[Quality and appropriateness of pain medication. Instrument for estimation in nursing home residents]. / Qualität und Angemessenheit der Schmerzmedikation. Instrument zur Einschätzung bei Pflegeheimbewohnern.

BACKGROUND: The pain medication appropriateness scale (PMASD) was developed in 2006 in the USA to evaluate the quality and appropriateness of pain treatment in nursing home residents (NHR). This tool can be used to identify potential problems with the pharmacological treatment of pain. METHODS: We developed a German version (PMASD) adapted to the German setting and applied it in Germany to NHR with and without cognitive impairment for the first time. In agreement with the original instrument a test result of >67 % was considered as appropriate pain treatment. RESULTS: For the 560 analyzed NHR the average SPMAS score was 39±1,7 (range from -67 to +100). Overall 72% of the study population did not achieve the defined threshold for appropriate pain management. CONCLUSIONS: An appropriate tool for quantitative evaluation of pain treatment was so far not available in Germany. The PMASD analysis showed deficits of pain management in NHR. This tool showed good practicability in Germany and could provide a valuable tool for pain treatment in clinical research and practice.

[Pain, fear of falling and functional performance in nursing home residents - a cross-sectional study]. / Schmerzen, Sturzangst und funktionelle Fähigkeiten von Menschen in Pflegeheimen - eine Querschnittsstudie.

Pain and fear of falling (FOF) are modifiable factors that might play an important role in functional performance of nursing homes residents (NHR). Both factors are characterised by deficits in research and provision of long-term care services. The purpose of this study was to examine the functional performance of NHR with and without pain or FOF. Quantitative data were collected on NHR in Berlin and Brandenburg using a cross-sectional design. The cognitive status was assessed using the Minimental state test. Existing pain and FOF were assessed as a question part of interview. Functional performance was examined using the Barthel Index (BI) the Timed «up & go¼-Test. Multiple linear regression analyses were performed to investigate the research question and the influence of additional explanatory variables (age, sex, relevant somatic morbidity). 217 NHR without considerable cognitive impairment (MMST >= 20) participated. 65 % of the NHR suffered from pain and 48 % had FOF. There was a statistically significant association between Pain or FOF und lower functional mobility. With respect to NHR able to walk, there was statistically significant association between Pain or FOF und lower performance in activities of daily living. Possibilities for interventions which might have positive effects on functional performance of NHR are an improved pain treatment and interventions to reduce FOF.

[Interdisciplinary guidance for pain management in nursing home residents]. / Interdisziplinäre Handlungsempfehlung zum Management von Schmerzen bei älteren Menschen in Pflegeheimen.

Pain management in nursing home residents (NHR) is insufficient. Hence, this guidance summarizes latest research results and guidelines of particular requirements on treatment of pain in the elderly. The purpose is to improve health care processes and outcomes on individual and institutional level. To reach this aim a multidisciplinary collaboration is essential. The prerequisite for adequate pain treatment is to conduct a standardized pain assessment. Likewise, the application of all opportunities of non-medical pain treatment strategies contributes to the reduction of occurrence of pain and therefore to the preservation of quality of life in NHR. Age-related changes in physiology may affect tolerance and effects of analgesics. Besides, drug interactions need to be considered. After all, education of NHR and involvement of their relatives in pain management foster successful management and treatment of pain.

Antipsychotic drugs predominate in pharmacotherapy of nursing home residents with dementia.

INTRODUCTION: The aim of this study was to investigate the frequency of benzodiazepines, antidementia and antipsychotic drug prescriptions in nursing home residents (NHR).Data of a German health insurance company were retrospectively analyzed for the year 2008. METHODS: The study cohort comprised 13,042 NHR (82% women, mean age 83.6 ± 7 years). Following analgetics, antipsychotic drugs were the second most frequently prescribed drug group with 13.3% of all prescriptions. Dementia was diagnosed in 8 017 (61.5%) NHR. Thereof 51.6% received an antipsychotic, 17.3% a benzodiazepine and 15.2% an antidementia pharmaceutical, respectively. 18.1% of NHR with dementia and antipsychotic drug prescriptions were in combined treatment with antidementia pharmaceuticals. The rate of antipsychotic drug prescribing was significantly doubled in NHR with dementia compared to those without this diagnosis (p<0.01); the most frequently prescribed antipsychotics were melperone, risperidone and pipamperone. DISCUSSION: This study demonstrates the wide-spread use of psychotropic drugs in NHR. Moreover, dementia in NHR was associated with antipsychotic drug prescribing in every second patient. This highlights the need for further studies analyzing alternative treatments for dementia-related symptoms.

Deficits in pain treatment in nursing homes in Germany: a cross-sectional study.

BACKGROUND: Current knowledge about the quality and appropriateness of pharmacological pain treatment in nursing home residents (NHR), particularly in NHR with moderate to severe cognitive impairment, is poor. METHODS: This observational cross-sectional study assessed pain treatment in a random sample of NHR with or without cognitive impairment from nursing homes in Germany. Prescribed drugs, pain intensity and frequency, diagnoses, and surgical procedures and injuries during the last 4 weeks were documented. Quality and appropriateness of pain medication were assessed by analysis of pain medications and the Pain Medication Appropriateness Scale (PMAS) score (S(PMAS) ), with a cut-off value of >67% indicating appropriate pain treatment. RESULTS: A total of 321 residents (62% women) were studied, including 152 (47%) with severe cognitive impairment. The most frequently prescribed analgesics were dipyrone, fentanyl, tramadol and ibuprofen. The mean S(PMAS) was 48.5 ± 1.5 (range, -33 to +100). Residents with prescribed scheduled analgesics had a significantly better S(PMAS) than patients without such treatment (S(PMAS) 58 ± 1.5 vs. 37 ± 2.5, p < 0.01). NHR without current pain had significantly better S(PMAS) than residents suffering from pain (S(PMAS) 47 ± 1.9 vs. 59 ± 4.2, p = 0.01). With an S(PMAS) of 69 ± 1.5, residents (n = 106) with scheduled pain medication plus PRN analgesics achieved the highest scores in the population. Overall, similar results were found in NHR with and in NHR without cognitive impairment. CONCLUSION: Our study points to a significant deficit in pain treatment in German NHR, including NHR with or without cognitive impairment.

