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Prescribing for older people discharged from the acute sector to residential aged-care facilities P. Hopcroft,1 N. M. Peel,1 A. Poudel,2 I. A. Scott,3 L. C. Gray1 and R. E. Hubbard1 1

Centre for Research in Geriatric Medicine, School of Medicine, 2School of Pharmacy, The University of Queensland and 3Department of Internal

Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

Key words polypharmacy, frail aged, residential aged care, adverse drug reaction. Correspondence Nancye May Peel, Centre for Research in Geriatric Medicine, Level 2, Building 33, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: [email protected]

Abstract For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratio.

Received 3 February 2014; accepted 28 June 2014. doi:10.1111/imj.12553

In older people, polypharmacy (defined here as the use of five or more medications per day) is a significant predictor of hospitalisation, increasing disability and death.1 Polypharmacy is potentially more hazardous for frail older patients who, compared with younger populations, have more comorbid chronic diseases and are more likely to experience adverse drug events (ADE).2 Many people who live beyond the age of 75 become frail at some point, and over 40% will spend time in a residential aged-care facility (RACF).3 In Australia, approximately 6% of people aged 65 and over live in RACF, and this proportion rises to 26% for those aged 85 and over; average length of stay is 168.1 weeks in women and 109.5 weeks in men, prior to death.4 For older people requiring nursing home care, admission to hospital is an opportunity to rationalise medication after weighing up the benefits and significant risks of polypharmacy. In the present study, we aimed to describe and classify medications prescribed for older hospitalised people returning to, or newly discharged to, RACF from the acute sector.

Funding: The preparation of this manuscript was funded by the Princess Alexandra Hospital Private Practice Trust Fund Research Support Grants scheme. The funding source had no involvement in the design, execution, analysis and interpretation of data nor writing of the paper. Conflict of interest: None.

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In this prospective cohort study, 1418 patients aged 70 and older were admitted to 11 acute care hospitals in Queensland and Victoria, Australia. Recruitment took place between July 2005 and May 2010 as part of three separate cohort studies described elsewhere.5–7 Patients were required to have a minimum hospital stay of 48 h, and were excluded if admitted to coronary or intensive care units, or receiving terminal care only. Of this cohort, 206 patients were discharged to RACF for permanent care. The interRAI Acute Care tool was used for data collection. This instrument screens a large number of domains, including cognition, communication, mood and behaviour, activities of daily living (ADL) and instrumental ADL (IADL), continence, nutrition, skin condition, falls and medical diagnosis.8 A number of scales embedded in the interRAI instruments combine single items belonging to a domain, such as ADL, IADL and cognition, that are used to describe the presence and extent of deficits in that domain.6 Trained nurse assessors gathered data about each patient’s physical, cognitive and psycho-social functioning at admission and discharge using information from the patient, carers, health staff and medical records. For each patient, all prescribed medications were documented from medication charts at admission to hospital and again at discharge. These lists were carefully reviewed so that medication used for a finite period in hospital to manage the patients’ acute medical conditions, such as intravenous antibiotics and subcutaneous anticoagulation, did not contribute to the number of © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

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regular prescribed drugs. The Anatomical Therapeutic Chemical (ATC) Classification System codes plus routes of administration were recorded at both admission and discharge. Data were entered by pharmacists or pharmacy students and verified by a second pharmacist or geriatrician. The number of medications was categorised into three groups. Hyper-polypharmacy was defined as concurrent prescription of 10 or more drugs per day, polypharmacy five to nine drugs per day and non-polypharmacy four or fewer drugs per day. These cut-off points were based on previous studies relating medication prescribing to adverse outcomes in older people.9 Medications were classified as controlling symptoms, preventive or both crossover preventive/symptomatic, in accordance with previous studies in palliative care settings.10,11 Frequency distributions were used to describe the characteristics of the study population. Depending on the distribution of the data, nonparametric or parametric comparisons of means tests were used to compare continuous data across the polypharmacy categories. For categorical variables, a Chi-squared test was performed. All proportions were calculated as percentages of patients with available data. Significance levels were set at P < 0.05. Patients with missing data were excluded from the relevant analyses. Analyses were performed using SPSS IBM Version 20 (SPSS, Inc., Chicago, IL, USA). Personal or proxy consent was obtained in writing prior to commencement of the study. Ethical approval was obtained from the Human Research Ethics Committee at each participating hospital and the University of Queensland Medical Research Ethics Committee. Of the 206 patients discharged to RACF, the mean (SD) age was 84.8 years (±6.8), and most were female (68.9%). The mean number of comorbidities was 6.0 (±2.2), and the majority of patients (64.6%) were residents in aged-care facilities prior to hospital admission. Patient characteristics and polypharmacy status are summarised in Table 1. Patients were prescribed a mean of 7.2 regular medications at admission to acute care and 8.1 on discharge to their RACF. Comparing admission and discharge medication regimens, there was little change in polypharmacy (106 patients [51.5%] vs 102 [49.5%]) and an increase in hyper-polypharmacy (50 patients [24.3%] vs 67 [32.5%]). Table 2 presents patterns of drug use at both admission and discharge. Prescribed medications were categorised as preventive or symptomatic, and in some cases crossover preventive/symptomatic. At discharge from hospital, aspirin and anti-aggregates were the most frequently prescribed medications (109, 54%), followed by anti-ulcer drugs in 105 (52%) patients. Other prevalent medica© 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

