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Clinical Drug Investigation

, Volume 30, Issue 5, pp 289–300 | Cite as

Quality of Drug Prescribing in Elderly People in Nursing Homes and Special Care Units for Dementia

A Cross-Sectional Computerized Pharmacy Register Analysis
  • Jonny Olsson
  • Åsa Bergman
  • Anders Carlsten
  • Thimothy Oké
  • Cecilia Bernsten
  • Ingrid K. Schmidt
  • Johan Fastbom
Original Research Article

Abstract

Background: Drug prescribing to the elderly is extensive and often inappropriate. Furthermore, the number of drugs used is the most important risk factor for adverse drug reactions. Despite this, drug prescribing in the elderly in Sweden is high and increasing. In 2003 the Swedish National Board of Health and Welfare launched a set of indicators to evaluate the quality of drug therapy in the elderly. Use of this tool in combination with the Swedish computerized national register covering all persons receiving multi-dose drug dispensing (drugs dispensed in one dose unit bag for each dose occasion) would enable detection of inappropriate drug prescribing and could help reduce the risk of drug-related problems among the elderly.

Objectives: To assess the extent and quality of drug prescribing in younger and older elderly residents receiving multi-dose drug dispensing in ordinary nursing homes (NHs) and special care units for dementia (NHDs), and to evaluate the relationship between the quality of prescribing and the number of prescribers per resident, in a Swedish county.

Methods: The computerized national pharmacy drug register provided the database and a cross-sectional design was used. Selected drug-specific quality indicators proposed by the Swedish National Board of Health and Welfare in 2003 were used to assess the quality of drug prescribing.

Results: This study included 3705 residents. Their mean age was 85 years and 72% were women. The mean number of prescribed drugs was 10.3 per resident. The proportion of residents with prescriptions for psychotropic drugs was 80% in NHs and 85% in NHDs. The prevalence of each drug-specific quality indicator was as follows: long-acting benzodiazepines 16.4% (NHs) versus 11.7% (NHDs), anticholinergic drugs 20.7% versus 18.5%, drug duplication 14.6% versus 13.6%, three or more psychotropic drugs 25.6% versus 35.3%, class C interactions (drug combinations that may require dose adjustment) 41.9% versus 38.7% and class D interactions (drug combinations that should be avoided) 8.1% versus 5.6%. Younger elderly residents (age 65–79 years) had a lower quality of drug prescribing. An increasing number of prescribers per resident was associated with a lower quality of drug therapy.

Conclusions: We found a lower quality of drug prescribing, e.g. anticholinergic drugs prescribed to approximately 20% of residents of NHs and NHDs, and a higher rate of psychotropic drug use (≥80%) compared with previous studies in NHs. Our results also demonstrated a negative correlation between quality of prescribing and number of prescribers per resident.

Keywords

Psychotropic Drug Nursing Home Resident Zopiclone Anticholinergic Drug Atypical Antipsychotic Drug 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

The study was funded by the National Corporation of Swedish Pharmacies’ Fund for Research and Studies in Health Economics and Social Pharmacy and the Swedish National Board of Health and Welfare. The authors have no conflicts of interest that are directly relevant to the content of this study.

