Burden of Potentially Harmful Medications and the Association With Quality of Life and Mortality Among Institutionalized Older People.

OBJECTIVES: This study investigated the overlap among 3 different definitions of potentially harmful medication (PHM) use and the corresponding associations with resident quality of life and mortality. DESIGN: Cross-sectional study with 3-year follow-up for mortality. SETTING: Assisted living facilities and nursing homes in Helsinki and Kouvola, Finland. PARTICIPANTS: A total of 326 residents. MEASUREMENTS: PHM use was defined as (1) use of medications with anticholinergic properties, (2) use of Beers Criteria medications, and (3) concomitant use 3 or more psychotropic medications. Health-related quality of life (HRQoL) was assessed using the 15D and psychological well-being (PWB) scale. Residents self-rated their own health using a 4-point scale. Mortality data were obtained from central registers. RESULTS: There were 38.0%, 28.2%, and 12.6% of residents who used PHMs according to 1 (G1), 2 (G2), and 3 definitions (G3), respectively. Overall, 21.2% of residents did not use PHMs according to any of the 3 definitions (G0). There were no significant differences in comorbidity, cognition, or functioning among groups. In adjusted analyses, there was a stepwise association between use of multiple PHMs and poorer self-rated health, poorer PWB, and poorer HRQoL. There was no association in adjusted analyses between PHM use and 3-year mortality (47.8%-63.8%). CONCLUSION: PHM use is highly prevalent in institutional settings, regardless of the definition of inappropriateness. Residents who used multiple categories of PHMs were at greatest risk of poor HRQoL, poor PWB, and poor self-rated health. However, there was no apparent association with increased mortality. Given the importance of quality of life as an outcome to older people, further efforts are needed to minimize PHM use in this setting.

Nurse Education to Reduce Harmful Medication Use in Assisted Living Facilities: Effects of a Randomized Controlled Trial on Falls and Cognition.

BACKGROUND: Psychotropic and anticholinergic medications may increase the risk of falls and impair cognition. OBJECTIVE: The aim of the study was to investigate whether educating nursing staff in assisted living facilities about harmful medication use has effects on the incidence of falls and cognition. METHODS: This was a secondary analysis of a cluster randomized controlled trial (N = 227 residents, ≥65 years) in 20 wards in assisted living facilities in Helsinki, Finland. Wards were randomized to those in which staff received two 4-h interactive training sessions to recognize potentially harmful medications (intervention group) and a control group. Cognition (verbal fluency, clock-drawing test) was assessed at baseline and 6 and 12 months. The number of falls per resident over the 12-month follow-up was recorded. RESULTS: The prevalence of harmful medication use declined in the intervention group {-11.7% [95% confidence interval (CI) -20.5 to -2.9]; p = 0.009}, but remained constant in the control group [+3.4% (95% CI -3.7 to 10.6); p = 0.34]. There were 171 falls in the intervention group (2.25 falls/person year, 95% CI 1.93-2.62) and 259 falls in the control group (3.25 falls/person year, 95% CI 2.87-3.67) [incidence rate ratio 0.72 (95% CI 0.59-0.88); p < 0.001]. Residents in the intervention group with a Mini-Mental State Examination (MMSE) score ≥10 had significantly less falls compared with respective residents in the control group (p < 0.001). Changes in verbal fluency or clock drawing test were not significantly different between the groups. CONCLUSION: Educating nurses using activating learning methods can reduce the prevalence of harmful medications and the incidence of falls among residents in institutional settings.

Eight-Year Trends in the Use of Opioids, Other Analgesics, and Psychotropic Medications Among Institutionalized Older People in Finland.