Table 1 Characteristics of study population Characteristics

Study population† n = 206

Age, mean (SD) (years) Females Admitted from: Community RACF low care RACF high care Number of comorbidities mean (SD) History of falls in last 90 days prior to hospital admission In-hospital fall Functional status at hospital discharge: Bladder incontinence Functional status: Dependent in ADL‡ Dependent in IADL§ Cognitive status¶: Intact Mild to moderate impairment Severe impairment Missing data

84.8 (±6.8) 142 (68.9)

Medications Number of regular prescribed medications mean (SD) Non-polypharmacy (0–4 drugs) Polypharmacy (5–9 drugs) Hyper-polypharmacy (≥10 drugs) Missing

73 (35.4) 64 (31.1) 69 (33.5) 6.0 (±2.2) 86 (41.7) 27 (13.1) 105 (51.0) 110 (53.4) 202 (98.1) 76 (36.9) 85 (41.3) 37 (18.0) 8 (3.9)

Admission

Discharge

7.2 (3.8)

8.1 (4.0)

47 (22.8) 106 (51.5) 50 (24.3) 3 (1.5)

35 (17.0) 102 (49.5) 67 (32.5) 2 (1.0)

†Prevalence given as number (%) unless otherwise specified. ‡ADL dependence classified as requiring extensive assistance on any ADL item (bathing, personal hygiene, toilet transfer, toilet use, bed mobility or eating). §IADL dependence classified as requiring extensive assistance on any IADL item (meal preparation, housework, finances, medication management, phone use, shopping or transport). ¶Cognitive status classified according to the Cognitive Performance Scale.6 ADL, activities of daily living; IADL, instrumental ADL; RACF, residential aged-care facility.

tions included antidepressants (28.2%), benzodiazepines (19.3%), antipsychotics (16.3%) and opioids (16.3%). Vitamin D prescribing was low at both admission (16.8%) and discharge (22.6%). Medications that can incur an increased intensity of care from nursing staff were also prevalent: inhaled medications (40, 19.8%), eye drops (40, 19.4%) and insulins (21, 10.4%).

Discussion The present study describes medications prescribed for older people discharged from acute care hospitals to RACF. Results confirm that these patients are frail, with high levels of cognitive impairment and functional disability. On average, number of medications prescribed increased during the hospital admission. Comparing drug 1035

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Table 2 Medication prevalence† at admission to hospital and discharge to residential aged care facility Drug Class Symptom control

Symptom control/Preventive

Admission

Discharge

105 (52.0) 94 (46.5) 72 (35.6) 69 (34.2) 65 (32.2) 72 (35.6) 52 (25.7) 64 (31.7) 63 (31.2) 52 (25.7) 47 (23.3) 44 (21.8) 36 (17.8) 38 (18.8) 34 (16.8) 28 (13.9) 33 (16.3) 24 (11.9) 29 (14.4) 23 (11.4) 26 (12.9) 16 (7.9) 17 (8.4) 11 (5.4) 9 (4.5) 8 (4.0) 3 (1.5)

