducted in home care settings in Finland. The participants were ≥65-year-old home care patients with ≥6 drugs daily, dizziness, orthostatic hypotension, or a recent fall.MethodsPrimary outcome measures over the 6-month follow-up were number of drugs, drug-drug-interactions, medication-related risk loads, and use of potentially inappropriate medications (PIMs) examined by SFINX, RENBASE, PHARAO, and Meds75+ databases. The databases classified information as follows: A (no known pharmacologic or clinical basis for an increased risk), B (evidence not available/uncertain), C (moderately increased risk which may have clinical relevance), and D (high risk, best to avoid). Logistic regression adjusted for age, sex, and the baseline level of the outcome measure served as statistical methods.ResultsThe mean number of all drugs for home care patients (n = 512) was 15. The odds of drug-induced impairment of renal function (RENBASE D, P = .020) and medication-related risk loads for bleeding (PHARAO D, P = .001), anticholinergic effects (PHARAO D, P = .009), and constipation (PHARAO D, P = .003) decreased significantly in the intervention group compared with usual care. The intervention also reduced the odds of using PIMs (Meds75+ D, P = .005). There were no significant changes in drug-drug-interactions or number of drugs.Conclusions and ImplicationsFIMA intervention improved the medication quality of home care patients. Risks for renal failure, anticholinergic effects, bleeding, constipation, and the use of PIMs were reduced significantly.     

Reducing Cost by Reducing Polypharmacy: The Polypharmacy Outcomes Project

ObjectiveTo examine the effect of intervention by geriatric medicine fellows and a geriatrician on medication cost among long term care residents with polypharmacy.DesignInterventional study.SettingA single hospital-affiliated long term care facility.ParticipantsLong term care residents with polypharmacy, defined as being on 9 or more medications.InterventionMedication lists of all nursing home residents were reviewed in October 2007 by geriatric medicine fellows and a faculty geriatrician using the 2003 Beers Criteria and the Epocrates online drug-drug interaction program. Recommendations for each resident were prepared and discussed directly with their primary physicians, who made the final decisions regarding medication discontinuation or taper.MeasurementsMean monthly costs (derived from current retail prices) for overall as well as scheduled and pro re nata (PRN) medications were compared before and after the intervention. Estimated reduction in nursing administration time and cost were calculated based on published literature on medication administration time and nursing labor costs.ResultsSeventy-four (46.3%) of 160 residents were on 9 or more medications. Four residents died or were discharged before the intervention, leaving a final sample of 70 residents for the intervention. After the intervention, mean monthly medication costs per resident significantly decreased; overall medications, from $874.27 to $843.56 (P < .0001); scheduled medications, from $814.05 to $801.14 (P = .007); PRN medications, from $60.22 to $42.43 (P < .0001). Gastrointestinal medications demonstrated the highest cost savings of all medication categories (eg, promethazine and proton pump inhibitors), followed by central nervous system–active medications (including benzodiazepines and fluoxetine), then analgesics and diabetes medications.ConclusionThis polypharmacy reduction intervention by physicians used readily available tools, demonstrated a significant decrease in medication-related costs, and provided training in the core competencies of practice-based learning and improvement and systems-based practice to geriatric medicine fellows in long term care.     

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

ObjectiveTo investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).DesignSystematic review.Setting and ParticipantsResidents with T2DM and aged ≥60 years living in LTCFs.MeasuresArticles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.ResultsFifteen studies were included. Prevalence of potential overtreatment (5%–86%, n = 15 studies) and undertreatment (1.4%–35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%–74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%–14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.Conclusions and ImplicationsThe prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.     

Impact of a Multifaceted,Pharmacist-Led Intervention on Psychotropic Medication Use for Residents of Aged Care Facilities: A Parallel Cluster Randomized Controlled Trial

ObjectiveTo investigate the effect of a multifaceted intervention on reduction in psychotropic medication use, falls, agitation, emergency department (ED) visits, and hospitalization in residential aged care facilities (RACFs).DesignParallel cluster randomized controlled trial. RACFs were randomized to the multifaceted intervention, Medication Management Consultancy (MMC) (n = 5) or control (n = 6) groups. MMC, comprising online education, medication audits, and resources on psychotropic medications and nonpharmacological strategies, educates RACF staff to help reduce the use of antipsychotic medication among RACF residents through a comprehensive understanding of behavioral and psychological symptoms of dementia.Setting and ParticipantsA total of 439 residents from 11 RACFs in Western Australia.MethodsThe primary outcome was change in monthly total equivalent doses (mg) of antipsychotic, antidepressant, and benzodiazepine medication use over 12 months compared with a control group. Clinical outcomes included falls, restraints, agitation, ED visits, hospitalization, and knowledge of psychotropic medications among RACF staff at pre- and postintervention were measured. The duration of the intervention was 3 to 6 months. Data were collected at T0 (baseline), T1 (6 months), and T2 (12 months).ResultsThe MMC group showed a significant 44% reduction in antipsychotic use compared with the control group at T1 (incidence rate ratios [IRR], 0.56; 95% CI, 0.32–0.99; P = .048) and also significantly reduced the number of ED visits at T1 (IRR, 0.15; 95% CI, 0.06–0.35; P < .0005) and T2 (IRR, 0.04; 95% CI, 0.01–0.13; P < .0005). Staff knowledge about psychotropic medications improved significantly from T0 to T1 and from T0 to T2. Reduction in antidepressant use at either T1 or T2 and benzodiazepine use, compared with control, at T1 and T2 were not significantly different. Other clinical outcomes showed limited impact.Conclusion and ImplicationsThe MMC intervention reduced the use of antipsychotics and ED visits and improved staff knowledge in RACFs, which impacts the safety and quality of aged care in Australia.     

