Primary Care Pharmacy September 2000 Vol 1 No 4 p105-108
Articles
Medication review in elderly care homes
By Gwen Klepping, DipClinPharm, MRPharmS
In this article, the benefits of regular medication reviews for elderly residents of homes are discussed
The elderly are defined as people over the age of 65 years and constitute almost 20 per cent of the UK population.1 Those aged over 75 years total 4 million and this figure is expected to double over the next 50 years. Those over 90 will increase five-fold.2 The elderly receive 45 per cent of all prescribed medication, 78 per cent of which is issued as repeat prescriptions.1
This potentially represents a huge problem as elderly patients in care tend to be at high risk from inappropriate prescribing, either from unsuitable choice of drug, dose or duration of treatment, or from inadequate monitoring.3
The average elderly resident tends to be taking five or more medicines.4 The drugs most commonly used tend to be those affecting the cardiovascular, gastrointestinal or central nervous system. Urinary appliances are also often used.
In addition, drug distribution is affected by a number of physical changes, which may predispose these patients to adverse reactions to drugs. For example:
- An increase in fat tissue — this results in a larger volume of distribution for lipid-soluble drugs and a prolonged half-life of, for example, psychotropics1
- Reduced total body water — this leads to higher plasma concentrations of polar drugs, such as lithium
- Decreased lean body mass — this can increase plasma concentrations of drugs like digoxin
- Reduced plasma albumin — this may result in higher concentrations of highly protein-bound drugs (eg, phenytoin, digoxin, warfarin)
Drug metabolism may also be compromised by decreased liver function and
also by renal elimination, which declines by 1 per cent per year from
the age of 40 onwards.
There is a recognised relationship between the number of drugs given,
the likelihood of a patient experiencing an adverse drug reaction (ADR)
and subsequent hospital admission.5 It is apparent
that patients over 80 years of age are twice as likely to develop an ADR
as younger patients. The detection of ADRs in this group may be further
complicated by polypharmacy, comorbidity and coexisting disease.6,7
Weighting factors for residential and nursing home patients were given in “Patients in homes”, a national study by the Prescribing Support Unit in Leeds. According to this study, such patients should be counted as two and three AstroPUs (Age Sex Temporary Resident Originated Prescribing Units), respectively, to allow realistic primary care budgeting.
The need for medication review in primary care was thus established. The elderly were targeted for review as the need in this population was most urgent and the process was most likely to be effective.
Method and results
My first experience of medication review in elderly care was on behalf of five fundholding practices combined under one board to form a larger fundholding group. It comprised 14 general practitioners. These practices were responsible for 120 patients in 11 residential or nursing homes.
During the study, each patient was reviewed using computer records and case-notes that were held in the relevant surgery. After discussions at the home with the main carer for each resident, a medication review was presented to the appropriate GP for further action. The GPs carried out 87 of the original 120 patient reviews. This resulted in 211 authorised changes (ie, agreed with by the doctor) from a suggested 256 interventions or recommendations. These recommendations mainly comprised updating the patient’s computer record but, in addition, 48 drugs were discontinued and 22 drug doses were altered. The study resulted in a saving of £3,768 per year to the practices.
The main drawback of this approach was a lack of communication between all parties. In addition, some of the authorised proposals were not carried out and 28 per cent of reviews were not processed at all for reasons such as the GP not agreeing with the proposed interventions or not being aware of the study.
Subsequent medication reviews have, therefore, involved a multidisciplinary approach, with the review being presented and the decision-making taking place in a meeting between the main carer, a GP and a pharmacist. I prepare the initial medication reviews, as before, and circulate copies to the GPs before the meeting. Any authorised changes arising from the meeting are recorded in the patient’s computer record to complete the review process. Figure 1 shows the type of form used to document the drug review process.
In one of the reviews, which involved 13 patients in a residential home,
the following recommendations were made. One patient needed no changes
to her medicines and two were awaiting further review via hospital consultant,
which left 10 patients. Changes to the medication of these 10 patients
included four drugs being deleted, six drugs being changed to more appropriate
alternatives and one drug being initiated. In addition, 10 updates to
computer records and six blood tests were requested.
