Medication prescribing to older people in care homes (nursing) is predominantly the role of the GP, with involvement of the multi-professional care-providing team and the resident (Department of Health, 2013b).
Inappropriate medication are those that should be avoided at age 65 or over because they are ineffective or pose unnecessary risk, such as adverse drug reactions, inappropriate drug choice, underuse of beneficial treatments, unnecessary prescribing or excessive use of psychotropic/neuroleptic medicines (Beers, 1997; Gallagher, Barry, & O'Mahony, 2007; Hughes et al., 2007). Tamura,
Bell, Inaba and Masaki (2012, p. 217) add that potentially inappropriate prescribing (PIP) are when risk outweighs clinical benefits, particularly when there is a safer and more effective alternative. Inappropriate prescribing is explained in three ways (Gallagher et al., 2007). First by the use of medicines that risk adverse drug events (ADEs) when continued for too long, second when used in addition to unnecessary polypharmacy, and third when clinically indicated medicines are underused and not prescribed for ageist reasons.
A body of knowledge exists regarding patterns of prescribing to older people in care homes, prescribing association with unnecessary hospital admissions, and overuse and underuse of medication. These findings are reported in the studies examined below.
Examination of nursing home residents’ (n=323) hospital admission records by Bowman, Elford, Dovey, Campbell and Barrowclough (2001) identified fractures (n=17) associated with confusion and sedative (n=12) and antidepressant use (n=6), prescribed individually or combined. The link between medication prescribing and falls resulted in a drive to reduce anti-psychotic/neuroleptic drug use. A cluster randomised trial by Fossey et al. (2006), conducted in nursing homes (n=12) in England, found neuroleptic prescribing reduced significantly in the intervention homes (23.0%) compared with the control homes (42.1%). The study promoted person-centred care for residents with dementia behaviour symptoms in 6 of the care homes (nursing) and evaluated the effectiveness of the 10-month training and weekly support intervention by dementia experts to nursing home staff in reducing neuroleptic prescribing. The promotion of person-centred care and good practice in the management of residents with dementia was recommended (Fossey et al., 2006).
On a larger scale, Grant et al. (2002) undertook a UK NHS funded national sentinel clinical audit of data collected in 1999 from 141 sites (102 hospitals, 24 GP surgeries, 15 nursing homes) and again in 2000 from 76 sites (62 hospitals, 8
general practices, 6 nursing homes) by multi-disciplinary teams. Prescription data of older people, including the nursing home residents, was analysed against prescribing indicators of unnecessary or potentially harmful medication and
evidence based prescribing (Batty et al., 2004; Grant et al., 2002). Prescriptions for regular, PRN and once only (STAT) were examined. The first audit identified 10,700 PRN medication were prescribed with instructions for frequency of administration documented in only 6599 (62%) of cases. PRN medication categories were not identified. Anticoagulants and aspirin associated with atrial fibrillation were underused and benzodiazepines and neuroleptics were prescribed when safer alternatives were available. Feedback on the first audit provided to participant hospitals, GPs, and nursing homes aimed to promote quality prescribing. On reassessment the second audit revealed little change with 10,551 prescriptions PRN and frequency documented on 62% of occasions (Batty et al., 2004; Grant et al., 2002). Prescribing relating specifically to the nursing home sites was not reported. However, the study focused on the importance of medication prescribing to older people in care homes and the need to develop robust criteria to assess the appropriateness of prescribing.
An objective criteria was developed by Oborne et al. (2002; Oborne, Hooper, Swift, & Jackson, 2003) to assess appropriateness of neuroleptic prescribing based on Omnibus Reconciliation Act 1990 (OBRA) guidelines used by nursing homes in America. Data were collected from MAR sheets, nursing and GP notes of 934 residents in 22 nursing homes in a South Thames region. Two hundred and twenty-nine residents were prescribed neuroleptics (notes were available for 225). Of these, only 40 residents (17.8%) receiving neuroleptics received appropriate therapy. The results were similar to those of McGrath and Jackson (1996) involving Glasgow nursing homes. Overall, Oborne et al. (2003) reported 1.5% of residents received no medication, a mean prescription rate of 5.1, of which 4.1 were for regular use. Prescriptions mostly recorded generic or recognised brands (90%), drug sensitivity was identified for 55% of residents and 73% had maximum frequency documented. Twenty-five percent of neuroleptic prescriptions and 19% of paracetamol prescribing had no maximum dose stated, risking inappropriate drug use (IDU). One-fifth (75/397) of residents had an unsafe prescription for paracetamol, a medication commonly administered PRN to relieve pain or a pyrexia. Duplicate prescriptions were also found in small numbers. The study found benzodiazepines were prescribed to 24% of residents
(temazepam 36% and diazepam 24%) and 76% were for routine use, not PRN. Prescribing indications for temazepam are insomnia and diazepam is used in anxiety and/or insomnia (British Medical Association and Royal Pharmaceutical Society, 2014). The British Medical Association and Royal Pharmaceutical Society (2014) recommend short-term intermittent use and therefore PRN prescribing is appropriate. Contraindications were recorded for 76% of users, but only 7% had withdrawal or reduction in dose considered. Antithrombotic therapy was prescribed to 79% of nitrate users, appropriate steroid prescriptions for airway obstruction to 58% of residents, and only 41% of residents with atrial fibrillation received appropriate stroke prophylaxis. Sub-optimal prescribing was the conclusion reached, including medication prescribed PRN. Inappropriate prescribing, considered to increase risks of morbidity and mortality to residents in care homes (nursing) became a focus for further research.