Cluster-Controlled Trial of an Intervention to Improve Prescribing in Nursing Homes Study

ObjectivesTo investigate the impact of a complex multifaceted intervention on the appropriateness of prescribing for Belgian nursing home (NH) residents.DesignA multicenter, nonblinded, cluster-randomized controlled trial, with randomization at the NH level, was set up [Cluster-Controlled Trial of an Intervention to Improve Prescribing in Nursing Homes (COME-ON) Study]. The complex intervention consisted of repeated interdisciplinary case conferences (ICCs) involving the general practitioner, pharmacist, and nurse, aimed at performing a medication review for each NH resident included. The ICCs were supported by a blended training program and local interdisciplinary meetings (discussion of the appropriate use of specific medication classes at the NH level). Control NHs delivered usual care. (isrctn.com: ISRCTN66138978).Setting and participantsBelgian NHs with at least 35 NH residents were eligible to participate. Eligible residents were those aged 65 years or over, not receiving palliative care, and being treated by a participating general practitioner.MeasuresThe primary outcome measure related to appropriateness of prescribing at resident level and was considered successful when at least 1 potentially inappropriate medication (PIM) or potential prescribing omission (PPO) present at baseline had been solved at the end of study and when there were no new PIMs or PPOs at the end of study compared with baseline. Secondary outcomes included clinical outcomes, medication use, criterion-specific prevalence of PIMs and PPOs, and ICC outcomes.ResultsIn total, 54 NHs (24 intervention; 30 control) and 1804 NH residents (847 intervention; 957 control) participated. Using a 3-level mixed-effects model accounting for data clustering, a significant effect in favor of the intervention was observed (odds ratio 1.479 [95% confidence interval 1.062-2.059, P = .021]). There was no significant difference between groups for most clinical outcomes. The median number of medications did not change over time in either group.Conclusions and implicationsThe complex multifaceted intervention tested in the COME-ON study successfully improved appropriateness of prescribing in NHs.     

Factors Associated with Perception of the Quality of Physicians' End-of-life Communication in Long-Term Care Facilities: PACE Cross-Sectional Study

ObjectiveTo examine factors associated with perceived quality of communication with physicians by relatives of dying residents of long-term care facilities (LTCFs).DesignA cross-sectional retrospective study in a representative sample of LTCFs conducted in 2015. In each LTCF, deaths of residents during the 3 months before the researcher's visit were reported. Structured questionnaires were sent to the identified relatives of deceased residents.Settings and participantsA total of 736 relatives of deceased residents in 210 LTCFs (in Belgium, Finland, Italy, the Netherlands, and Poland).MethodsThe Family Perception of Physician-Family Communication scale (FPPFC) was used to assess the quality of end-of-life (EOL) communication with physicians as perceived by relatives. We applied multilevel linear regression models to find factors associated with the FPPFC score.ResultsThe quality of EOL communication with physicians was perceived by relatives as higher when the relative spent more than 14 hours with the resident in the last week of the resident's life (b = 0.205; P = .044), and when the treating physician visited the resident at least 3 times in the last week of the resident's life (b = 0.286; P = .002) or provided the resident with palliative care (b = 0.223; P = .003). Relatives with higher emotional burden perceived the quality of EOL communication with physicians as lower (b = −0.060; P < .001). These results had been adjusted to countries and LTCF types with physicians employed on-site or off-site of the facility.ConclusionThe quality of EOL communication with physicians, as perceived by relatives of dying LTCF residents, is associated with the number of physician visits and amount of time spent by the relative with the resident in the last week of the resident's life, and relatives' emotional burden.ImplicationsLTCF managers should organize care for dying residents in a way that enables frequent interactions between physicians and relatives, and emotional support to relatives to improve their satisfaction with EOL communication.     

