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MEDICINES MANAGEMENT

Medicines management in care homes for older people: the nurse’s role David Cowan, Alison While, Julia Roberts, Joanne Fitzpatrick David Cowan is Research Fellow, Ageing and Health Section, Alison While is Professor of Community Nursing, Julioa Roberts is Senior Lecturer, Ageing and Health Section and Joanne Fitzzpatrick is Senior Lecturer, Health and Ageing Section, Florence Nightingale School of Nursing and Midwifery, King’s College London

uring the past decade increasing attention has been paid to the inappropriate use of medicines in care homes for older people (Beers et al, 1991; Rochon and Gurwitz, 1997; Manias, 1998; Shepard, 1998; Burstow and Stokoe, 2001). The UK Government’s national service framework (NSF) for older people defines polypharmacy as the prescription of four or more medicines for one person (Department of Health (DH), 2001). Polypharmacy is a term used to describe the growing problem of concurrent use of multiple medicines, either through prescription or ‘over the counter’ purchase (LeSage, 1991; Shepard, 1998; Larsen and Hoot-Martin, 1999; DH, 2001). While polypharmacy may occur in any age group it is a common occurrence in older people (Larsen and Hoot-Martin, 1999). Polypharmacy is particularly prevalent in care homes for older people in the UK, with a mean number of 5.7 medicines currently prescribed for men and 5.5 for women (Health Survey for England (HSE), 2000). In describing the surveyed care homes (n = 544), the HSE (2000) did not differentiate between local authority residential homes, private residential homes, private nursing homes or dual registered residential/nursing homes. While it is not clear what proportion of the care homes surveyed

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ABSTRACT Increasing attention is being paid to the inappropriate use of medicines in UK care homes for older people. While polypharmacy may sometimes be necessary, older people can be particularly sensitive to the effects of medicines due to physiological changes, while the effect of a mixture of medicines is often unknown. The harmful consequences of inappropriate prescribing for older people unnecessarily add to overall healthcare expenditure and the workload of staff. Community nurses can play an important role in attenuating some of these problems while enhancing the quality of life of older people in care homes. The growing population of older people and burgeoning health-care expenditure on medicines demands that greater attention is given to medicine management among older people so that the efficacy of therapeutic regimes are maximized.

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were non-nursing homes it is likely that significant numbers of older people resident in these homes were reliant on health-care delivery from community nurses. Therefore, in this context, community nurses could make an impact on the medicines management of these older people. This article discusses aspects of medicines management in care homes for older people. It looks at some of the reasons why inappropriate prescribing may occur and the consequences that this may have. It then considers what community nurses can do to address the problem of inappropriate prescribing in this setting. While the focus is on UK care homes, relevant evidence from other parts of the world is also cited. For the purposes of this article, the term ‘care home for older people’ may be defined as a residential home visited by district or community nurses, a nursing home employing their own nurses or a dual registered residential/nursing home.

Polypharmacy is not always inappropriate While polypharmacy is a risk factor for potential harm from medicines to older people (DH, 2001), the issue of prescribing in care homes for older people cannot be viewed as simply whether or not polypharmacy occurs. This is because polypharmacy in itself may not necessarily be a bad practice and may sometimes be a requirement for the treatment of older people with multiple pathologies. The broader term of ‘inappropriate prescribing’ is more useful because it also relates to adverse effects arising from prescribing practices in addition to unnecessary polypharmacy. For example, harm to older people may result from the under-use of certain medicines such as analgesics (Closs, 1996; Forman, 1996; Joseph and Harvarth, 1998; DH, 2001; Fine, 2001; Glajchen and Bookbinder, 2001; Herr, 2002), or medicines to prevent stroke, asthma and depression (DH, 2001). Harm may also result from the use of a single medicine, if taken excessively with regard to dose, duration or both (Beers et al, 1991), such as in the case of tranquillizers (Svarstad and Mount, 1991).