References

  1. 1.
    Stewart RB, Cooper JW. Polypharmacy in the aged: practical solutions. Drugs Aging 1994; 4(6): 449–61PubMedCrossRefGoogle Scholar
  2. 2.
    Avorn J, Gurwitz JH. Drug use in the nursing home. Ann Intern Med 1995; 123: 195–204PubMedGoogle Scholar
  3. 3.
    Williams B, Betley C. Inappropriate use of nonpsychotropic medications in nursing homes. J Am Geriatr Soc 1995; 43(5): 513–9PubMedGoogle Scholar
  4. 4.
    National Board of Health and Welfare. Läkemedel på sjukhem [Drug use in nursing homes].The National Board of Health and Welfare Follows Up and Evaluates, 1996; 1 [in Swedish]. Stockholm: National Board of Health and Welfare, 1996Google Scholar
  5. 5.
    Spore DL. Inappropriate drug prescriptions for elderly residents of board and care facilities. Am J Public Health 1997; 87: 404–9PubMedCrossRefGoogle Scholar
  6. 6.
    Giron MST, Claesson C, Thorslund M, et al. Drug use patterns in a very elderly population: a seven-year review. Clin Drug Investig 1999; 17(5): 389–98CrossRefGoogle Scholar
  7. 7.
    Schmidt IK, Fastbom J. Quality of drug use in Swedish nursing homes: a follow-up study. Clin Drug Investig 2000; 20: 433–46CrossRefGoogle Scholar
  8. 8.
    Giron MST, Wang H-X, Bernsten C, et al. The appropriateness of drug use in an older nondemented and demented population. J Am Geriatr Soc 2001; 49: 277–83PubMedCrossRefGoogle Scholar
  9. 9.
    Dhalla IA, Anderson GM, Mamdani MM, et al. Inappropriate prescribing before and after nursing home admission. J Am Geriatr Soc 2002; 50: 995–1000PubMedCrossRefGoogle Scholar
  10. 10.
    Pittrow D, Krappweis J, Rentsch A, et al. Pattern of prescriptions issued by nursing home-based physicians versus office-based physicians for frail elderly patients in German nursing homes. Pharmacoepidemiol Drug Saf 2003; 12(7): 595–9PubMedCrossRefGoogle Scholar
  11. 11.
    Fastbom J, Schmidt IK. Shortages in the treatment of depression of the elderly in nursing homes in Stockholm: diagnosis is based on flimsy ground, follow up performed rarely. J Swedish Med Assoc (Läkartidningen) 2004; 101(46): 3683–8Google Scholar
  12. 12.
    Kragh A. Two out of three persons living in nursing homes for the elderly are treated with at least ten different drugs: a survey of drug prescriptions in the northeastern part of Skane [in Swedish]. J Swedish Med Assoc (Läkartidningen) 2004 Mar 11; 101(11): 994–6, 999Google Scholar
  13. 13.
    Lane CJ, Bronskill SE, Sykora K, et al. Potentially inappropriate prescribing in Ontario community-dwelling older adults and nursing home residents. J Am Geriatr Soc 2004; 52: 861–6PubMedCrossRefGoogle Scholar
  14. 14.
    Perri3rd M, Menon AM, Desphande AD, et al. Adverse outcomes associated with inappropriate drug use in nursing homes. Ann Pharmacother 2005 Mar; 39(3): 405–11PubMedCrossRefGoogle Scholar
  15. 15.
    Johnell K, Fastbom J. Multi-dose drug dispensing and inappropriate drug use: a nationwide register-based study of over 700,000 elderly. Scand J Prim Health Care 2008; 26(2): 86–91PubMedCrossRefGoogle Scholar
  16. 16.
    Nolan L, Malley K. Prescribing for the elderly. Part I: sensitivity of the elderly to adverse drug reactions.J Am Geriatr Soc 1988; 36: 142–9PubMedGoogle Scholar
  17. 17.
    Tsujimoto G, Hashimoto K, Hoffman BB. Pharmacokinetic and pharmacodynamic principles of drug therapy in old age: part 1. Int J Clin Pharmacol Ther Toxicol 1989; 27(1): 13–26PubMedGoogle Scholar
  18. 18.
    Tsujimoto G, Hashimoto K, Hoffman BB. Pharmacokinetic and pharmacodynamic principles of drug therapy in old age: part 2. Int J Clin Pharmacol Ther Toxicol 1989; 27(3): 102–16PubMedGoogle Scholar
