Inappropriate Drug Prescribing and Polypharmacy Are Major Causes of Poor Outcomes in Long-Term Care

Abstract

56 Previously in your Journal, we have stressed the problems associated with medications in long-term care.1e12 In this issue, we have 6 further articles stressing the problems of inappropriate prescribing and providing some solutions to control medication usage in the nursing home.13e18 Inappropriate medications are a major reason for readmission to hospital from long-term care.19e30 This is spurred by the ridiculous medications that many patients are started on in the hospital by physicians who have no concept of how to manage the frail elderly.31e37 Cool13 reports that potentially inappropriate drug prescribing occurs more often in sicker persons (higher Charlson Co-Morbidity Index), those receiving a psychiatric consult, and in those without dementia. Smeets et al,18 focusing on excess psychotropic medicines that are used in residents with dementia, found 4 major possible areas: (1) the beliefs of physicians and advanced practice nurses, (2) previous experiences and education of the health care professionals, (3) effective communication between physicians and family, and (4) staffing issues and policies. Reeve et al38 found that 92% of older persons were willing to stop medications if possible. This highlights the appropriateness of soliciting the opinions of residents and family as a way to help reduce medications. An important component in the reduction of psychotropic medications in the nursing home is to have available behavior therapy programs, meaningful activities, and exercise programs in the nursing home.39e45 Delirium is a common problem in nursing homes.46e50 In a geriatric care unit in France, deliriumwas present in 69% of residents on 6 or more drugs a day and in only 30% of those on fewer drugs.15 This study confirms that limiting drug burden is an important component of reducing delirium in nursing homes. Landi14 highlighted that anticholinergic burden due to drugs is a major cause of delirium, and also found that anticholinergic burden increased functional decline and falls. Fox et al,51 in a systematic review, found that anticholinergic medicines had adverse effects on cognition and physical function. Inappropriate medications have been shown to contribute to poor balance.52 Psychotropicmedications are amajor cause of delirium, and many of themhave a high anticholinergic burden.53 Polypharmacy has previously been recognized as a major cause of falls.54,55 A number of lists of potentially inappropriate drugs for older persons have been developed. These include the Screening Tool of