British Journal of Community Nursing, 2002, Vol 7, No 12

Reasons for inappropriate prescribing in care homes Inappropriate prescribing may occur in care homes for older people due to several factors. The treatment needs of older people with several coexisting chronic conditions necessitate the prescription of multiple medicines concurrently. This may be carried out by several health-care providers with minimal coordination of medicines management (Larsen and HootMartin, 1999). Unfortunately, little research has been conducted to determine the effects of combining multiple medicines in a single person (LeSage, 1991; Larsen and Hoot-Martin, 1999) and polypharmacy has been likened to an uncontrolled experiment (Larsen and Hoot-Martin, 1999). It is recognized that older people can be particularly sensitive to the effects of medicines (Furniss et al, 2000). Age-related physiological changes in metabolism and clearance affect the way medicines are absorbed, distributed and excreted from the body and may contribute to adverse drug reactions (ADRs) (Beers et al, 2000). Equally, older people often have altered organ sensitivity to medicines, for example, brain cells may be more sensitive to the effects of benzodiazepines (Beers et al, 2000). While those prescribing for older people can do little about age-related physiological changes, they do not always consider the potential effects of these changes, leading to inappropriate prescribing (Beers et al, 2000). Rochon and Gurwitz (1997), in describing the ‘prescribing cascade’, have noted that prescribers do not necessarily consider new symptoms as a possible consequence of new drug treatment, as opposed to a new disease. This ‘cascade’ of inappropriate prescribing begins when an adverse reaction to a drug is mistaken for a new medical condition. This leads to the prescription of another drug, so putting the patient at risk of manifesting additional adverse reactions, leading to the potential for further unnecessary treatment. Rochon and Gurwitz (1997) have provided examples of the prescribing cascade, including the use of metoclopramide to increase gastric motility in older people, leading to the antidopaminergic effects of metoclopramide being mistaken for symptoms of Parkinson’s disease and the consequent further prescription of anti-Parkinson’s drugs. This type of situation is likely to arise when prescribers do not stop to consider all the implications of the medicines that they are prescribing, or when they do not possess adequate knowledge about these medicines. In addition, evidence to underpin such knowledge may not be available, particularly with regard to the age-related adverse drug effects in older people (Cameron and Williams, 1996).


Medicines for pain relief are inappropriately under-used among older people (Closs, 1996; Forman, 1996; Fine, 2001; Glajchen and Bookbinder, 2001; Herr, 2002). This may lead to behaviour such as increased agitation due to undertreated pain, which is mistaken for dementia and leads in turn to further inappropriate prescribing of antipsychotic medicines (Joseph and Harvarth, 1998). Sengstaken and King (1993) noted that older people with pain were more likely to be receiving benzodiazepines, warning that prescribers needed to be aware of the dangers of over-use of these drugs in older people with pain, as such use is potentially detrimental. It is also suggested that other psychotropic medicines may be inappropriately prescribed to control undesired behaviour in older people, such as antipsychotic medicines given to treat pacing, wandering, lack of self-care, insomnia, poor memory and indifference to their surroundings (Manias, 1998). In a study of the residents (n = 760) of seven US nursing homes, Svarsted and Mount (1991) found that residents in facilities with less adequate staffing were significantly more likely to be given tranquillizers to control their behaviour. Nearly 19% of all older people studied were exposed to at least one type of excessive tranquillizer use, such as daily use for an excessive duration, concurrent use of three or more psychotropic medicines or the concurrent use of two or more tranquillizers. In a recent report (commissioned and edited by the Liberal Democrat MP, Paul Burstow) highlighting the inappropriate over-prescribing of antipsychotic medicines in UK care homes for older people, Burstow and Stokoe (2001) claimed that there is a lack of guidance and information provided to general practitioners (GPs) and psychogeriatricians regarding the prescription of antipsychotics to older people. Burstow and Stokoe (2001) note that this situation is exacerbated because there is a shortage of staff trained in caring for demented older people, which may result in the easier and cheaper option of controlling care home residents with antipsychotic medicines in the UK. Also, the staff who are available lack training and information about such medicines. According to Burstow and Stokoe (2001), the UK government does not provide enough funding for the provision of nursing and residential care for older people and has failed to direct the National Institute for Clinical Excellence (NICE) to issue guidelines for the prescription of antipsychotic medicines to older people. Furthermore, there is no review body to monitor the potential of inappropriate prescribing for older people.

