Public Health (1991), 105, 24%255

© The Society of Public Health, 1991

Use of Benzodiazepines in Private Nursing Homes: a Drug "Index" as an Indicator of Quality in Nursing H o m e Care M. C. Robertson and J. A. Muir Gray

Community Health Offices. Radcliffe Infirmary, Oxford

Benzodiazepines have attracted criticism as drugs on which patients can become dependent. This paper examines how widely these drugs were prescribed by GPs to patients in 15 Oxfordshire nursing homes during 1987. About one in three patients was found to have such a prescription. The potential relationship between benzodiazepine prescribing and rate of incidents in the homes did not prove clear-cut, although pointing toward a slight negative correlation. Duration of action of the type of benzodiazepine had relevance. An index of benzodiazepine prescriptions per resident was derivable (the 'benzodiazepine index'). This provided an indicator of quality of care which could be used to compare practice between different nursing homes.

Introduction Since 1983 private nursing h o m e places in Britain have expanded rapidly. 1 They have filled a gap between long-stay hospital beds and residential care, when an elderly person can no longer manage, or be managed, in their home. Health authorities are responsible for inspecting these nursing homes through their teams of monitoring offÉcers. The overall aim is to assure quality. Aspects to be considered by inspecting officers in pursuit of this goal are numerous. Prescription and administration of drugs to nursing home patients (residents) is one of them. As a step towards the main aim, the objective of the study described here was to make an audit, by direct observation, o f the use of benzodiazepines in private nursing homes for the elderly. Benzodiazepines were selected because o f increasing reservations a b o u t their effects, especially long-term. A text-book o f 1984 cautions on this aspect while r e c o m m e n d i n g benzodiazepines as hypnotics along with chlormethiazole and chloral derivatives? In 1987 benzodiazepines, along with haloperidol, barbiturates, cerebral vasodilators and metabolic enhancers, were described as 'drugs to avoid' in the elderly. 3 Withdrawal methods were suggested and alternative methods of coping with anxiety and tension recommended. 4 Some were summarised in the publication from the Consumers' Association aimed at doctors? Doctors who control prescribing in private nursing homes are for a large part GPs. Although its f o r m may vary f r o m h o m e to home, a drug prescription chart is usually kept for each resident (the drug 'Kardex'). On this the home doctor, where there is one, or the doctor visiting the resident in the normal course of providing primary medical services, writes up the dose and times of drugs to be given to each resident by nursing staff. The Correspondence: M. C. Robertson at the above address

250

M. C. Robertson and J. A. Muir Gray

availability of nursing staff to administer drugs according to written instruction means that monitoring an elderly person's regular pattern of drug consumption is less uncertain than it would be in the domestic situation. Nurses initial all medicines when they are given, as in a hospital (the 'prescription chart'). Ongoing medication can be seen at a glance. Homes also keep account of 'incidents', i.e. happenings to residents on their premises. It is therefore possible to examine together, incident rates and the sum total of 'prescriptions' for any particular drug, such as benzodiazepines. This can be done for an individual home, and comparisons can be made between homes. This may be of value to relate whether or not the use, or amount of use, of certain drugs, contributes to, or reduces, incidents in the home. Here are reported findings on benzodiazepine and other drug usage among subjects residing in private nursing homes. This is matched to the 'incident' status of the home as perceived from records, to note any observable relationship.

