Lääkehoito helsinkiläisissä vanhainkodeissa

Prescribing for older patients is challenging. The prevalence of diseases increases with advancing age and causes extensive drug use. Impairments in cognitive, sensory, social and physical functioning, multimorbidity and comorbidities, as well as age-related changes in pharmacokinetics and pharmacodynamics all add to the complexity of prescribing. This study is a cross-sectional assessment of all long-term residents aged ≥ 65 years in all nursing homes in Helsinki, Finland. The residents’ health status was assessed and data on their demographic factors, health and medications were collected from their medical records in February 2003. This study assesses some essential issues in prescribing for older people: psychotropic drugs (Paper I), laxatives (Paper II), vitamin D and calcium supplements (Paper III), potentially inappropriate drugs for older adults (PIDs) and drug-drug interactions (DDIs)(Paper IV), as well as prescribing in public and private nursing homes. A resident was classified as a medication user if his or her medication record indicated a regular sequence for its dosage. Others were classified as non-users. Mini Nutritional Assessment (MNA) was used to assess residents’ nutritional status, Beers 2003 criteria to assess the use of PIDs, and the Swedish, Finnish, INteraction X-referencing database (SFINX) to evaluate their exposure to DDIs. Of all nursing home residents in Helsinki, 82% (n=1987) participated in studies I, II, and IV and 87% (n=2114) participated in the study III. The residents’ mean age was 84 years, 81% were female, and 70% were diagnosed with dementia. The mean number of drugs was 7.9 per resident; 40% of the residents used ≥ 9 drugs per day, and were thus exposed to polypharmacy. Eighty percent of the residents received psychotropics; 43% received antipsychotics, and 45% used antidepressants. Anxiolytics were prescribed to 26%, and hypnotics to 28% of the residents. Of those residents diagnosed with dementia, 11% received antidementia drugs. Fifty five percent of the residents used laxatives regularly. In multivariate analysis, those factors associated with regular laxative use were advanced age, immobility, poor nutritional status, chewing problems, Parkinson’s disease, and a high number of drugs. Eating snacks between meals was associated with lower risk for laxative use. Of all participants, 33% received vitamin D supplementation, 28% received calcium supplementation, and 20% received both vitamin D and calcium. The dosage of vitamin D was rather low: 21% received vitamin D 400 IU (10 µg) or more, and only 4% received 800 IU (20 µg) or more. In multivariate analysis, residents who received vitamin D supplementation enjoyed better nutritional status, ate snacks between meals, suffered no constipation, and received regular weight monitoring. Those residents receiving PIDs (34% of all residents) more often used psychotropic medication and were more often exposed to polypharmacy than residents receiving no PIDs. Residents receiving PIDs were less often diagnosed with dementia than were residents receiving no PIDs. The three most prevalent PIDs were short-acting benzodiazepine in greater dosages than recommended, hydroxyzine, and nitrofurantoin. These three drugs accounted for nearly 77% of all PID use. Of all residents, less than 5% were susceptible to a clinically significant DDI. The most common DDIs were related to the use of potassium-sparing diuretics, carbamazepine, and codeine. Residents exposed to potential DDIs were younger, had more often suffered a previous stroke, more often used psychotropics, and were more often exposed to PIDs and polypharmacy than were residents not exposed to DDIs. Residents in private nursing homes were less often exposed to polypharmacy than were residents in public nursing homes. Long-term residents in nursing homes in Helsinki use, on average, nearly eight drugs daily. The use of psychotropic drugs in our study was notably more common than in international studies. The prevalence of laxatives equaled other prior international studies. Regardless of the known benefit