‘The UK government does not provide enough funding for the provision of nursing and residential care for older people and has failed to direct the National Institute for Clinical Excellence (NICE) to issue guidelines for the prescription of antipsychotic medicines to older people.’

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‘There is evidence to suggest that in addition to avoiding the harmful consequences of inappropriate prescribing for older people and the costs that this will add to overall health-care expenditure, more appropriate prescribing will in itself save money.’

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Consequences of inappropriate prescribing The inappropriate over-prescribing of antipsychotic medicines in care homes has been described as a form of abuse, denying resident older people their dignity, which could result in unnecessary adverse drug effects and even death (Burstow and Stokoe, 2001). Antipsychotic phenothiazines such as chlorpromazine and perphenazine have a sedating effect for which they are commonly used in older people. However, because of their anticholinergic effects, phenothiazines may also cause postural hypotension, constipation, urinary retention, xerostomia, cardiac arrhythmias and delirium (Manias, 1998). They are contraindicated in prostatic hypertrophy and glaucoma (Lesseig, 1998), diseases which are common in older people. Neuroleptic agents such as haloperidol may have less of a sedating and anticholinergic effect. However, the results of a study by McShane et al (1997) suggested that when neuroleptic drugs are used to treat dementia they may worsen already poor cognitive function. Their study showed that the rate of cognitive decline among patients taking neuroleptics was twice that of those not taking them and that the start of neuroleptic treatment was associated with an increase in the rate of cognitive decline. Neuroleptics may cause loss of appetite, leading to increased risk of malnutrition (Varma, 1994), which is already prevalent in care homes (Copeman, 2000). Neuroleptics may also cause extrapyramidal sideeffects such as muscle rigidity, shuffling gait, tremor, dystonia (muscle weakness) and akathisia (involuntary movements). (McGrath and Jackson, 1996; Manias, 1998). These adverse effects may interfere with older peoples’ ability to walk and to undertake day-to-day activities (Manias, 1998). As Rochon and Gurwitz (1997) have noted, some of these symptoms may be mistaken for other pathologies, leading to further inappropriate prescribing. Also, druginduced delirium may be perceived as advancing dementia (Lesseig, 1998), leading to further prescription of antipsychotics, and extrapyramidal side-effects may be perceived as Parkinson’s disease leading to the prescription of anti-Parkinson’s drugs. Several studies have indicated that significant numbers of older people are hospitalized as a result of inappropriate prescribing and sometimes avoidable, adverse drug effects (Cunningham et al, 1997; Mannesse et al, 1997; Cooper, 1999). In one study of ADRs contributing to hospitalization, admissions of patients aged 70 years and over (n = 128) to a Dutch hospital were analysed over a 3-month period. The definition of an ADR was based on several criteria, including those identified in the British

