In the past 15 years the number of people admitted to private nursing homes has increased six-fold (Royal College of Physicians, 1997), and increasing levels of physical and mental ill health in residents entering homes have resulted in raised dependency levels (Reference Stern, Jagger and ClarkStern et al, 1993). Elderly nursing home residents receive up to four times as many prescription items as older people living in their own homes (Reference Walley and ScottWalley & Scott, 1995). There is evidence of inappropriate prescribing in nursing homes - about half of nursing home residents are on at least one inappropriate drug (Reference Beers, Ouslander and RollingherBeers et al, 1991; Reference Lunn, Chan and DonoghueLunn et al, 1997). Studies have demonstrated the value of pharmacists in reducing medication in nursing homes (Reference ObenchainObenchain, 1991; Reference HirshfieldHirshfield, 1993; Reference Miller, Warnock and MarshallMiller et al, 1993; Reference Neel, Pittman and MarascoNeel et al, 1993; Reference Cole, Jacobs and SilverCole et al, 1996) and in the USA, pharmacists are legally required to carry out monthly medication reviews. In the UK, few studies have examined this issue (Reference LapsleyLapsley, 1988; Reference CorbettCorbett, 1997); none have been controlled trials or have included an economic analysis. The current study aimed to investigate the effect of a review of the medication of nursing home residents by a pharmacist.
METHOD
A 4-month observation phase was followed by a 4-month intervention; these periods were chosen to provide acceptably precise estimates of pharmacist activity.
Homes and residents
Fourteen homes took part in the study, matched into seven pairs equivalent in number of beds, registration status and resident mix. Each home in the pair came from different areas in South Manchester, to avoid a situation in which a general practitioner (GP) was looking after residents in both a control home and an intervention home. Using computer-generated pseudorandom numbers, one home in each pair was randomly allocated to receive a regular medication review by a pharmacist (intervention group) and the other to receive no pharmacist review (‘normal’ control group). Homes were randomised at the start of the observation phase. Written consent was obtained from each resident (from the next of kin if necessary) and the investigation was approved by the local ethics committee.
Intervention
The intervention consisted of a medication review by the study pharmacist for all consenting residents in homes in the intervention group. The review took place at the beginning of the intervention phase, in the GP's surgery, at the nursing home or (in exceptional circumstances) over the telephone. The pharmacist (L.F.) collected details of current medication for each resident from the Medicines Administration Record (MAR) chart in the home, together with a brief medical history and any current problems identified by the home staff. Three weeks after the medication review, the homes were revisited, to ascertain whether there had been any immediate problems with the changes in medication and to see if the suggested changes had been implemented.
Assessments
The following standardised tests were carried out on each resident in both groups at the beginning of the study (Time 0), after 4 months (Time 1, i.e. the beginning of the intervention) and 8 months (Time 2, i.e. the end of the intervention): Mini-Mental State Examination (MMSE; Reference Folstein, Folstein and McHughFolstein et al, 1975); Geriatric Depression Scale (GDS; Reference YesavageYesavage, 1988); Brief Assessment Schedule Depression Cards (BASDEC; Reference Adshead, Cody and PittAdshead et al, 1992); and Crichton-Royal Behaviour Rating Scale (CRBRS; Reference RobinsonRobinson, 1965; Reference Wilkin, Mashiah and JolleyWilkin et al, 1978).
Data were also collected on the types and numbers of drugs each resident was taking, and the reason for the use of any neuroleptic drugs was obtained from the nursing staff. The study pharmacist assessed whether the use of neuroleptics complied with the US Ombudsman Reconciliation Act (OBRA) guidelines (i.e., that the use of a neuroleptic is appropriate for psychotic disorders and organic mental syndromes associated with types of behaviour that present a danger to others or interfere with the abilities of staff to provide care for the resident) (Reference McGrath and JacksonMcGrath & Jackson, 1996). Information was collected on the use of primary and secondary care resources, and the number of accidents and deaths.
The initial assessments were made by the study pharmacist and the psychiatrist. The second and third assessments were carried out by six Registered Mental Nurses trained in the administration of the instruments, to ensure consistency and reliability.
Statistical analysis
The size of the study sample was determined from changes observed in behavioural characteristics (CRBRS) in a previous study (Reference Wilkin, Mashiah and JolleyWilkin et al, 1978). Assuming a within-homes variance of 50 and an intra-class correlation between 0.01 and 0.05, six to eight homes, each containing at least 20 residents, were required to detect differences of four points on the CRBRS scale as being statistically significant at the conventional 5% level with 90% power. To allow for drop-outs and refusals, homes with more than 20 residents were sought; the average number of residents per home who agreed to take part in the study was 23.6.