and recommendation of vitamin D supplementation for elderly residing mostly indoors, the proportion of nursing home residents receiving vitamin D and calcium was surprisingly low. The use of PIDs was common among nursing home residents. PIDs increased the likelihood of DDIs. However, DDIs did not seem a major concern among the nursing home population. Monitoring PIDs and potential drug interactions could improve the quality of prescribing.Ikääntyvät ihmiset sairastavat paljon ja käyttävät runsaasti lääkkeitä. Monilääkitys on yleistä erityisesti laitoksissa asuvien vanhusten keskuudessa. Toimintakyvyn ja aistitoimintojen heikkeneminen sekä ikääntymisen aiheuttamat muutokset farmakokinetiikassa ja farmakodynamiikassa altistavat vanhukset lääkehoidon aiheuttamille haitoille. Tämä tutkimus on poikkileikkaus helsinkiläisten vanhainkotien yli 64-vuotiaiden pitkäaikaisasukkaiden lääkehoidosta ja siihen vaikuttavista tekijöistä. Tarkastelimme psyykelääkkeiden (osatyö I), ummetuslääkkeiden (osatyö II), D-vitamiinin ja kalsiumin (osatyö III), sekä iäkkäillä erityisesti vältettävien lääkkeiden (osatyö IV) käyttöä. Tarkastelimme myös lääkkeiden yhteisvaikutusten yleisyyttä (osatyö IV). Asukkaiden terveydentilaa ja lääkitystä koskevat tiedot kerättiin helmikuussa 2003. Asukas luokiteltiin lääkkeen käyttäjäksi, jos hänen sairaskertomuksestaan ilmeni määräys lääkkeen säännölliseksi annosteluksi. Asukkaiden ravitsemustila arvioitiin Mini Nutritional Assessment-menetelmällä. Iäkkäillä vältettävien lääkkeiden käyttöä arvioitiin Beersin vuonna 2003 julkaistun kriteeristön avulla ja lääkkeiden yhteisvaikutuksille altistumista SFINX-interaktiotietokannan avulla. Osatutkimuksiin I, II ja IV osallistui 82% (n=1987) helsinkiläisten vanhainkotien asukkaista. Osatutkimukseen III osallistui 87% (n=2114) asukkaista. Asukkaiden keski-ikä oli 84 vuotta, heistä 81% oli naisia ja 70%:lla oli dementiadiagnoosi. Asukkaiden keskimääräinen päivittäinen lääkemäärä oli lähes 8 lääkettä ja 40% asukkaista käytti päivittäin yli yhdeksää lääkettä. Asukkaista 80% käytti psyykelääkkeitä. Antipsykoottisiä lääkkeitä käytti 43% asukkaista ja 45% asukkaista käytti mielialalääkkeitä. Rauhoittavia lääkkeitä käytti säännöllisesti 26% ja unilääkkeitä 28% asukkaista. Dementiaa sairastavista asukkaista 11% käytti dementialääkitystä. Yli puolet asukkaista (55%) käytti ummetuslääkkeitä säännöllisesti. Ummetuslääkkeiden käyttöön liittyi korkea ikä, huono liikkumiskyky, huono ravitsemustila, puremisongelmat, Parkinsonin tauti ja suuri lääkemäärä. Välipalojen syönti liittyi vähäisempään ummetuslääkkeiden käyttöön. D-vitamiinivalmistetta käytti 33% ja kalsiumvalmistetta 28% asukkaista. Yhtäaikaisesti D-vitamiini- ja kalsiumvalmistetta käytti 20% asukkaista. D-vitamiiniannokset olivat pieniä: 21% asukkaista sai D-vitamiinia tutkimuksen aikaisen suositusannoksen 10μg (400 IU) ja 4% sai D-vitamiinia 20μg (800 IU) tai enemmän. D-vitamiinia käyttäneillä asukkailla oli parempi ravitsemustila, he söivät useammin välipaloja, heillä oli harvemmin ummetusta ja heidän painoaan seurattiin useammin kuin asukkailla, jotka eivät käyttäneet D-vitamiinivalmisteita. Iäkkäillä vältettäviä lääkkeitä käytti 34% asukkaista. Yleisimmin käytetyt vältettävät lääkkeet olivat lyhytvaikutteiset bentsodiatsepiinit, joiden annostus oli suositusta suurempi, sekä antihistamiini hydroksitsiini ja antibiootti nitrofurantoiini. Näiden osuus kaikista vanhuksille sopimattomista lääkkeistä oli yhteensä lähes 77%. Kahden lääkkeiden mahdolliselle yhteisvaikutukselle altistui alle 5% asukkaista. Helsinkiläisten vanhainkotien pitkäikaisasukkaat käyttävät keskimäärin lähes kahdeksaa lääkettä päivittäin. Psyykelääkkeiden käyttö on kansainvälisiin tutkimuksiin verrattuna erityisen yleistä. Laksatiivien käytön yleisyys ei eroa kansainvälisistä tutkimuksista. Vaikka D-vitamiinin hyödyt ovat tiedossa ja sen käytöstä on olemassa kansallinen suositus, yllättävän harvat vanhainkodin asukkaat saavat D-vitamiinia. Vanhuksille sopimattomien lääkkeiden käyttö on melko yleistä. Lääkkeiden yhteisvaikutukset eivät käytetyn mittarin valossa vaikuta olevan keskeinen ongelma vanhainkodeissa