National Formulary (BNF) and laboratory tests. Of the patients who were receiving drug treatment (n = 102, mean 5.9 drugs per patient), 42% were deemed to have had an ADR, including 24% who had had a severe ADR (Mannesse et al, 1997). In a UK study of older people admitted to hospital owing to suspected drug-related problems, Cunningham et al (1997) found that 14% of admissions (n = 144) had drug-related problems and 5.3% were deemed to be definitely or probably caused by a drug-related problem. The definition of a drug-related problem and its relationship to the hospital admission was determined by a panel comprising three of the authors. Non-steroidal anti-inflammatory drugs (NSAIDs) were found to be the main drug group responsible, causing 28% of admissions caused by drug-related problems, mainly due to haemorrhage of gastrointestinal ulcers, 66% of which were deemed to have been preventable if appropriate prescribing had taken place. The authors suggested a continuous education programme to limit NSAID use in older people. In a prospective 4-year study of the residents (n = 332) of two US nursing homes, Cooper (1999) found that the hospitalization of 52 (15.7%) older people was associated with ADRs. ADRs were defined by combining observed symptoms and events with laboratory results. For example, an NSAID-related ADR hospitalization was defined by emesis and blood present in stools combined with low haemoglobin, requiring administration of circulatory volume expanding agents, blood products and gastrointestinal protective medicines. The most common ADRs were: NSAID-related gastrointestinal injury, antipsychotic medicine-related falls resulting in fracture, digoxin-related toxicity and insulin-related hypoglycaemia. Cooper (1999) concluded that while the preventability of ADRs was not specifically addressed in this study, some ADRs could have been avoided, particularly those occurring in six patients who suffered ADR recurrences.

The cost of inappropriate prescribing There is evidence to suggest that in addition to avoiding the harmful consequences of inappropriate prescribing for older people and the costs that this will add to overall health-care expenditure, more appropriate prescribing will in itself save money. The NSF for older people (DH, 2001) reiterated that almost half of the NHS drugs bill is spent on older people. While noting that this money should be spent in a clinical and cost-effective manner to improve the health of older people while not increasing the effects of existing conditions, the NSF for older people high-


lighted that it has been shown that every £1 spent on pharmacist review of prescribed medicines resulted in cost savings of £2 (DH, 2001). Further to this, randomized, controlled reviews of medicines by pharmacists – of both care home residents and older people attending general practices – have indicated that savings can be made (Furniss et al, 2000; Zermansky et al, 2001). In a study of residents in 14 UK nursing homes (intervention group, n = 158; control group, n = 172), Furniss et al (2000) found that 74% of older people were receiving four or more medicines. On reviewing the intervention group the pharmacist made 85 recommendations that the indication for the medicine being taken was no longer present and 77 recommendations for the safer or more efficacious use of medicines. Over the 4-month interventionplus-review phase, the cost of medicines in the intervention group fell by £27.47 per resident compared with £1.29 per resident in the control group, without any detriment to the mental or physical health of residents in the intervention group. In fact, 14 of the residents in the control group died compared with 4 in the intervention group. However, the authors did not state what costs were incurred as a result of the pharmacist’s review (Furniss et al, 2000). Among older people (intervention group, n = 590; control group, n = 233) receiving repeat prescriptions in four general practices in the UK, Zermansky et al (2001) demonstrated a net saving of over £4 per patient per 28 days in the intervention group, whose prescribing was reviewed by a pharmacist. The authors stated that the costs incurred by the pharmacist’s review were £7 per resident. Extrapolating this cost to Furniss et al’s (2000) study would still mean that costs per resident in the intervention group fell by £20.47 over 4 months. If these exercises could be repeated throughout the UK, it is likely that considerable savings in expenditure on medicines for older people in care homes could be made, given the high prevalence of polypharmacy in this setting. Regular audit of prescribing practices in care homes should be undertaken to ensure that appropriate prescribing standards are met and maintained. However, these interventions will depend on greater commitment and funding from the UK government. Burstow and Stokoe (2001) highlighted the fact that in contrast to Australia, Sweden and the USA, there is an absence of a national initiative by the UK government to address inappropriate prescribing in care homes systematically.