Changes over the study period were compared between the two study groups, using multivariate regression methods. To account properly for the cluster randomisation design used, ‘nursing home’ was forced into all regression models as a cluster variable (thus the unit of analysis was nursing home, not individual resident). In order to make full use of the study subjects remaining alive at each assessment time, separate analyses were carried out using the Time 1 and Time 2 observations; for both analyses, Time 0 observations were used as covariates to adjust appropriately for baseline differences between the study groups. All computations were done using the SPSS and STATA statistical computer packages.
RESULTS
Characteristics of the study sample (Table 1)
The 14 homes contained 424 residents, of whom 330 (78%) agreed to participate. On average, residents in the control homes were slightly younger, and there were proportionally fewer residents in these homes. The residents in the intervention group were served by 24 GPs, none of whom refused to take part. Over the course of the study, 28 (16.3%) residents in the control homes and 26 (16.5%) in the intervention homes died.
Table 1 Characteristics of study sample
| Control group | Intervention group | |
|---|---|---|
| No. of residents at time 0 | 172 | 158 |
| Age, years: mean (s.d.) | 78.9 (13.7) | 83.5 (9.2) |
| Females, n (%) | 115 (67%) | 125 (79%) |
| No. of deaths during observation phase | 14 | 22 |
| No. of residents at Time 1 | 158 | 136 |
| No. of deaths during intervention phase | 14 | 4 |
| No. of residents at Time 2 | 144 | 132 |
Mental and physical state (Table 2)
Table 2 shows the mean differences in the rating scores between the two study groups; those reported for Times 1 and 2 are covariate, adjusted for the differences observed between the groups at Time 0. In addition, the numbers of residents scoring above or below the accepted cut-off points are summarised for each scale.
Table 2 Mean rating scale scores
| Time 0 | Time 1 | Time 2 | |
|---|---|---|---|
| MMSE | |||
| Control (no. with score < 23) | 15.6 (120/172 (70%)) | 15.5 (103/149 (69%)) | 17.1 (72/116 (62%)) |
| Intervention (no. with score < 23) | 13.8 (120/158 (76%)) | 13.5 (99/132 (75%)) | 12.5 (93/118 (79%)) |
| Difference (95% CI) | 2.0 (-1.5 to 5.4) | 0.6 (-1.0 to 2.3)1 (P=0.46) | 1.6 (-0.1 to 3.3)1 (P=0.07) |
| GDS | |||
| Control (no. with score > 5) | 3.63 (29/105 (28%)) | 4.35 (38/114 (33%)) | 3.86 (22/91 (24%)) |
| Intervention (no. with score > 5) | 3.31 (16/81 (20%)) | 4.74 (37/97 (38%)) | 4.41 (26/86 (30%)) |
| Difference (95% CI) | 0.09 (-0.96 to 1.14) | -0.41 (-1.42 to 0.61)1 (P=0.43) | -0.75 (-2.03 to 0.52)1 (P=0.25) |
| BASDEC | |||
| Control (no. with score > 6) | 3.79 (25/107 (23%)) | 3.83 (5/112 (22%)) | 3.26 (11/87 (13%)) |
| Intervention (no. with score > 6) | 4.38 (18/82 (22%)) | 4.72 (25/93 (27%)) | 3.77 (15/81 (19%)) |
| Difference (95% CI) | -0.64 (-1.66 to 0.38) | -0.37 (-1.47 to 0.73)1 (P=0.51) | -0.18 (-1.45 to 1.09) (P=0.79) |
| CRBRS | |||
| Control (no. with score > 8) | 14.9 (119/172 (69%)) | 15.1 (112/154 (85%)) | 14.5 (86/127 (85%)) |
| Intervention (no. with score > 8) | 17.4 (128/158 (81%)) | 18.8 (116/136 (85%)) | 19.4 (109/118 (85%)) |
| Difference (95% CI) | -2.5 (-5.9 to 0.9) | -1.5 (-3.5 to 0.4)1 (P=0.13) | -2.2 (-4.1 to ‒0.3)1 (P=0.02) |
The MMSE scores and the numbers of residents with scores below 23 did not change significantly over the study period, although there was a decline in the total MMSE scores for the intervention group. No statistically significant changes were observed in the depression scores during the study. Mean CRBRS scores tended to increase in the intervention group relative to the control group, and the difference between the groups became significant at Time 2. However, these changes could not be attributed to the intervention, as the increase in impairment occurred before this.
