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Toronto, CANADA – Older adults who live in Ontario nursing homes are half as likely to be dispensed a potentially inappropriate drug compared to community-dwelling older adults, according to a study by Baycrest Centre for Geriatric Care.
The study is published in the June 2004 issue of the Journal of the American Geriatrics Society.
“Potentially inappropriate drugs” are those which should always be avoided or are rarely appropriate in older adults because the risks outweigh the benefits and there are now better alternatives that are as effective with fewer side effects. The definition is based on the well-known Beers criteria – established in 1991 by a consensus panel of experts in geriatric medicine, psychiatry and pharmacology from the U.S. and Canada.
Among the drug therapies included on the Beers list in the always avoid or rarely appropriate categories are certain types of anti-anxiety medications that stay in the body for prolonged periods of time, skeletal muscle relaxants that can cause sedation and weakness, and barbiturates because they are highly addictive. Of the 19 drugs in these two categories combined, fewer than one third are currently available from the Ontario Drug Benefit (ODB) Formulary.
“We found that those who live in nursing homes were 48% less likely to be dispensed a potentially inappropriate drug than community-dwelling older adults,” says senior author Dr. Paula Rochon, a geriatrician and scientist with Baycrest. She co-authored the study with Dr. Chris Lane of the University of Toronto.
What explains the difference in vigilant prescribing practices between nursing homes and the community? One of the most important factors may be that in Ontario the provision of clinical pharmacy services is mandated in the nursing home setting. The pharmacist is required to prepare a record of each resident’s drug regimen every three months for the primary care physician. No comparable program exists for older adults in the community.
However, Dr. Rochon cautions that even though nursing homes did better in this comparison, the fact remains that inappropriate prescribing is going on in both nursing home and community-dwelling settings – and the goal should be to eliminate this activity wherever possible.
The Toronto researchers examined three databases (ODB plan, Canadian Institute for Health Information and the Registered Persons database) that collectively comprisedMore than 1.2 million adults aged 66 and older who were dispensed at least one prescription from the comprehensive provincial drug plan in 2001. The seniors were then divided into two groups – those living in nursing homes (58,719) and those who were community-dwelling (1,216,900).
“Our investigation found that, overall, 3.3% of community-dwelling older adults and 2.3% of nursing home residents in Ontario were getting these potentially inappropriate drugs,” says Dr. Rochon. After adjusting for patient characteristics, the patients in long-term care were found to be about half as likely to be dispensed these drugs.
“In population numbers this translates into 40,307 older adults in the community and 1,328 adults in nursing homes getting these drugs,” says Dr. Rochon.
The authors point out that their database study did not look at individual cases to determine if potentially inappropriate drugs from the Beers list led to an adverse health event, including death.
“All drugs come with some degree of side effects,” she says. “The take-home message from our study is that every effort should be made to choose a drug that will be best tolerated in older and frailer individuals, with the least potential for adverse side effects.”
How to reduce potentially inappropriate prescribing in older adults?
Community-dwelling older adults may benefit from a regular review of their drug therapy by a clinical pharmacist working in conjunction with their primary care physician, similar to the nursing home model, says Dr. Rochon. In addition technological innovations, such as computerized physician order entry (POE) with clinical decision support, may provide an opportunity to reduce inappropriate prescribing in both the nursing home and community settings. POE has been successful in improving prescribing decisions in the acute care setting. Baycrest Centre will soon become the first nursing home in Canada, and one of the few internationally, to use POE for the approximately 800 seniors it cares for in its hospital and nursing home.
The Baycrest study was funded by the Canadian Institutes of Health Research’s Chronic Disease New Emerging Team (NET) program. Baycrest Centre is an internationally-renowned academic health sciences centre, affiliated with the University of Toronto, that focuses on care for older adults.