This review, although small, resulted in an estimated saving of £1,170
per year to the practice.
Discussion
In 1989, the contract for pharmacists to advise residential care homes was introduced and subsequently extended to include nursing homes.8 However, the NHS does not require pharmacists to provide this service and only 36 per cent of pharmacies have such a contract. Some homes in rural communities may be dependent on a dispensing GP service. The Northern Community Services Pharmacists Group’s document “Standard for the management of medicines in registered nursing homes” suggests that a local community pharmacy should be used for the supply of medicines. This makes monitoring for potential interactions and incompatibilities easier and informed advice on all aspects of a patient’s medication can be given. This system has been endorsed by other studies. 5,9,10
While repeat prescriptions are convenient for both GP and carer, they may prevent regular drug reviews from taking place.3 Drug review identifies medicines that are no longer required, those prescribed for an ADR that could be prevented by changes in therapy, and use of similar drugs for the same indication. Clinical trials have shown that the intervention of a clinical pharmacist reduces medicine use in the nursing/residential home setting.
Drug review for elderly patients is a time-consuming but worthwhile process for all involved. I found the staff in the homes to be receptive to this approach. Most had excellent links with their local community pharmacist, who was used mainly for supply and advice. As a primary care pharmacist working within the practice I had close links with other surgery staff and direct access to patient’s notes. This reduced the time it took to undertake reviews, making them an easier and more positive process. Evidence suggests that pharmacists may be less successful at changing a GP’s prescribing patterns than fellow GPs. However, with the rapidly increasing numbers of pharmacists working in practices and at primary care group level, GPs are becoming more receptive to evidence-based reviews and recommendations from this source and appreciate the information provided that enables them to make more informed decisions.7,11,12
Residents of elderly care homes rarely have direct access to a pharmacist and to pharmaceutical care. Multidisciplinary review generally tends to exclude the patient or carer, despite the fact that most carers are knowledgeable about their charge. With appropriate prompting of the carer or patient about potential problems or difficulties with drugs (eg, side effects, use of inhalers or eye-drops, or timing of doses), a pharmaceutical care-plan can be evolved. By conducting these reviews within the home itself, any queries the main carer cannot answer can be relayed to other staff or to the patients themselves.
Compliance is not usually an issue in the residential home setting but any discrepancies may be identified by comparing the drug administration form supplied by the community pharmacist for use within the home and the patient medication record from the doctor’s surgery.
Pharmacists are well placed to identify ADRs that might lead to loss of independence or hospital admission. They are, therefore, extremely useful members of multidisciplinary teams that are involved in the care of elderly residents. Most elderly patients would benefit from pharmaceutical care over and above the usual supply or destruction of drugs.5,13 Pharmacists can promote safer prescribing practices by advising patients, doctors and carers.7 The primary care pharmacist is ideally situated to liaise with primary and secondary care to coordinate the pharmaceutical care for patients. The training needs of care staff in relation to medicines management can also be identified and addressed by primary care pharmacists.
Most of the care staff I have met, have expressed enthusiasm for medication reviews, in particular for laxative protocols, the use of enteral feeds and dressings policies (although district nurses usually deal with this last area). The input of the primary care pharmacist working with other health care professionals who look after elderly patients in homes could be coordinated with local community pharmacists and social services.
Conclusion
Drug review in elderly care provides benefits to:
- the patient — by encouraging appropriate and minimal prescribing
- the home — by making medicines management easier and increasing confidence in drug regimes used for patients
- the practice — both financially and by increasing confidence in the repeat prescribing process
The most effective way to achieve a satisfactory drug review is a multidisciplinary approach involving the main carer and/or patient, GP and pharmacist, with input from district nurses and others as appropriate.
Acknowledgement: the author would like to thank Gillian Johnson, pharmaceutical adviser, North Cumbria health authority, for her support and proof-reading of this article.