Interventions to optimize medication use in nursing homes: a narrative review

Abstract

Purpose Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. Methods We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. Results Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. Conclusion Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.

Potentially inappropriate medications in nursing homes and the community older adults using the French health insurance databases

“…and the feasibility of their large-scale implementation are not well established. 35,36 As previously reported, the pattern of individual PIM indicators differed according to the place of residence. 25,37 This difference could be related to distinct goals and organization of care between the community and NH.…”

“…In CDOAs, randomized controlled trials have also demonstrated that pharmacist intervention, computerized clinical decision support information, and multifaceted interventions were effective in reducing PIMs 35 . However, as ADRs are multifactorial, the direct impact of these interventions on clinical outcomes (such as hospitalization, quality of life, and ADRs) and the feasibility of their large‐scale implementation are not well established 35,36 …”

Enhancing deprescribing: A qualitative understanding of the complexities of pharmacist‐led deprescribing in care homes

“…In the United Kingdom, the NHS Long-Term plan commits to increasing the number of pharmacists in primary ). Yet, there are suggestions that mandatory strategies may be more effective than guidance or recommendations at supporting medicine review practices (Spinewine et al, 2021). The impact of national guidance will need to be monitored to see if legislation is needed to support evidence-based guidance.…”

Deprescribing as a strategy for improving safety of medicines in older people: Clinical and regulatory perspective

“…Different types of interventions to optimize medications in nursing homes have been identified (Spinewine et al, 2021): micro-level interventions, such as medication review or patientcentered care, and macro-level interventions, such as guidelines and legislation (defined as change in reimbursement, initiation of public reporting of antipsychotic use). Some examples of microlevel interventions are reported in five recent multicenter trials in Europe, which involved multidisciplinary interventions consisting of education of healthcare providers and medication reviews (Fog et al, 2017;Wouters et al, 2017;Cool et al, 2018;Husebø et al, 2019;Strauven et al, 2019); these interventions showed positive effects on reduction of the number of drugs by 9% and PIMs by 65%.…”