[Use of health insurance data to analyse pain management practices in the nursing-home setting]. / Sekundärdatenanalyse von Routinedaten einer Krankenkasse - Ein Zugangsweg zur Beschreibung schmerzbezogener Versorgungsleistungen von Pflegeheimbewohnern.

Pain is the most common health-related complaint in older persons. International estimations mention up to 80% of nursing home residents suffering from pain. In the meantime, no reliable epidemiological data on pain in nursing home residents are available for Germany, because of restricted access to the nursing-home population. This pilot study aimed to evaluate whether routine data from a German statutory health insurance fund can be used to generate data on pain prevalence and analgesic therapy in nursing home residents. To this end, data of all insured persons of Deutsche BKK who received long-term care insurance benefits for nursing-home care between April and June 2007 were selected anonymously. These data were combined with data on diagnoses and analgesic prescriptions. 3 pain-related diagnoses were selected: R 52 (pain, not elsewhere classified), M 16 (coxarthrosis) and G 53.0 (postherpetic neuralgia) and analysed for corresponding prescriptions. The study sample shows similar characteristics regarding age distribution and care needs in terms of long-term care insurance benefits compared to the official data on nursing-home residents for Germany in 2007. The rate of dementia was within the expected range, too. Therefore, external validity of the sample is assumed. One of the 3 selected diagnoses had been documented in 15% of the sample. About 58% of those received an analgesic prescription. Deficits were discovered regarding the documentation of postherpetic neuralgia, the combination of different analgesics and prescriptions for adjuvant drugs. Prevalence rate and numbers of prescriptions were as frequent as expected. The routine method for this analysis proved to be practicable and reliable. Data quality is deemed sufficient so that the main study will proceed to include a longer period of time and additional data.

[Prescribing of antihypertensive drugs to elderly residents of nursing homes in Germany]. / Verordnung von Antihypertensiva bei geriatrischen Pflegeheimbewohnern in Deutschland.

OBJECTIVE: To analyse and evaluate the use of antihypertensive medication in elderly patients of nursing homes in Germany. METHODS: Data from a large German health insurance company were collected in a cross sectional study. Included were all insured persons aged 65 years or older, who were residents of a nursing home between 1 April and 30 June 2007 throughout Germany. Antihypertensive drugs were those classified according to the current guidelines published by the German Hypertension Society. RESULTS: The study comprised 8,685 residents of nursing homes, 84 % women. The mean age was 84 years (range 65 - 106 years). Antihypertensive drug prescriptions accounted for 17 % of all drug prescriptions and about 70 % of all residents received at least one prescription for antihypertensive drugs. The most frequently prescribed antihypertensive drugs were diuretics, of which 70 % were loop diuretics. Potentially inappropriate combinations of antihypertensive drugs were noted in 5.2 % of patients receiving these drugs. CONCLUSION: Antihypertensive drugs account for a notable part (17 %) of all drug prescriptions in elderly residents of nursing homes throughout Germany. These results indicate that only a minority of all residents were treated with potentially inappropriate or potentially harmful drug combinations. However, the relatively high rate of prescriptions for loop diuretics is a matter of potential concern in this vulnerable group of patients.

[Antihypertensive drug treatment and renal function in geriatric emergency patients]. / Antihypertensive Pharmakotherapie und Nierenfunktion bei geriatrischen Notfallpatienten.

OBJECTIVE: The aim of this study was to assess drug prescriptions and renal function in a cohort of geriatric emergency patients with a focus on antihypertensive drug treatment. PATIENTS AND METHODS: The one-year observational study was conducted among patients from nursing and retirement homes or outpatient care who were treated by the emergency medical service. Overall, 109 patients (85 women, mean age 85+/-8 years) were studied. Glomerular filtration rate was estimated (eGFR) on the basis of creatinine and cystatin C serum concentrations. RESULTS: The most common emergency admission diagnosis was syncope (n = 23), while the most common clinical diagnoses were dementia (n = 61) and hypertension (n = 60). Overall, 603 drugs were prescribed (mean 5.5 +/- 3, range 0 - 13), with 65 patients (60 %) receiving >/= 5 drugs per day. Of 60 patients with the known diagnosis of hypertension 55 (92 %) were being treated, while 71 % received at least 2 antihypertensive drugs. ACE-inhibitors (n = 33), loop diuretics (n = 28), beta-blockers (n = 22) and hydrochlorothiazide (n = 15) were the most frequently prescribed drugs. Mean creatinine (1.33 +/- 0.66 mg/dl) and cystatin C (1.78 +/- 0.83 mg/l) concentrations were elevated. Overall, up to two thirds of patients had eGFR values of < 60 ml/min/1.73 m (2). In up to 31 % of patients dosages were too high in relation to renal dysfunction. CONCLUSIONS: The prescription of antihypertensive drugs contributes significantly to polypharmacy in geriatric emergency patients. About two thirds of these patients had clinically relevant impairment of renal function. The latter, together with the high number of prescribed drugs, may expose geriatric patients to an increased risk of adverse drug reactions requiring emergency treatment.