Medication use in rest and nursing homes in Belgium. - KCE

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28 Medication use in Nursing Homes KCE reports 47 4. Resident Assessment Instrument for Nursing Homes (RAI) 5. ACOVE (Assessing Care of Vulnerable Elders) Quality Criteria 2.3 RESULTS OF THE LITERATURE REVIEW 2.3.1 Why are elderly institutionalized? Nursing home placement is often the result of dementia, multiple illnesses, severe disease, or lack of social support. It is triggered by a sentinel event (e.g., major illness, accident, hospitalization). Wandering and disruptive behavioral problems are also significant factors leading to long-term care placement. Determining the specific circumstances that led to a nursing home admission is an important element of the initial evaluation. The most common diagnoses at nursing home admission are 16 : Mental disorders (dementia, depression) Heart disease and cerebrovascular disease (heart failure, stroke) Nervous system disorders Injuries Endocrine disorders (e.g., diabetes mellitus) Respiratory tract disorders (e.g., chronic obstructive pulmonary disease) Musculoskeletal disorders History taking at the moment of admission to the nursing home provides the opportunity to learn the most about residents, not only their medical condition but also their functional abilities, social background, support system, interests, hobbies, and previous daily routines. Inclusion of family members in the initial resident assessment can help allay anxiety or guilt feelings surrounding a nursing home admission and provide opportunities to discuss expectations regarding care and to establish treatment preferences. Dementia emerged as the most potent risk factor for institutionalization in a 12-year prospective population-based epidemiological study. 17 Persons with dementia had nearly five times the risk of institutionalization as those who were not demented. At 3- and 12year follow-ups, 5.8% and 13.6%, respectively, of the cohort members had been institutionalized. Increasing age, impairment in ADL (activities of daily life) and less social support emerged as other less-critical risk factors in this study. Interestingly, the interaction between the number of prescription medications and dementia was significant in the model predicting institutionalization. Specifically, prescription medication count had less effect on institutionalization in those with dementia than in those without dementia. A likely explanation for this phenomenon is the clinical observation that cognitively intact persons are generally institutionalized for medical rehabilitation, whereas the potency of dementia as a risk factor far outweighs the effect of medical co-morbidity in the cognitively impaired. The burden of care to immediate care givers is a crucial element in the process of institutionalization. Often families are able to care for an elderly patient at home until he or she loses the ability to perform basic functions. The course of the events leading up to nursing home placement can provide insight into the patient's level of functioning and rate of decline. Research studies published between 1989 and 1995 were analyzed by Chenier 18 to identify variables that led to caregiver burden and nursing home placement of non-demented elders. Although the variables impact each caregiving situation differently, decreased functional abilities of the care receiver, interrupted sleep of the caregiver or the presence of multiple factors within the caregiving situation were positively correlated with caregiver burden and increased risk of nursing home
KCE reports 47 Medication use in Nursing Homes 29 placement. Increased awareness of these issues is essential to provide successfully for the aging population. Cost savings by postponing institutionalization Although expenditures did not increase with age for most services, the high personal cost for nursing home care among the oldest old underlines the need for increased efforts to support them in the community (USA). 19 Greater spending by those in poor health highlights the importance of preventing age-related health conditions and their complications. Improved access to discretionary care among the oldest old may help to reduce the need for care in higher cost settings. The high prevalence of out-of-pocket prescription spending across the age range provides impetus for current efforts to reduce these costs. Canadian research examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. Chappell et al. 20 computed the costs of formal care and informal care in both settings and ensured comparable groups of clients in both settings by comparing individuals at the same level of care. The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage. Loss of independence in older persons places considerable financial burden on them, their families, and the health care system. 21 The Medicare Current Beneficiary Survey estimated the additional medical and long-term care costs that occur during the year when older persons make the transition to dependency at home or move to a nursing home. Average long-term care costs were $3,400 for persons who developed activities of daily living disability at home sometime during the year, $6,800 for those starting and ending the year with disability who remained at home, and more than $21,000 for those moving into a nursing home during the year. 2.3.2 What are the most prevalent functional and clinical problems among residents? In order to assess properly the medication needs of nursing home residents, it is necessary to have an idea of the clinical problems common to this elderly population. We will address 2.3.2.1 Clinical assessment Clinical Assessment Functional Assessment Nutritional assessment Assessment of communication needs Assessment of palliative care needs Patient Autonomy Heckman et al. 22 found that heart failure is common in Canadian long-term care (LTC) facilities, but undertreated. The prevalence of heart failure was 20%. LTC residents with heart failure were older, more often women, and more functionally impaired and burdened by co-morbidity than were participants in heart failure trials. Documentation
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KCE reports 33 Effects and costs of
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Medication use in rest and nursing homes in Belgium. - KCE

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