Subjects and Methods Fifteen private nursing homes in Oxfordshire were visited (by MCR) during the study. Visits were made on separate days due to the time necessary to compile 'prescription' details from individual Kardex drug-sheets. Visits were spread throughout the year (1987). Each current record sheet (covering a calendar month when completed) gave a snapshot of what each patient was being prescribed, and given (or expected to be given) that month. Note was taken of all prescriptions for benzodiazepines, including time prescribed, and of other hypnotics, anxiolytics, antipsychotics and antidepressants. The time the drug was intended to be given was noted, to assess the a m o u n t o f sedation which might be attributable to daytime use of benzodiazepines. The time a drug was actually given was also noted, including for 'p.r.n.' prescriptions. Whether a resident had been on this medication on entering the home was not pursued, as the study was of actual prescribing while that person was in the home. Duration of past use was similarly not assessed. F o r the purpose of the audit it was the fact of present prescribing (and administration) which was looked at. The assumption was made that use of these medicines was ongoing, and prescriptions likely to be renewed. Most residents in the nursing homes were there permanently. Homes studied were those which cared for the elderly, i.e. over 65. Ages of subjects ranged up to over 100 years. Actual descriptive terms on nursing home registration certificates were 'elderly', 'geriatric', 'medical' and 'psychogeriatric'. High dependency patients were not distinguished at the time. Homes which were acute hospitals, a children's hospice and for the young disabled, were excluded from the study. At the start of the year the homes had potential to provide a study population of 473, in that this was the total number of beds formally registered. However, this changed during the year due to home expansion and registration of additional beds. In the opposite direction, homes might not be full. It was intended to calculate an activity rate for each nursing home, the number of benzodiazepine prescriptions per resident (the 'benzodiazepine index'). Actual number of subjects recorded for each home was therefore taken as the number of patients said by the person in charge to be in residence on the day of the visit. This was expected to equal the total of Kardex drug-sheets seen. (In practice there were small differences.) The benzodiazepine activity rate for each home could have been associated with two possible outcomes. Excessive prescribing in a home might lead to confusion, motor

Use of Benzodiazepines in Private Nursing Homes

251

impairment, and an increase in incidents such as falls, or alternatively, to oversedation, inactivity and few incidents/falls. An attempt was made to measure this outcome by reference to each home's incident book. The number of incidents, mostly falls, in the home during the six months prior to the visit was given a score based on previous observations at all homes. Those showing an incidence of four recorded incidents per bed registered per a n n u m were denoted 'average' (score 2), those with more, 'above average' (score 3), those with less, ~below average' (score 1). The 'activity rates' were plotted against this measure of outcome. Results

Subjects said to be resident in the homes on the respective visit dates totalled 481. For purposes of this study, calculations were based on stated numbers of residents (Table I). Prescriptions found for the type of drugs under study totalled 401, of which 177 were for the benzodiazepines listed in Table II (Carbamazepine excluded). One hundred and sixty-three individuals (33.9% of the total) had a prescription for at least one benzodiazepine, 13 had two prescriptions, usually daytime diazepam plus an evening hypnotic, and one had three (see below). Diazepam was prescribed for daytime use, t.d.s., in 25 instances, but in two homes (five patients) was not always administered. Thirteen homes had at least one resident on diazepam, and five had five persons with this prescription. These were larger homes, all with over 20 residents. Twenty-five patients in 11 homes had benzodiazepines prescribed p.r.n. (20 hypnotics, five diazepam) but four o f these were invariably given the prescribed hypnotic. One patient had three prescriptions for the same benzodiazepine. The first had not been cancelled, the second was apparently being

Table I Home

Individual prescriptions, benzodiazepine index and incident score for all homes.

Number said to be in residence

Number of prescriptions Total study drugs

Benzodiazepines (%)

Number of Number of benzo- Incident individuals diazepine score prescribed benzo- prescriptions per diazepines resident (Index)

A

29

30

13

(45)

10

0.45

2

B

17

6

2

(33)

2

0.12

-

C D E F G H I J K L M N O

46" 31" 35 31" 70 38 29* 20* 16 38 12 58 11

46 29 35 32 17 27 40 40 19 24 12 34 10

24 11 14 I0 2 13 19 24 12 10 4 16 3

(52) (38) (40) (31) (12) (48) (48) (63) (63) (42) (33) (47) (30)

21 10 14 9 2 13 18 23 10 10 4 14 3

0.52 0.36 0.40 0.32 0.03 0.34 0.66 1.20 0.75 0.26 0.33 0.28 0.27

2 3

* Homes where at least five residents had prescriptions for daytime diazepam

2 1 1 1 2 2 3

M. C. Robertson and J. A. Muir Gray

252

Table II Types of benzodiazepine prescribed

Drugs included in study.