The number of accidents and falls (recorded in the nursing home reports) in each group did not differ significantly throughout the study. Over the intervention phase, there were 14 deaths in the control homes (one death in each of three homes; two in each of two homes; three in one home; four in one home) compared with just four deaths in the intervention group homes (two deaths in each of two homes). This difference was statistically significant (Mann-Whitney U-test: P=0.028).
Drug use and pharmacist recommendations
The mean number of drugs prescribed for all residents at admission to the study was 4.91, with a range of 0-17 (see Table 3). In 54% of cases, prescribing of neuroleptics was inappropriate according to the US OBRA guidelines. Residents in both groups of homes experienced a decrease in the mean number of drugs prescribed during the intervention phase (Table 4). After adjustment for baseline differences, the reduction in the homes where medication was reviewed was greater than that in control homes, but this difference was not statistically significant (P=0.070).
Table 3 Medications being prescribed at baseline
| (a) Number of medications per subject | No. (%) of subjects | No. of medications | No. (%) of subjects |
| 0 | 8 (2%) | 6 | 33 (10%) |
| 1 | 23 (7%) | 7 | 29 (9%) |
| 2 | 34 (10%) | 8 | 22 (7%) |
| 3 | 51 (16%) | 9 | 11 (3%) |
| 4 | 47 (14%) | 10 | 17 (5%) |
| 5 | 47 (14%) | 11-17 | 8 (2%) |
| (b) Common types of medication prescribed | British National Formulary class | % of residents | |
| Laxatives | 1.6 | 49 | |
| Diuretics | 2.2 | 44 | |
| Antipsychotics | 4.2 | 30 | |
| Hypnotics/anxiolytics | 4.1 | 28 | |
| Anti-platelet drugs | 2.9 | 28 | |
| Analgesics | 4.7 | 27 | |
| Antidepressants | 4.3 | 25 | |
| Ulcer-healing drugs | 1.3 | 21 | |
| Musculoskeletal | 10 | 16 | |
| Nitrates/Ca antagonists | 2.6 | 15 | |
| Anti-Parkinsonian | 4.9 | 12 | |
| Anti-epileptics | 4.8 | 10 | |
Table 4 Mean numbers of prescribed drugs
| Time 0 | Time 1 | Time 2 | |
|---|---|---|---|
| Control | 4.9 | 4.5 | 4.4 |
| Intervention | 5.1 | 5.1 | 4.2 |
| Difference (95% CI) | -0.02 (-1.2 to 1.2) | -0.3 (-0.06 to ‒0.04)1 (P=0.03) | 0.5 (-0.04 to 1.0)1 (P=0.07) |
A total of 261 recommendations were made by the pharmacist, of which 239 (91.6%) were accepted by the GP and resulted in 144 actual treatment changes. Thirty residents received no modification to their drug treatment and the mean number of recommendations per resident for the other residents was 2.46, with a range of 0-7. Recommendations were classified according to the reasons given in Table 5.
Table 5 Reasons for recommendations suggested by pharmacist
| Reasons for recommendation | No. of recommendations |
|---|---|
| Indication for medication no longer present | 85 |
| Safer or more efficacious use of drug used | 77 |
| Safer or more efficacious drug available | 22 |
| Review of treatment - individual drugs | 22 |
| Economy | 17 |
| Indication present, no medication prescribed | 14 |
| Review whole treatment | 13 |
| Side-effect/adverse drug reaction | 5 |
| Contra-indication | 3 |
| Therapeutic duplication | 2 |
| Drug interaction | 1 |
| Total | 261 |
Economic data
Numbers and associated costs of all contacts with primary and secondary care services were calculated for each resident alive at the end of each phase of the study, using contemporaneous local figures for comparative costing. It is likely that costs per resident do overlap between the intervention and control homes: the degree of overlap might not be great, but sufficient to prevent statistical significance being established. Costs vary very considerably between residents, making average costs per home very variable also. Costs relating to the use of primary and secondary care resources could not always be determined for individual home residents. For example, a GP or physiotherapist might attend more than one resident on a single visit to a home. Costs were thus computed for each home overall for each study period and divided by the number of individual residents in that period, to provide average costs per resident. These are summarised in Table 6. Because only 14 nursing homes in total could be included in the study, no formal statistical comparison of these average costs between the control and the intervention groups was possible. However, there was a clear trend for reduction in costs in the intervention group.
