Therapeutic optimization through goal-oriented prescription in nursing homes

Abstract

Background People living in nursing homes are highly vulnerable and frail. Polypharmacy and inappropriate prescription (IP) are also common problems. Objectives The objectives of the study are (i) to study the baseline situation and calculate the frailty index (FI) of the residents, (ii) to assess the results of routine clinical practice to do a pharmacotherapy review (patient-centred prescription (PCP) model) (Molist Brunet et al., Eur Geriatr Med. 2015;6:565–9) and (iii) to study the relationship between IP and frailty, functional dependence, advanced dementia and end-of-life situation. Setting Two nursing homes in the same geographical area in Catalonia (Spain). Method This was a prospective, descriptive and observational study of elderly nursing home residents. Each patient’s treatment was analysed by applying the PCP model, which centres therapeutic decisions on the patient’s global assessment and individual therapeutic goal. Main outcome measure Prevalence of polypharmacy and IP. Results 103 patients were included. They were characterized by high multimorbidity and frailty. Up to 59.2% were totally dependent. At least one IP was identified in 92.2% of residents. Prior to the pharmacological review, the mean number of chronic medications prescribed per resident was 6.63 (SD 2.93) and after this review it was 4.97 (SD 2.88). Polypharmacy decreased from 72.55% to 52.94% and excessive polypharmacy fell from 18.62% to 5.88%.The highest prevalence of IP was detected in people with a higher FI, in those identified as end-of-life, and also in more highly dependent residents (p < 0.05). Conclusions People who live in nursing homes have an advanced frailty. Establishing individualized therapeutic objectives with the application of the PCP model enabled to detect 92.2% of IP. People who are frailer, are functionally more dependent and those who are end-of-life are prescribed with inappropriate medication more frequently.

Individualized Medication Review in Older People: Differences Due To Place of Residence Being Their Own Home or A Nursing Home

“…The differences detected in the baseline status in institutionalized patients compared to those living at home are similar to those described in other studies [14,28]. It is remarkable that more than half of the people living in nursing homes are identi ed as end-of-life, a higher proportion than that observed in other national and international studies [29,30].…”

“…Other studies conducted in the nursing home setting have also detected a prevalence of around 90% of IP [14]. Overall, this could suggest that MR in the frailest patients is a bene cial practice, regardless of their average of chronic medications.…”

“…Post-MR DBI shows a relevant decrease in both settings, with no statistical differences. This is likely to be related to the higher prevalence of patients with cognitive impairment in nursing homes [14,29].…”

“…Each patient's treatment was analyzed by applying the Patient-Centered-Prescription (PCP) model [14]. This is a systematic 4-stage process, carried out by a multi-disciplinary team formed by patient's General Practitioner and the nurse with a consultant team (a geriatrician and a clinical pharmacist).…”

“…Criteria used to determine IP: the following recommendations were used to identify IP in the most prevalent chronic conditions [14]:…”