Numbers of prescriptions

(%)

Other drugs studied

77 33 33 16 12 3 1 1 1

(43.5) (18.6) (18.6) (9.0) (6.8) (1.7) (0.6) (0.6) (0.6)

177

(100)

Antidepressants Melleril Chlormethiazole Prochlorperazine Chloral Chlorpromazine Haloperidol Other antipsychotics Promazine HCI Barbiturates Dichloralphenazone Trimeprazine

Temazepam Nitrazepam Diazepam Triazolam Lorazepam Oxazeparn Clonazepam Lormetazepam Chlordiazepoxide

81 51 30 18 9 9 7 5 5 5 3 1

Carbamazepine not included in study--four prescriptions given, the third was unsigned. Among 33 unsigned prescriptions for miscellaneous drugs, observed during the study, six were for benzodiazepines. Twenty-four o f the unsigned prescriptions related to one home, five to another. The majority o f GPs initialled all their prescriptions. A complication was that numbers of drug charts shown did not always tally with numbers said to be resident. Some persons may not have had a chart. Charts seen totalled 481, which coincided with the subject total, but this was fortuitous owing to variations cancelling each other out. Four homes produced a few more, and three produced less charts than the number of persons said to be in residence. The effect o f the largest discrepancy, if genuine (if missing charts really did mean absent residents), would have been to increase the calculated overall rate o f benzodiazepine prescribing from 33.9 to 35.1%, i.e. still about one in three. The number of prescriptions for antidepressants (20.2% o f the total study drug prescriptions) exceeded that for the most used benzodiazepine, the hypnotic temazepam (19.2%).

Above average

O

Average o

E ,-

Below average

O

O

11

OOO

O

o

o

o

Home K

Home L

I

I

I

I

I

I

1

0.1

0.2

0.3

0.4

0.5

0.6

0.7

I 0.8

Benzodiazepine prescriptions per resident

Figure 1 Incident score and benzodiazepine prescriptions per resident

Use of Benzodiazepines in Private Nursing Homes

x

253

x

,= O

=o

x

x

xxx

E ¢x

x

x

I

I

I

I

I

I

I

10

20

30

40

50

60

70

Benzodiazepines

as % of total study drugs

Incident score and benzodiazepines as percentage of total study drugs

Figure 2

On the basis of the previously determined average incident rate, five homes were average, three below, and two above. Records for five homes were incomplete. Benzodiazepine prescriptions per resident plotted against the incident score apparently suggested that incidents declined with a higher prescribing rate, as might have been expected if people were more sedated (Figure 1). A slight negative correlation could be demonstrated by plotting the benzodiazepine prescriptions as a percentage of total study drug prescriptions against the incident score for homes which had records (Figure 2). When the type of benzodiazepine in use was examined, it was seen that at home L, the hypnotic most prescribed was triazolam, a short-acting benzodiazepine, whereas at home K, with almost all other homes, it was temazepam, intermediate acting. So duration of action

1,2o

1.1-

~-

1,0-

Q"

0.8-

0.9-

._~ ~ 0.6*t:J ~ ~, o.s~.-

e.-

c~

nn

0.4-

"~

0.3-

-~ E

0.2-

7

0.1-

$

A

I Ill B

Figure 3

C

D

E

F

G H Nursing

I

J

K

L

M

homes

Benzodiazepine index, different homes

N

O

254

M. C. Robertson and J. A. M u i r Gray

of a benzodiazepine in use has to be taken into account, the shorter-acting one here being associated with a low incident score. H o m e L employed a home doctor, i.e. just one GP. No dependency rates were available in 1987. But some scores became available, for some homes, in 1989. For interest, scores from 1989 (Barthel Index where low dependency = 20 and high dependency = 0) were: homes E, L, and 0, 6; home D, 8; B and N, 9; H and K, 10; A, 12; and I, 16.