The nurse’s role in preventing inappropriate prescribing In the absence of government initiative, relatively simple interventions can help to reduce inappropriate


prescribing and can result in less expenditure on medicines for older people. Community nurses can utilize their knowledge and experience regarding effective prescribing and the importance of assessing need, choice of product and efficacy of any prescription. In defining clinical governance, McKnight (2002) stated that medicines management is an integral part of the clinical governance development agenda and can be undertaken by all relevant health-care professionals. This could be particularly so for community nurses who have responsibility for and access to older people in care homes in the course of their work. Community nurses have the opportunity to refer to and collaborate with community pharmacists and doctors to realize the requirements set out in the NSF for older people (DH, 2001). Community nurses could use their contact with older people opportunistically by instigating medication reviews for care home clients in their caseload. Care home managers could be educated to recognize the value of such reviews in the light of evidence that a significant proportion of older people do not gain maximum benefit from their existing medication regimes through avoidable iatrogenesis (DH, 2001). While some medicines are under-used in older people, there is also evidence of substantial wastage of resources and inappropriate continued use of long-term treatments. Detailed medication reviews provide an opportunity to reassess the older person's needs and institute the most effective therapeutic regime (Zermansky et al, 2001). Community nurses may not currently be able to undertake ‘second order’ risk assessment for medicine-related problems (MRPs), where complex MRP identification would be required through specialist assessment using validated risk assessment tools (DH, 2001). No validated risk assessment tools currently exist and research is still needed to develop and validate them. However, community nurses could easily undertake ‘first order’ MRP risk assessments (DH, 2001), as part of joint social/health-care assessments which will identify inappropriate prescribing and associated health problems. This may require some modification of existing protocols. In the absence of formalized coordination of medicines management, community nurses can help to address the information needs of older people (and their carers) in care homes and help to ensure that older people have access to the appropriate medicine in the correct dose and form. This would help to ensure that older people were gaining the maximum benefit from their medicines while not suffering unnecessarily from inappropriate prescribing practice (DH, 2001). Community nurses can advise care home staff regarding good practice in medicine

‘In the absence of formalized coordination of medicines management, community nurses can help to address the information needs of older people (and their carers) in care homes and help to ensure that older people have access to the appropriate medicine in the correct dose and form.’

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administration, in line with Nursing and Midwifery Council guidelines (NMC, 2002). It may be that community nurses are already overworked and understaffed. However, in investing some extra time to achieve improved therapeutic regimes, community nurses may help to prevent some of the adverse effects that inappropriate prescribing has on older people, which could ultimately reduce the demands on them to provide support to older people in care homes.

Conclusion Older people can be particularly sensitive to the effects of medicines due to age-related physiological changes and often it is not known what the effect of a mixture of medicines may have on older people. Studies have indicated that significant numbers of older people are harmed and/or hospitalized because of the adverse effects of inappropriate prescribing. Inappropriate prescribing for older people and the harmful consequences unnecessarily add to the overall health-care expenditure and workload of staff. In the absence of government action, community nurses can still play an important role in reducing some of these problems and enhancing the quality of life of older people in care homes. The growing population of older people and burgeoning health-care expenditure on medicines demand that greater attention is given to medicines management among older people so that the efficacy of therapeutic regimes is maximized. ■ Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC (1991) Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 151: 1825–32 Beers MH, Baran RW, Frenia K (2000) Drugs and the elderly part 1: The problems facing managed care. Am J Man Care 6: 1313–20 Burstow P, Stokoe R (2001) Keep taking the medicine: antipsychotics and the over medication of older people.

KEY POINTS ● Polypharmacy (concurrent use of multiple medicines) is common in older people, particularly in care homes, and may sometimes be a requirement for the treatment of multiple pathologies. ● ‘Inappropriate prescribing’ can lead to adverse effects arising from prescribing practices in addition to unnecessary polypharmacy, e.g. underor over-prescribing. ● Inappropriate prescribing may occur in care homes for older people when chronic conditions necessitate the prescription of multiple medicines concurrently. This may be carried out by several health-care providers with minimal coordination of medicines management. ● Community nurses are in a position to undertake first-order risk assessments as part of health/social care assessments, and to provide information to care home residents and staff.

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