Polypharmacy and Possible Drug-Drug Interactions Among Diabetic Patients Receiving Home Health Care Services

SUMMARY

Objectives: In this study, we examined the drug regimens of diabetic patients receiving home health care services to measure the prevalence of polypharmacy and to assess the likelihood of drug-drug interactions, a consequence of polypharmacy.

Design: The sample consisted of 139 diabetic patients who received home health care services from one home health agency in a large mid-Atlantic city. The data were collected from March 1, 1998 to September 30, 1999. Information regarding medications was collected by the home health nurse during the initial home visit and was recorded on the medication sheet in the patient's clinical record. Any changes in medications were noted on the medication sheets.

Methods: We identified all systemic medications prescribed for 139 home health patients. To assess drug-drug interactions, we used Micromedex® formulary DRUG-REAX® System.

Outcomes: We calculated (1) the number of systemic medications taken, and (2) the number of possible severe, moderate, and mild drug-drug interactions.

Results: We found that the average number of medications taken was 8.9 (SD 3.4) prescribed medications per day. Our results show that 38.8% of the patients in the sample could potentially be subject to at least one severe drug-drug interaction. Nearly all of the patients (92.8%) were at risk for moderate drug-drug interactions, and 70.5% could have mild drug-drug interactions.

Conclusion: We conclude that polypharmacy is a concern for home health care patients with diabetes and the potential for drug-drug interactions is substantial. Our results indicate that the drug regimens of diabetic patients should be monitored systematically to avoid adverse events such as hospitalization. Family practitioners and home health care takers are in a unique position to identify polypharmacy and to modify drug regimens.     

Quality of Life and Pain Medication Use in Persons With Advanced Dementia Living in Long-Term Care Facilities

ObjectivesIn residents with dementia living in a long-term care facility (LTCF), un(der)treated pain may trigger behavioral disturbances, mood syndromes, and deterioration of physical functioning and self-maintenance. Because these factors can have considerable impact on the quality of life (QoL), this study aimed to (1) compare characteristics of persons with advanced dementia living in LTCFs with and without pain medication; (2) compare QoL in these persons with and without pain, stratified by type of pain medication use; and (3) explore associations between the use of paracetamol and QoL in persons with advanced dementia living in LTCFs.Design and settingThis study analyzed baseline data from the Communication, Systematic Assessment and Treatment of Pain, Medication Review, Occupational Therapy, and Safety Study; a multicenter, cluster-randomized effectiveness-implementation clinical hybrid trial in 67 Norwegian LTCF clusters.ParticipantsIn total, 407 LTCF residents (rural and urban areas) aged ≥65 years, with Functional Assessment Staging scores of 5–7 (ie, moderate to advanced dementia).Main outcome measureQoL as assessed by the 6 QUALIDEM (validated questionnaire to measure QoL in persons with dementia living in LTCF) domains applicable to persons with moderate to severe dementia. The association between QoL and paracetamol was estimated using linear mixed-effect models, adjusting for confounding variables.Results62.0% used pain medication (paracetamol, opioids, or both). QoL was lower in residents using pain medication, compared with those without pain medication [mean QUALIDEM score 68.8 (standard deviation 17.4 vs) 75.5 (standard deviation 14.6), respectively, P < .001). Multilevel analysis showed that paracetamol use was not associated with QoL.Conclusions and ImplicationsPersons with advanced dementia living in LTCF using pain medication have a lower QoL compared with those not using pain medication. These results are of key importance for the clinician because they stress the need for regular medication review and pain management. When measured cross-sectionally, use of paracetamol is not associated with increased QoL.     

Medication Reconciliation in Continuum of Care Transitions: A Moving Target

ObjectiveTo study medication discrepancies in clinical transitions across a large health care system.DesignRandomized chart review of electronic medical records and paper chart medication reconciliation lists across 3 transitions of care.Settings and participantsSubacute patient medication records were reviewed through 3 transition care points at a large health care system, including hospital admission to discharge (time I), hospital discharge to skilled nursing facility (SNF; time II) and SNF admission to discharge home or long term care (LTC; time III).MeasurementsMedication discrepancies were identified and categorized by the principal investigator and a pharmacist. Discrepancies were defined as any unexplained documented change in the patients' medication lists between sites and unintentional discrepancies were defined as any omission, duplication, or failure to change back to original regimen when indicated.ResultsWe reviewed 1696 medications in the 132 transition records of 44 patients, identifying 1002 discrepancies. Average age was 71.4 years and 68% were female. Median hospital stay was 5.5 days and 14.5 SNF days. Total medications at hospital admission, hospital discharge, SNF admission, and SNF discharge were 284, 472, 555, and 392, respectively. Total medication discrepancies were 357 (time I), 315 (time II), and 330 (time III). All patients experienced discrepancies and 86% had at least 1 unintentional discrepancy. The average number of medications per patient increased at time I from 6.5 to 10.7 (P < .001), increased at time II from 10.7 to 12.6 (P <.0174), and decreased at time III from 12.6 to 8.9 (P < .001). Patients, on average, had 8.1, 7.2, and 7.6 medication discrepancies at times I, II, and III, respectively. Surgical patients had more discrepancies than medical at times I and III (8.94 vs 5.3, P < .019; 8.0 vs 5.8, P < .028). In the unintentional group, cardiovascular drugs represented the highest number of discrepancies (26%).ConclusionThis study is the first to follow medication changes throughout 3 transition care points in a large health care system and to demonstrate the widespread prevalence of medication discrepancies at all points. Our findings are consistent with previously published results, which all focused on single site transitions. Outcomes of the current reconciliation process need to be revisited to insure safe delivery of care to the complex geriatric patient as they transition through health care systems.     

Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities

ObjectiveTo compare 30-day mortality in long-term care facility (LTCF) residents with and without COVID-19 and to investigate the impact of 31 potential risk factors for mortality in COVID-19 cases.DesignRetrospective cohort study.Setting and ParticipantsAll residents of LTCFs registered in Senior Alert, a Swedish national database of health examinations in older adults, during 2019-2020.MethodsWe selected residents with confirmed COVID-19 until September 15, 2020, along with time-dependent propensity score–matched controls without COVID-19. Exposures were COVID-19, age, sex, comorbidities, medications, and other patient characteristics. The outcome was all-cause 30-day mortality.ResultsA total of 3731 residents (median age 87 years, 64.5% female) with COVID-19 were matched to 3731 controls without COVID-19. Thirty-day mortality was 39.9% in COVID-19 cases and 5.7% in controls [relative risk 7.05, 95% confidence interval (CI) 6.10-8.14]. In COVID-19 cases, the odds ratio (OR) for 30-day mortality was 2.44 (95% CI 1.57-3.81) in cases aged 80-84 years, 2.99 (95% CI 1.93-4.65) in cases aged 85-89 years, and 3.28 (95% CI 2.11-5.10) in cases aged ≥90 years, as compared with cases aged <70 years. Other risk factors for mortality among COVID-19 cases included male sex (OR, 2.60, 95% CI 2.22-3.05), neuropsychological conditions (OR, 2.18; 95% CI 1.76-2.71), impaired walking ability (OR, 1.45, 95% CI 1.17-1.78), urinary and bowel incontinence (OR 1.51, 95% CI 1.22-1.85), diabetes (OR 1.36, 95% CI 1.14-1.62), chronic kidney disease (OR 1.37, 95% CI 1.11-1.68) and previous pneumonia (OR 1.57, 95% CI 1.32-1.85). Nutritional factors, cardiovascular diseases, and antihypertensive medications were not significantly associated with mortality.Conclusions and ImplicationsIn Swedish LTCFs, COVID-19 was associated with a large excess in mortality after controlling for an extensive number of risk factors. Beyond older age and male sex, several prevalent clinical risk factors independently contributed to higher mortality. These findings suggest that reducing transmission of COVID-19 in LTCFs will likely prevent a considerable number of deaths.     

Palliative Care Implementation in Long-Term Care Facilities: European Association for Palliative Care White Paper

ObjectivesThe number of older people dying in long-term care facilities (LTCFs) is increasing globally, but care quality may be variable. A framework was developed drawing on empirical research findings from the Palliative Care for Older People (PACE) study and a scoping review of literature on the implementation of palliative care interventions in LTCFs. The PACE study mapped palliative care in LTCFs in Europe, evaluated quality of end-of-life care and quality of dying in a cross-sectional study of deceased residents of LTCFs in 6 countries, and undertook a cluster-randomized control trial that evaluated the impact of the PACE Steps to Success intervention in 7 countries. Working with the European Association for Palliative Care, a white paper was written that outlined recommendations for the implementation of interventions to improve palliative and end-of-life care for all older adults with serious illness, regardless of diagnosis, living in LTCFs. The goal of the article is to present these key domains and recommendations.DesignTransparent expert consultation.SettingInternational experts in LTCFs.ParticipantsEighteen (of 20 invited) international experts from 15 countries participated in a 1-day face-to-face Transparent Expert Consultation (TEC) workshop in Bern, Switzerland, and 21 (of 28 invited) completed a follow-up online survey.MethodsThe TEC study used (1) a face-to-face workshop to discuss a scoping review and initial recommendations and (2) an online survey.ResultsThirty recommendations about implementing palliative care for older people in LTCFs were refined during the TEC workshop and, of these, 20 were selected following the survey. These 20 recommendations cover domains at micro (within organizations), meso (across organizations), and macro (at national or regional) levels addressed in 3 phases: establishing conditions for action, embedding in everyday practice, and sustaining ongoing change.Conclusions and implicationsWe developed a framework of 20 recommendations to guide implementation of improvements in palliative care in LTCFs.