Psychotropic medication use among nursing home residents in Austria: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The use of psychotropic medications and their adverse effects in frail elderly has been debated extensively. However, recent data from European studies show that these drugs are still frequently prescribed in nursing home residents. In Austria, prevalence data are lacking. We aimed to determine the prevalence of psychotropic medication prescription in Austrian nursing homes and to explore characteristics associated with their prescription.</p> <p>Methods</p> <p>Cross-sectional study and association analysis in forty-eight out of 50 nursing homes with 1844 out of a total of 2005 residents in a defined urban-rural region in Austria. Prescribed medication was retrieved from residents' charts. Psychotropic medications were coded according to the Anatomical Therapeutic Chemical Classification 2005. Cluster-adjusted multiple logistic regression analysis was performed to investigate institutional and residents' characteristics associated with prescription.</p> <p>Results</p> <p>Residents' mean age was 81; 73% of residents were female. Mean cluster-adjusted prevalence of residents with at least one psychotropic medication was 74.6% (95% confidence interval, CI, 72.0–77.2). A total of 45.9% (95% CI 42.7–49.1) had at least one prescription of an antipsychotic medication. Two third of all antipsychotic medications were prescribed for bedtime use only. Anxiolytics were prescribed in 22.2% (95% CI 20.0–24.5), hypnotics in 13.3% (95% CI 11.3–15.4), and antidepressants in 36.8% (95% CI 34.1–39.6) of residents. None of the institutional characteristics and only few residents' characteristics were significantly associated with psychotropic medication prescription. Permanent restlessness was positively associated with psychotropic medication prescription (AOR 1.54, 95% CI 1.32–1.79) whereas cognitive impairment was inversely associated (AOR 0.70, 95% CI 0.56–0.88).</p> <p>Conclusion</p> <p>Frequency of psychotropic medication prescription is high in Austrian nursing homes compared to recent published data from other countries. Interventions should aim at reduction and optimisation of prescriptions.</p

Effectiveness of laxatives in elderly - a cross sectional study in nursing homes

<p>Abstract</p> <p>Background</p> <p>Laxatives are efficient drugs, but the effectiveness has been questioned. In nursing homes, the prevalence of constipation is high and laxatives are commonly used drugs. The aims of the study were to assess the effectiveness of laxative therapy in an everyday setting in Norwegian nursing homes, study differences between treatment regimens and factors associated with normal bowel function.</p> <p>Methods</p> <p>A cross-sectional study. After giving informed consent, residents above 60 years of age using laxatives for functional constipation were included, and their characteristics, medical history, use of drugs and bowel functions were recorded. Normal bowel function was defined as bowel movements from 3 times/week to 3 times/day and stool consistency 3-5 on Bristol Stool Form Scale.</p> <p>Results</p> <p>Out of 647 residents in the nursing homes, 197 were included and 116 (59%) had normal bowel function. The treatment effect did not differ significantly between the laxatives, treatment regimens or expected efficacy of the regimens. The treatment was unsatisfactorily adapted to individual needs. In subjects with normal bowel function, 113 (97%) had persistent complaints; 68 (59.5%), 10 (8.0%), 34 (28.6%) and 26 (22.5%) reported straining, manual manoeuvre to facilitate bowel movements, feeling of incomplete bowel movements, and feeling of anorectal obstruction respectively. Good nutritional status, previous or present cancer disease and anxiety/depression were predictors of normal bowel function.</p> <p>Conclusions</p> <p>Treatment of constipation in nursing homes was unsatisfactory. Nearly all patients with normal stool frequency and consistence had some persistent complaints. Improved nutrition and individualization of the treatment could improve the outcome.</p