Table 6 Use and costs per resident of primary and secondary care resources
| Control group | ||||
| Item | Observation phase | Intervention phase | ||
| Frequency | Cost (£) | Frequency | Cost (£) | |
| Drugs | 4.41 | 142.53 | 4.37 | 141.24 |
| Non-drug | ||||
| General practitioner visits | 2.15 | 65.99 | 1.60 | 46.31 |
| In-patient days | 1.51 | 249.13 | 1.26 | 256.54 |
| Out-patient visits | 0.58 | 30.16 | 0.53 | 27.27 |
| Domiciliary visits | 0.08 | 4.36 | 0.09 | 4.70 |
| Primary care visits | 1.13 | 16.66 | 1.26 | 16.91 |
| Totals | 508.83 | 492.98 | ||
| Intervention group | ||||
| Item | Observation phase | Intervention phase | ||
| Frequency | Cost (£) | Frequency | Cost (£) | |
| Drugs | 4.92 | 159.01 | 4.07 | 131.54 |
| Non-drug | ||||
| General practitioner visits | 2.81 | 82.19 | 2.85 | 75.41 |
| In-patient days | 1.44 | 197.60 | 0.55 | 55.67 |
| Out-patient visits | 0.38 | 23.70 | 0.30 | 19.77 |
| Domiciliary visits | 0.24 | 13.32 | 0.32 | 13.72 |
| Primary care visits | 1.26 | 16.88 | 1.16 | 13.41 |
| Pharmacist hours | 0.41 | 5.36 | ||
| Totals | 492.69 | 314.89 | ||
DISCUSSION
The main findings of this study are: that a simple and low-cost intervention using existing skills can reduce the number of drugs prescribed to elderly people in nursing homes; that the intervention may reduce costs; and that it can be instituted without detriment to the mental or physical health of residents. The average number of medicines taken by nursing home residents in the UK is between six and seven, with a proportion taking up to 19 (Reference CorbettCorbett, 1997; Reference Lunn, Chan and DonoghueLunn et al, 1997). These figures are similar in the USA (Reference Beers, Beers and FingoldBeers et al, 1992). Half the residents take five or more drugs (Reference Nolan and O'MalleyNolan & O'Malley, 1989) and 19% of admissions to hospital may be due to inappropriate drug therapy (Reference Cannon and HughesCannon & Hughes, 1997; Reference Cunningham, Dodd and GrantCunningham et al, 1997) with half being preventable (Reference Lindley, Tully and ParamsothyLindley et al, 1992).
Previous reports that nursing home residents are prescribed medication which can be changed (Reference Beers, Ouslander and RollingherBeers et al, 1991; Reference Lunn, Chan and DonoghueLunn et al, 1997) is substantiated by this study, in which one-third of all the recommendations made by the pharmacist was that medications no longer indicated should be reviewed. The prescription of neuroleptics was higher than in previous studies (24% in the Glasgow study by Reference McGrath and JacksonMcGrath & Jackson, 1996) but their inappropriate prescription, as judged against the US OBRA guidelines, was far less than the comparative figure of 88% in the Glasgow study. Not all the changes suggested by the pharmacist were implemented; the reasons for this were not specifically recorded. The study showed positive benefits nonetheless.
It appears that medication review by a pharmacist with GPs can reduce the number of inappropriate drugs prescribed for residents. Such a review may be cost-effective for the National Health Service, and could potentially have positive benefits for residents. The number of older people entering nursing and residential homes in the future is likely to increase (Reference Melzer, Ely and BrayneMelzer et al, 1997). This study is the first controlled trial in the UK of the effects of a medication review by a pharmacist, and should be of interest to purchasers of health and social care.
Clinical Implications and Limitations
CLINICAL IMPLICATIONS
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▪ An assessment by a multi-disciplinary team can reduce the number of drugs prescribed to elderly people in nursing and residential homes.
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▪ This reduction can be achieved with minimal impact on residents' physical and mental health.
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▪ The introduction of such an assessment should be considered as a marker of good practice.
LIMITATIONS
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▪ The specific nature of the intervention needs further study.
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▪ Not all the recommendations were followed by the general practitioners.
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▪ The study took place in one area and so the generalisability of the results cannot be assumed.
ACKNOWLEDGEMENTS
We are grateful to the staff and residents of the homes, to the GPs who took part and to our community nurse colleagues who carried out the ratings.
eLetters
No eLetters have been published for this article.