IMPORTANCE: It is recognized that pain has been undertreated and psychotropic medications overused in institutional settings. OBJECTIVE: To investigate the change in prevalence of opioids, other analgesics, and psychotropic medications in institutional settings over an 8-year period. SETTINGS: Institutional settings in Helsinki, Finland. PARTICIPANTS: Older residents in nursing homes in 2003 (n = 1987) and 2011 (n = 1576) and in assisted living facilities in 2007 (n = 1377) and 2011 (n = 1586). OUTCOME MEASURES: Comparable audits of medication use were conducted among institutionalized residents at 3 time points over 8 years. The prevalence of regular opioid, other analgesic, and psychotropic medications was compared across the 3 time periods. RESULTS: Nursing home and assisted living facility residents were older; more disabled, had a higher prevalence of dementia, and greater comorbidity in the latter cohorts. The prevalence of regular opioid use was 11.8% and 22.9% in nursing homes in 2003 and 2011 (P < .001), and 8.6% and 17.3% in assisted living facilities in 2007 and 2011 (P < .001), respectively. The prevalence of regular acetaminophen and pregabalin/gabapentin increased and NSAIDs decreased in both nursing homes and assisted living facilities. The prevalence of regular antipsychotic use decreased from 42.6% to 27.8% in nursing homes (P < .001) but increased from 26.9% to 32.0% in assisted living facilities (P = .0017). The mean number of psychotropic medications (antipsychotics, antidepressants, anxiolytics, hypnotics) per resident decreased from 1.9 in 2003 to 1.0 in 2011 in nursing homes (P < .001) but increased from 1.1 to 1.2 in assisted living facilities (P = .040). CONCLUSIONS: The prevalence of opioid use in institutional settings has doubled during the past decade. The prevalence of psychotropic medications has decreased in nursing homes but increased in assisted living facilities. The increase in opioid use may reflect improved recognition and treatment of pain. However, initiatives are needed to monitor opioid-related adverse drug events and ensure appropriate use of psychotropic medications, particularly in assisted living facilities.

Education to reduce potentially harmful medication use among residents of assisted living facilities: a randomized controlled trial.

OBJECTIVES: The objectives of this study were (1) to investigate the effect of nurse training on the use of potentially harmful medications; and (2) to explore the effect of nurse training on residents' health-related quality of life (HRQoL), health service utilization, and mortality. DESIGN: A randomized controlled trial. SETTING AND PARTICIPANTS: In total, 227 residents in 20 wards of assisted living facilities in Helsinki were recruited. The 20 wards were randomized into those in which (1) staff received two 4-hour training sessions on appropriate medication treatment (intervention group), and (2) staff received no additional training and continued to provide routine care (control group). INTERVENTION: Two 4-hour interactive training sessions for nursing staff based on constructive learning theory to recognize potentially harmful medications and corresponding adverse drug events. MEASUREMENTS: Use of potentially harmful medications, HRQoL assessed using the 15 dimensional instrument of health-related quality of life, health service utilization, and mortality assessed at baseline, and 6 and 12 months. RESULTS: During the 12-month follow-up, the mean number of potentially harmful medications decreased in the intervention wards [-0.43, 95% confidence interval (CI) -0.71 to -0.15] but remained constant in the control wards (+0.11, 95% CI -0.09 to +0.31) (P = .004, adjusted for age, sex, and comorbidities). HRQoL declined more slowly in the intervention wards (-0.038 (95% CI -0.054 to -0.022) than in the control wards (-0.072 (95% CI -0.089 to -0.055) (P = .005, adjusted for age, sex, and comorbidities). Residents of the intervention wards had significantly less hospital days (1.4 days/person/year, 95% CI 1.2-1.6) than in the control wards (2.3 days/person/year; 95% CI 2.1-2.7) (relative risk 0.60, 95% CI 0.49-0.75, P < .001, adjusted for age, sex, and comorbidities). CONCLUSIONS: Activating learning methods directed at nurses in charge of comprehensive care can reduce the use of harmful medications, maintain HRQoL, and reduce hospitalization in residents of assisted living facilities.

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial.

BACKGROUND: Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services. METHODS AND DESIGN: During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations. DISCUSSION: To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people. TRIAL REGISTRATION: ACTRN12611001078943.