109 (54.0) 105 (52.0) 81 (40.1) 80 (39.6) 80 (39.6) 72 (35.6) 68 (33.7) 69 (34.2) 61 (30.2) 57 (28.2) 45 (22.3) 40 (19.8) 39 (19.3) 35 (17.3) 46 (22.6) 33 (16.3) 33 (16.3) 32 (15.8) 29 (14.4) 28 (13.9) 26 (12.9) 21 (10.4) 19 (9.4) 14 (6.9) 10 (5.0) 9 (4.5) 8 (4.0)

Preventive Anti-platelet agents

Antiulcer agents ACEI/ARB Diuretics Vitamin and/or mineral supplements ‡ Beta blockers Laxatives Non opioid analgesics Statins Antidepressants Nitrates Inhaled corticosteroids and bronchodilators Benzodiazepines Calcium channel blockers Vitamin D with or without calcium Antipsychotics Opioids Antiosteoporosis drugs Corticosteroids Digoxin Oral hypoglycaemic agents Insulins Thyroid Hormones Antiemetics Antidementia drugs Antiparkinsonian drugs Warfarin (included as anticoagulants)

†Prevalence given as number (%). ‡Excluding Vitamin D. ACEI, angiotensin-converting enzyme inhibitor. ARB, angiotensin receptor blocker.

regimens on discharge and admission, the percentage of patients prescribed potentially inappropriate medication such as benzodiazepines, statins and antipsychotics was higher, polypharmacy was essentially unchanged and hyper-polypharmacy increased. Polypharmacy prevalence in our cohort was similar to that in a recent cross-sectional study of European nursing homes which reported polypharmacy in 49.7% and hyper-polypharmacy in 24.3% of residents.12 Australian studies have reported even higher rates of polypharmacy. Patients with dementia in RACF from Western Australia were prescribed an average of 9.75 drugs per day,13 and in high-care residents hospitalised in Melbourne, polypharmacy was reported in 39% and hyper-polypharmacy in 54%.14 However, the methodology of these studies differed from our own; the former included herbal remedies, and the latter, short-term medications. The frequent use of benzodiazepines, antidepressants, antipsychotics and opioid analgesics in this frail group is of concern, as these medications are associated with adverse outcomes in older people.15 On the other hand, some medications were under-prescribed. Vitamin D, for example, is currently recommended by the Australian and New Zealand Bone and Mineral Society and Osteoporosis Australia for all older people in RACF16 but was not 1036

prescribed for 77.4% of our cohort on discharge from hospital. In this context, a post-discharge residential medication management review by an accredited pharmacist within an RACF may, under certain circumstances, have a positive impact on medication use, although the evidence is of low quality.17 Such reviews may lead to a reduction in sedative and anticholinergic drug burden on patients.18 The pattern of prescribing in older patients needs to be individualised and based on goals of care, particularly for frail patients.14 Older patients have different priorities for their care and they may be unwilling to take medication associated with adverse effects.19 For example, there is no convincing evidence that statins are beneficial in individuals aged 85 and older, whereas there is considerable potential for clinically significant adverse effects leading to poorer quality of life.20 The increased number of preventive medications being taken in this study may not be justified, given the long time (2 years or more) before benefit for most of these medications, making them potentially inappropriate in this age group.21,22 The present study has several limitations. Indications for prescribing based on clinical conditions at an individual patient level using appropriateness criteria, such as Beer’s,23 were not explored, and the sample size is small. The method of collecting medication data documented © 2014 The Authors Internal Medicine Journal © 2014 Royal Australasian College of Physicians

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from patients’ prescription charts is not the current gold standard. To achieve complete medication reconciliation, multiple sources of information (including patient interview, general practitioner letter and dispensing history from pharmacy) would be needed.24 The lack of follow up denies the opportunity to weigh up the benefits of pharmacotherapy against adverse effects of polypharmacy in this particular cohort. Alterations in medication doses or dosing regimens by hospital physicians were not captured. Study strengths include the recruitment of patients from different hospitals across Australian states, which

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increases the generalisability of our findings. Furthermore, investigation of the role as well as the number of medications and detailed characterisation of participants facilitate a more informed consideration of the appropriateness of prescribing. Although an admission to hospital is an opportunity to rationalise medications according to their appropriateness, this did not appear to be the case in this study. Patients discharged to RACF from hospital continued to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratios.

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Prescribing for older people discharged from the acute sector to residential aged-care facilities.

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescri...
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