Skip to main content
SpringerLink
Log in

Nurse Education to Reduce Harmful Medication Use in Assisted Living Facilities: Effects of a Randomized Controlled Trial on Falls and Cognition

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background

Psychotropic and anticholinergic medications may increase the risk of falls and impair cognition.

Objective

The aim of the study was to investigate whether educating nursing staff in assisted living facilities about harmful medication use has effects on the incidence of falls and cognition.

Methods

This was a secondary analysis of a cluster randomized controlled trial (N = 227 residents, ≥65 years) in 20 wards in assisted living facilities in Helsinki, Finland. Wards were randomized to those in which staff received two 4-h interactive training sessions to recognize potentially harmful medications (intervention group) and a control group. Cognition (verbal fluency, clock-drawing test) was assessed at baseline and 6 and 12 months. The number of falls per resident over the 12-month follow-up was recorded.

Results

The prevalence of harmful medication use declined in the intervention group {−11.7 % [95 % confidence interval (CI) −20.5 to −2.9]; p = 0.009}, but remained constant in the control group [+3.4 % (95 % CI −3.7 to 10.6); p = 0.34]. There were 171 falls in the intervention group (2.25 falls/person year, 95 % CI 1.93–2.62) and 259 falls in the control group (3.25 falls/person year, 95 % CI 2.87–3.67) [incidence rate ratio 0.72 (95 % CI 0.59–0.88); p < 0.001]. Residents in the intervention group with a Mini-Mental State Examination (MMSE) score ≥10 had significantly less falls compared with respective residents in the control group (p < 0.001). Changes in verbal fluency or clock drawing test were not significantly different between the groups.

Conclusion

Educating nurses using activating learning methods can reduce the prevalence of harmful medications and the incidence of falls among residents in institutional settings.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Fick DM, Wade WE, Waller JL, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–24.

    Article  PubMed  Google Scholar 

  2. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.

  3. Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508–13.

    Article  PubMed  Google Scholar 

  4. Svenska Socialstyrelsen: Indikatorer för god läkemedelterapi hos äldre. (The National Board of Health and Welfare of Sweden; in Swedish). Available at: http://www.socialstyrelsen.se. Accessed 25 Aug 2015.

  5. Hartikainen S, Lönnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007;62:1172–81.

    Article  PubMed  Google Scholar 

  6. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169:1952–60.

    Article  PubMed  Google Scholar 

  7. Berdot S, Bertrand M, Dartigues JF, et al. Inappropriate medication use and risk of falls—a prospective study in a large community-dwelling elderly cohort. BMC Geriatr. 2009;23(9):30.

    Article  Google Scholar 

  8. Bennett A, Gnjidic D, Gillett M, et al. Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging. 2014;31:225–32.

    Article  PubMed  Google Scholar 

  9. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59:148–57.

  10. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146.

  11. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664–72.

  12. Rosso AL, Eaton CB, Wallace R, et al. Geriatric syndromes and incident disability in older women: results from the women’s health initiative observational study. J Am Geriatr Soc. 2013;61:371–9.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Fletcher PC, Guthrie DM, Berg K, et al. Risk factors for restriction in activity associated with fear of falling among seniors within the community. J Patient Saf. 2010;6:187–91.

    Article  PubMed  Google Scholar 

  14. Abellan van Kan G, Rolland Y, Bergman H, et al. The I.A.N.A Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging. 2008;12:29–37.

    Article  CAS  PubMed  Google Scholar 

  15. Uusvaara J, Pitkala KH, Tienari PJ, et al. Association between anticholinergic drugs and apolipoprotein E epsilon4 allele and poorer cognitive function in older cardiovascular patients: a cross-sectional study. J Am Geriatr Soc. 2009;57:427–31.

    Article  PubMed  Google Scholar 

  16. Fox C, Richardson K, Maidment ID, et al. Anticholinergic medication use and cognitive impairment in the older population: the Medical Research Council Cognitive Function and Ageing Study. J Am Geriatr Soc. 2011;59:1477–83.

    Article  PubMed  Google Scholar 

  17. Shah RC, Janos AL, Kline JE, et al. Cognitive decline in older persons initiating anticholinergic medications. PLoS One. 2013;8:e64111.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  18. Wright RM, Roumani YF, Boudreau R, et al. Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: findings from the Health, Aging And Body Composition Study. J Am Geriatr Soc. 2009;57:243–50.

    Article  PubMed Central  PubMed  Google Scholar 

  19. Puustinen J, Nurminen J, Löppönen M, et al. Use of CNS medications and cognitive decline in the aged: a longitudinal population-based study. BMC Geriatr. 2011;11:70.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465.

  21. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ. 2007;334:82.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Avorn J, Soumerai SB, Everitt DE, et al. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327:168–73.

    Article  CAS  PubMed  Google Scholar 

  23. Meador KG, Taylor JA, Thapa PB, et al. Predictors of antipsychotic withdrawal or dose reduction in a randomized controlled trial of provider education. J Am Geriatr Soc. 1997;45:207–10.

    Article  CAS  PubMed  Google Scholar 

  24. Fossey J, Ballard C, Juszczak E, et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ. 2006;332:756–61.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Schmidt I, Claesson CB, Westerholm B, et al. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46:77–82.

    Article  CAS  PubMed  Google Scholar 

  26. Roberts MS, Stokes JA, King MA, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51:257–65.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  27. Crotty M, Whitehead C, Rowett D, et al. An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475]. BMC Health Serv Res. 2004;4:6. Available at: http://www.biomedcentral.com/1472-6963/4/6.

  28. Pitkälä KH, Juola AL, Kautiainen H, et al. Education to reduce potentially harmful medication use among residents of assisted living facilities: a randomized controlled trial. J Am Med Dir Assoc. 2014;15(12):892–8.