Discussion

It was a matter of observation during the study that different GPs favoured different drug combinations. Where more than one G P visited a home it was often possible to identify which patient had which GP, by the pattern of prescribing. Where a G P oversaw an entire home, this naturally governed the type o f prescription throughout the home, but philosophy of the home owner also had an effect. Less sedation might mean more freedom, but freedom to wander might in certain circumstances pose an unacceptable hazard to the patient. One home in the study managed its patients largely without benzodiazcpines. Evidence as to the effect on specific psychogeriatric patients was anecdotal, but seemed to confirm that wandering was a problem. The home maintained its philosophy o f little sedation, but by 1990 had taken steps to improve the security o f its boundaries for patients. To establish a full outcome relationship between overall prescription o f benzodiazepines in a home and its incident rate was not possible due to information gaps. Another shortcoming of the present study was that it did not measure duration o f use of benzodiazepines for individuals. The concept of the benzodiazepine index proved of some interest as a monitoring tool, demonstrating the range of variation in prescribing between homes (or doctors) being from 0.03 to 1.20. This represented a forty-fold difference despite the limited numbers in the study and the similarity o f subjects (Figure 3). The study probably generated its own 'Hawthorn effect' by leading to greater awareness of benzodiazepine prescribing in both homes and their doctors. Staff subsequently have taken part in compiling lists of how many patients are on a particular drug at any one time. This would enable same-date comparisons to be planned. Morgan et al. in a study of drug use among the elderly living at home (1,020 randomly selected subjects aged 65 and over) found a usage o f (mainly) benzodiazepine drugs of 16%. 6 The higher incidence o f benzodiazepine prescriptions in nursing homes reported here (33.9%) is unsurprising if it is considered that 'difficult' patients tend to end up in nursing homes, often long stay. A higher rate of prescribing may be a 'just in case' measure, because nursing homes by definition have qualified nurses as intermediaries who can report or judge necessity. In the present study, this type of latitude did occur but did not seem excessive; it might have been expected to be more likely in homes where numbers had a bearing, as was in fact observed. Elaine Murphy notes existing recognition that sedative psychotropic drugs increase the risk of falls? The slight negative correlation observed here between incident score and benzodiazepines as a percentage of total study drugs prescribed in a nursing home, could have been the reflection of a positive correlation with other drugs. Blake et al. 7 suggested for residential (not nursing) homes that the number of falls occurring is a useful measure of performance, being associated with level of staffing o f the home. Staffing was not part of the present study.

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255

A symposium held in 1987 discussed the use o f benzodiazepines in current clinical practice. 8 Rodrigo et al. commented that 'long term treatment with benzodiazepines is not necessarily o p t i m u m m a n a g e m e n t but m a y reflect the realities of general practice'. 9 The prescription o f benzodiazepines in nursing homes m a y reflect the same reality, since medical attendants are GPs. However, a simple concept, demonstrating range o f use of a drug in like circumstances, such as the benzodiazepine index for nursing homes, m a y demonstrate that variation is feasible, and contribute to change in prescribing habits. It potentially provides educational feedback to homes, staff, and doctors. References 1. MacLennan, W.J. (1988). Private nursing home care: the middle way. British Medical Journal, 296, 732. 2. Spector, R., Rogers, H. & Roy, D. (1984). Psychiatry: Common Drug Treatments. London: Martin Dunitz. 3. Murphy, E. (1987). Drug treatment of behaviour problems in the elderly. Prescribers" Journal, 27(6), 20-25. 4. Ramster, D., Barber, A. J., Deb, A., Free, K., Carney, M. W. P. & Ellis, P. G. (1987). A policy on benzodiazepines (Letter). Lancet, ii, 1406. 5. Herxheimer, A. (Ed.), Lessening the use of Benzodiazepines. (1987). Drug and Therapeutics Bulletin, 25(15), 57-59. 6. Mor~;an, K., Dallozzo, H., Ebrahim, S., Arie, T. & Fenton, P. H. (1988). Prevalence, frequency, and duration of hypnotic drug use among the elderly living at home. British Medical Journal, 296, 601-602. 7. Blake, C. & Morfitt, J. M. (1986). Falls and staffing in a residential home for elderly people. Public Health, 100, 385-391. 8. Freeman, H. & Rue, Y. (eds.) (1987). International Congress and Symposium Series No. 114, The benzodiazepines in current clinical practice. London: Royal Society of Medicine. 9. Rodrigo, E.K., King, M. B. & Williams, P. (1988). Health of long term benzodiazepine users. British Medical Journal, 296, 803-805.

Use of benzodiazepines in private nursing homes: a drug 'index' as an indicator of quality in nursing home care.

Benzodiazepines have attracted criticism as drugs on which patients can become dependent. This paper examines how widely these drugs were prescribed b...
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