  19. 19.
    Moore AR, O’Keeffe ST. Drug-induced cognitive impairment. Drugs Aging 1999; 15(1): 15–28PubMedCrossRefGoogle Scholar
  20. 20.
    Cancelli I, Beltrame M, Gigli GL, et al. Drugs with anticholinergic properties: cognitive and neuropsychiatric side-effects in elderly patients. Neurol Sci 2009; 30(2): 87–92PubMedCrossRefGoogle Scholar
  21. 21.
    Turnheim K. Drug therapy in the elderly. Exp Gerontol. 2004; 39: 1731–8PubMedCrossRefGoogle Scholar
  22. 22.
    Atkin PA, Veitch PC, Veitch EM, et al. The epidemiology of serious adverse drug reactions among the elderly. Drugs Aging 1999; 14(2): 141–52PubMedCrossRefGoogle Scholar
  23. 23.
    Walker J, Wynne H. The frequency and severity of adverse drug reactions in elderly people. Age Ageing 1994; 23: 255–9PubMedCrossRefGoogle Scholar
  24. 24.
    Beard K. Adverse reactions as a cause of hospital admission in the aged. Drugs Aging 1992; 2(4): 356–67PubMedCrossRefGoogle Scholar
  25. 25.
    Sarlov C, Andersén-Karlsson E, von Bahr C. Adverse effects of drugs in patients with heart disease lead to hospital care [in Swedish]. J Swedish Med Assoc (Läkartidningen) 2001; 47: 5349–53Google Scholar
  26. 26.
    Beijer HJ, deBlaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 2002; 24(2): 46–54PubMedCrossRefGoogle Scholar
  27. 27.
    Mjorndal T, Boman MD, Hägg S, et al. Adverse drug reactions as a cause for admissions to a department of internal medicine. Pharmacoepidemiol Drug Saf 2002; 11(1): 65–72PubMedCrossRefGoogle Scholar
  28. 28.
    Klarin I, Wimo A, Fastbom J. The association of inappropriate drug use with hospitalisation and mortality: a population-based study of the very old. Drugs Aging 2005; 22(1): 69–82PubMedCrossRefGoogle Scholar
  29. 29.
    Douglas IJ, Smeeth L. Exposure to antipsychotics and the risk of stroke; self controlled case series study. BMJ 2008; 337: a1227PubMedCrossRefGoogle Scholar
  30. 30.
    Ray WA, Chung CP, Murray KT, et al. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med 2009; 360(3): 225–35PubMedCrossRefGoogle Scholar
  31. 31.
    The National Board of Health and Welfare (Socialstyrelsen, Stockholm, Sweden). Indikatorer för utvärdering av kva-liteten i äldres läkemedelsterapi: socialstyrelsens förslag. Stockholm: Socialstyrelsen, 2003Google Scholar
  32. 32.
    Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997; 157: 1531–6PubMedCrossRefGoogle Scholar
  33. 33.
    Fick DM, Cooper JW, Wade WE, 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(22): 2716–24PubMedCrossRefGoogle Scholar
  34. 34.
    McLeod PJ. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997; 156: 385–91PubMedGoogle Scholar
  35. 35.
    Oborne CA, Batty GM, Maskrey V, et al. Development of prescribing indicators for elderly medical inpatients. Br J Clin Pharmacol 1997; 43: 91–7PubMedCrossRefGoogle Scholar
  36. 36.
    Bergman A, Olsson J, Carlsten A, et al. Evaluation of the quality of drug therapy among elderly patients in nursing homes. Scand J Prim Health Care 2007 Mar; 25(1): 9–14PubMedCrossRefGoogle Scholar
  37. 37.
    Giron MST, Forsell Y, Bernsten C, et al. Psychotropic drug use in elderly people with and without dementia. Int J Geriatr Psychiatry 2001; 16: 900–6PubMedCrossRefGoogle Scholar
  38. 38.
    Nilsson L, Petersson C. Consumption of psychopharmaceuticals in residential facilities for the elderly: evaluation of the extent, indications and effects [in Swedish]. J Swedish Med Assoc (Läkartidningen) 2001; 98: 1371–73Google Scholar
  39. 39.