    Article  PubMed  Google Scholar 

  29. Morris JN, Fries BE, Bernabei R, et al. RAI-home care (RAI-HC) assessment manual for version 2.0. Marblehead: Opus Communications; 2000.

  30. Hughes CP, Berg L, Danziger WL, et al. A new clinical scale for the staging of dementia. Br J Psychiatry. 1982;140:566–72.

    Article  CAS  PubMed  Google Scholar 

  31. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.

    Article  CAS  PubMed  Google Scholar 

  32. Morris JC, Heyman A, Mohs RC, et al. The Consortium to Establish a Registry for Alzheimer´s Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer’s disease. Neurology. 1989;39:1159–65.

    Article  CAS  PubMed  Google Scholar 

  33. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin Geriatr Med. 2002;18:737–57.

    Article  PubMed  Google Scholar 

  34. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  CAS  PubMed  Google Scholar 

  35. WHO Collaborating Centre for Drug Statistics Methodology: The Anatomical Therapeutic Chemical classification system. 2015. Available at: http://www.whocc.no/atcddd/. Accessed 25 Aug 2015.

  36. Teramura-Grönblad M, Bell S, Poysti MM, et al. Risk of death associated with use of PPIs in 3 cohorts of institutionalized older people in Finland. J Am Med Dir Assoc. 2012;488:9–13.

    Google Scholar 

  37. Dolmans DH, De Grave W, Wolfhagen IH, et al. Problem-based learning: future challenges for educational practice and research. Med Educ. 2005;39:732–41.

    Article  PubMed  Google Scholar 

  38. Spencer JA, Jordan RK. Learner centred approaches in medical education. BMJ. 1999;318:1280–3.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  39. Pitkala KH, Juola AL, Soini H, et al. Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial. Trials. 2012;13:85.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  40. SFINX Drug interactions Swedish, Finnish, INteraction X-referencing database. Available at: http://www.terveysportti.fi/terveysportti/interaktio.sfinxpharao.koti#. Accessed 25 Aug 2015.

  41. Renbase—drug dosing in renal failure. Available at: http://www.terveysportti.fi/terveysportti/renbase.koti. Accessed 25 Aug 2015.

Download references

Acknowledgments

The authors thank the Helsinki City Social Services Department for its support. This organization had no impact on the research process, results or writing/content of the manuscript. All authors participated in the study’s conception and design, drafting or critically revising the manuscript for important intellectual content, and approval of the final manuscript. Kaisu Pitkala, Hannu Kautiainen and Anna-Liisa Juola were responsible for acquisition or analysis and interpretation of data.

Author information

Authors and Affiliations

  1. City of Porvoo, Health Sevices, PO Box 23, 06101, Porvoo, Finland

    Anna-Liisa Juola

  2. Department of General Practice, University of Helsinki, PO Box 20, 00014, University of Helsinki, Finland

    Anna-Liisa Juola, Mikko P. Bjorkman, Hannu Kautiainen & Kaisu H. Pitkala

  3. Unit of Primary Health Care, Helsinki University Central Hospital, PO Box 20, 00014, University of Helsinki, Finland

    Anna-Liisa Juola, Mikko P. Bjorkman, Hannu Kautiainen & Kaisu H. Pitkala

  4. Division of Social Pharmacy, Faculty of Pharmacy, University of Helsinki, PO Box 56, 00014, University of Helsinki, Finland

    Sarita Pylkkanen

  5. Carea Central Hospital Pharmacy, Kotkantie 41, 48210, Kotka, Finland

    Sarita Pylkkanen

  6. National Institute for Health and Welfare, PO Box 30, 00271, Helsinki, Finland

    Harriet Finne-Soveri

  7. Social Services and Health Care Department, 4 A, PO Box 8555, 00099, City of Helsinki, Finland

    Helena Soini

  8. Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, Australia

    J. Simon Bell

  9. School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, Australia

    J. Simon Bell

  10. Faculty of Health Sciences, Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland

    J. Simon Bell

Authors
  1. Anna-Liisa Juola
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mikko P. Bjorkman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sarita Pylkkanen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Harriet Finne-Soveri
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Helena Soini
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hannu Kautiainen
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. J. Simon Bell
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Kaisu H. Pitkala
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anna-Liisa Juola.

Ethics declarations

Funding

This study was supported by the Päivikki and Sakari Sohlberg Foundation, the Uulo Arhio Foundation, Helsinki University Hospital, Societas Gerontologica Fennica, and the Medical Society of Kouvola. These organizations had no impact on the research process, results or writing/content of the manuscript.

Conflict of interest

Anna-Liisa Juola received support from Novartis to participate in a 2014 Springfield symposium held in Geneva, Switzerland. Kaisu Pitkala has participated in a speaker forum supported by Orion. These activities are not related to this study. Anna-Liisa Juola, Mikko Bjorkman, Sarita Pylkkanen, Harriet Finne-Soveri, Helena Soini, Hannu Kautiainen, Simon Bell and Kaisu Pitkala declare that they have no conflicts of interest relevant to the content of this study.

Ethical approval

The study was approved by the Ethics Committee of the Helsinki University Central Hospital.

Informed consent

All potential participants were provided with information about the study. Written informed consent was obtained from all individual participants included in the study. If a resident had cognitive decline (MMSE <20), consent was obtained from his or her closest proxy.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Juola, AL., Bjorkman, M.P., Pylkkanen, S. et al. Nurse Education to Reduce Harmful Medication Use in Assisted Living Facilities: Effects of a Randomized Controlled Trial on Falls and Cognition. Drugs Aging 32, 947–955 (2015). https://doi.org/10.1007/s40266-015-0311-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-015-0311-8

Keywords

Search

Navigation