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

34 Medication use in Nursing Homes KCE reports 47
receive more medications than the community dwelling elderly. 43, 44 For example, a
study on 1,106 residents in 12 nursing homes of a large city in the US showed residents
are on an average of 7.2 medications. 45 Furthermore, as people age, pharmacokinetic
and pharmacodynamic changes occur that can affect the disposition of medications in
the body. This combination of polypharmacy and pharmacokinetic and
pharmacodynamic changes lead to an increased risk of adverse drug reactions (ADR),
defined as an injury from medication. There is a linear relationship between the number
of drugs taken and the increased potential for ADR. 46 The nursing home residents are
the frailest segment of the geriatric population, using the highest number of medications
compared to the non-institutionalized elderly, thus having the highest risk for an ADR.
Further complicating this issue, ADR are often interpreted as a disease of old age
resulting in another drug added to the patient s therapy by the doctor. 47
Misprescribing
Certain drugs should be avoided in older adults or should only be used under certain
circumstances, since their potential risk outweighs the potential benefit. 48 The
prescription of such contraindicated drugs also represents an area of concern in the
medication use of nursing home residents, as it can lead to morbidity, mortality and
increased costs of care. 49
The quality of drug management in nursing homes is also affected by the inappropriate
use of psychoactive drugs to control problematic behaviors and induce sedation of the
residents ( chemical restraint ). The effectiveness of psychotropic drugs to treat
disruptive behavior remains uncertain because most episodes are self-limited. Research
has shown that not only are the drugs often ineffective, but they may actually precipitate
an agitated state. 50
Underprescribing
Another important and increasingly recognized problem in nursing home residents is
undertreatment, defined as the omission of drug therapy that is indicated for the
treatment or prevention of a disease or condition. Undertreatment has been reported
for diseases as asthma, cardiovascular disease, dyslipidemia, osteoporosis, pain,
hypertension and depression, and underuse of angiotensin-converting enzyme (ACE)
inhibitor medications in patients with congestive heart failure, anticoagulation in elderly
patients with atrial fibrillation, and preventive therapy after myocardial infarction.
51, 42, 52
Undertreatment may have an important relationship with negative health outcomes in
the elderly, including disability, death and health services use. 42
Drug-related hospital admissions
Many studies have shown that a high number of geriatric patients experience drugrelated
problems leading to hospital admission. 53-62 However, the definition of the
problems investigated in these studies varies markedly from study to study. In all the
publications mentioned in the reference list, we found that adverse drug reactions
(ADRs) were considered; in some publications non-compliance, improper drug
selection, untreated indications and drug use without indication were also considered.
These last problems can be defined as drug therapy failures (DTFs).
The frequency of hospital admissions due to drug-related problems in the elderly is
found to be 10 to 30%. The majority of these problems seem to be adverse drug
reactions. Difference in incidence can be explained by a different classification system of
type of problems, and of contribution to hospital admission.
Several studies have investigated the preventability of drug-related problems in the
elderly, which is found to be substantial, varying from 50% to 97%. 53, 55, 57, 59, 61, 63 From
those studies criteria for inappropriate medication use in geriatric patients can be
defined, with medications that should be avoided generally in the elderly, or in the
presence of specific co-morbidities, or when dosages or frequencies may exceed
tolerable levels. 64, 48, 65-69 The drugs concerned are central nervous drugs, drugs with
anticholinergic properties, drugs with a narrow therapeutic-toxic range, slow release