A controlled observational study by Fahey, Montgomery, Barnes and Protheroe (2003) used quality indicators from UK sources to assess prescribing to residents in nursing homes (n=172) and patients living in the community (n=526) in Bristol. Medication prescribed for routine or PRN use were not reported independently. The overuse of inappropriate or unnecessary drugs was reported as well as the underuse of beneficial medicine (pneumococcal vaccines), with care home residents (23%) less likely to receive or be offered pneumococcal vaccinations than the community residents (63%). Data was collected from 3 Bristol GP practices computerised or paper patient records. Prescribing was found inadequate irrespective of residence, but particularly in nursing homes where more residents were prescribed neuroleptic medication (28% compared with 11%) and laxatives (39% compared with 16%). Laxatives should be used PRN for short-term treatment if constipation is diagnosed or is a side-effect of medication being taken (National Prescribing Centre, 2011). Two-fifths of nursing home residents were currently prescribed laxatives (routine or PRN) suggesting constipation was common. The findings raised awareness of prescribing differences in Bristol between the two groups and highlighted the need for a national study.
This was addressed by Shah, Carey, Harris, DeWilde and Cook (2011, 2012b) who analysed prescribing to care home residents (n=10,387) in comparison with community residents (n=403,259) in England and Wales. Primary care data held in The Health Improvement Network (THIN) database provided anonymised patient information of patients aged 65 to 104 years. PRN medication was not reported in the published research. A modified version of the American Beers criteria was used to identify PIP (Beers, 1997). The study identified 3677 (0.91%) patients in the community were prescribed antipsychotics in comparison with 982 (20.8%) in residential homes and 926 (21.7%) in nursing homes (Shah et al., 2011). Overall, 64.5% of antipsychotic prescribing to community patients and 81.2% to care home residents was without a diagnosis of severe mental illness. Shah et al. (2012b) reported residents were more frequently prescribed anticholinergic antihistamines (95%, CI = 2.38 to 3.23), loop diuretics (95%, CI = 1.41 to 1.53) and anticholinergic bladder medication (95%, CI = 1.52 to 1.88). Cardiovascular medication were prescribed less in care homes. Despite a determination to reduce antipsychotic use in people with dementia in England and Wales, due to extra deaths and serious adverse events (Banerjee, 2009), the study identified the practice continues and a persistent depiction of PIP is evident. The Beers criteria was also used to identify potentially inappropriate medication (PIM) in a 2-year cohort study undertaken by Barnett et al. (2011) involving 65,742 patients living in the community and 4557 residents in care homes in the Tayside area of Scotland (2230 in nursing homes, 1799 in residential care, 528 in dual homes). The study identified residents received twice as many prescriptions and were prescribed a higher number of drug classes. As found by previous studies, prescribing of PIMs was not associated with care homes only. Prescribing of specific PIMs (long acting benzodiazapines, nitrofurantoin, fluoxetine, muscle relaxants, dipyridamole) were higher in nursing homes although other PIMs were lower. The study concluded that the Beers criteria did not apply to the majority of drugs used in the UK and recommended a European-based PIP criteria be researched. In response, a European physiological system-based screening tool (STOPP/START) to identify PIP in older persons’ prescriptions and to also identify potential prescribing omissions (PPOs) was formulated by an expert UK
panel and inter-reliability tested (Gallagher, Ryan, Byrne, Kennedy, & O'Mahoney, 2008).
Using the STOPP and START tool, Ryan et al. (2013) obtained an indication of the prevalence of PIP and PPOs for residents (n=313) in 7 Irish nursing homes. Routine and PRN prescribed medication were categorised and reported collectively using the anatomical therapeutic chemical (ATC) code. STOPP identified 329 instances of PIP in 187 (59.8%) residents, with medication for the central nervous system (n=111; 33.7%) and benxodiazepine (n=85; 25.8%) the highest. START identified 199 PPOs in 132 (42.2%) residents. The most common PPOs involved the cardiovascular system (n=114; 57.3%), endocrine system (n=40; 20.1%), musculoskeletal system (n=24; 12.1%), and respiratory system (n=12; 6%).
Potentially inappropriate prescribing of common PRN medication has the potential to harm residents (Batty et al., 2004). Lack of regard to PRN medication in most of the studies suggests they were not considered of significant risk by researchers.
These studies show suboptimal prescribing to older people resident in care homes (nursing) despite it being clearly identified as an issue for many years. PIP of PRN medication, omissions in records, and care home staff training needs are clearly identified in these studies and highlight that this is a suitable exemplar for looking at nursing work.