    Ruths S, Straand J, Nygaard HA. Psychotropic drug use in nursing homes: diagnostic indications and variations between institutions. Eur J Clin Pharmacol 2001; 57: 523–8PubMedCrossRefGoogle Scholar
  40. 40.
    Wolf-Klein GP, Siverstone FA, Brod MS, et al. Are Alzheimer patients healthier? J Am Geriatr Soc 1988; 36(3): 219–24PubMedGoogle Scholar
  41. 41.
    Gobert M, D’hoore W. Prevalence of psychotropic drug use in nursing homes for the aged in Quebec and in the French-speaking area of Switzerland. Int J Geriatr Psychiatry 2005 Aug; 20(8): 712–21PubMedCrossRefGoogle Scholar
  42. 42.
    Mann E, Köpke S, Haastert B, et al. Psychotropic medication use among nursing home residents in Austria: a cross-sectional study. BMC Geriatr. 2009; 9: 18PubMedCrossRefGoogle Scholar
  43. 43.
    Schatzberg AF, Kremer C, Rodrigues HE, et al. Doubleblind, randomized comparison of mirtazapine and paroxetine in elderly depressed patients. Am J Geriatr Psychiatry 2002; 10: 541–50PubMedGoogle Scholar
  44. 44.
    Sweet RA, Pollock BG. New atypical antipsychotics: experience and utility in the elderly. Drugs Aging 1998; 12(2): 115–27PubMedCrossRefGoogle Scholar
  45. 45.
    Risperdal (risperidone) 2003 safety alerts for drugs, biologics, medical devices, and dietary supplements. US Food and Drug Administration, 2003 [online]. Available from URL: http://www.fda.gov/medwatch/SAFETY/2003/safety03.htm#risper [Accessed 2003 Jan 31]
  46. 46.
    Fastbom J. Treatment issues in elderly patients with Alzheimer’s disease. Alzheimer Insights 1998; 4: 7–10Google Scholar
  47. 47.
    National Board of Health and Welfare. The quality of the drug use in elderly people [in Swedish]. The National Board of Health and Welfare Follows Up and Evaluates, 2000: 8. Stockholm: National Board of Health and Welfare, 2000Google Scholar
  48. 48.
    Campbell AJ. Drug treatment as a cause of falls in old age: a review of the offending agents. Drugs Aging 1991; 1(4): 289–302PubMedCrossRefGoogle Scholar
  49. 49.
    Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis. I. Psychotropic drugs. J Am Geriatr Soc 1999; 47(1): 30–9PubMedGoogle Scholar
  50. 50.
    FASS (Pharmaceutical Specialities in Sweden) [in Swedish]. Stockholm: LINFO Läkemedelsinformation AB, 2003Google Scholar
  51. 51.
    Nygaard HA, Naik M, Ruths S, et al. Nursing-home residents and their drug use: a comparison between mentally intact and mentally impaired residents. The Bergen District Nursing Home (BEDNURS) study. Eur J Clin Pharmacol 2003; 59: 463–9PubMedCrossRefGoogle Scholar
  52. 52.
    Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA 2003; 289: 1652–8PubMedCrossRefGoogle Scholar
  53. 53.
    Preskorn SH, Silkey B, Shah R, et al. Complexity of medication use in the Veterans Affairs Healthcare System. Part 1: outpatient use in relation to age and number of prescribers. J Psychiatr Pract 2005; 11:5–15PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  • Jonny Olsson
    • 1
    • 2
  • Åsa Bergman
    • 3
  • Anders Carlsten
    • 3
  • Thimothy Oké
    • 4
  • Cecilia Bernsten
    • 3
    • 5
  • Ingrid K. Schmidt
    • 6
  • Johan Fastbom
    • 2
    • 6
  1. 1.Department of Drug SafetyMedical Products AgencyUppsalaSweden
  2. 2.Aging Research CenterKarolinska Institutet-Stockholm UniversityStockholmSweden
  3. 3.Apoteket ABGothenburgSweden
  4. 4.Department of Public Health SciencesKarolinska InstitutetStockholmSweden
  5. 5.Department of Public Health and Caring SciencesUppsala UniversityUppsalaSweden
  6. 6.Swedish National Board of Health and WelfareStockholmSweden

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