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MATERIAL AND METHOD
This study was designed as a retrospective study evaluating clinical practice using medical records, and was carried out at the department of Geriatric medicine at Örebro University Hospital. The study was part of a two-year follow-up protocol to investigate how geriatric care is conducted at a nursing home called Tullhuset.
Participants: Patients included were those entering Tullhuset from the 15th of August to the 14th of October in 2016, after discharge from hospitals in region Örebro län. Exclusion criteria were patients younger than 65 years old and those admitted directly from their households, due to the lack of medical records.
Study procedure: A structured protocol of all included patients was completed through information from the database “Kliniska Portalen”, the software containing medical records. The same person collected and evaluated all data.
Information regarding number of drugs and current medications was primarily collected from the discharge summary from the hospitals. If current medications were missing, the information was collected from the electronic drug administration system. Parameters of interest were also sex, age, main diagnosis and number of secondary diagnoses.
The patient was considered exposed to IDU if any inappropriate drugs were found on the list of current medications. If the indication for the IDU was documented in the medical records and seemed reasonable, it was considered a valid indication. The search for a valid indication for each patient with IDU was mainly accomplished in current documentation of the hospital stay, however, if no indication was found, medical records from previous hospital admissions and primary care consultations were also used.
In this study elderly patients were defined as 65 years or older. Multimorbidity was described as the number of secondary diagnoses, and partly as the occurrence of diagnoses in three or more organ systems. Polypharmacy was defined as five or more drugs per patient at the same time, and excessive polypharmacy as ten or more drugs [8]. IDU was defined as drugs that should be prescribed restrictively to the elderly, according to the regional Drug Therapeutic Committee (DTC) in Örebro (Long acting benzodiazepines, anticholinergics, Codeine, Tramadol, NSAID, Propiomazin and Zolpidem) [19]. This list of drugs represents current guidelines used at the hospitals in region Örebro län, regarding IDU among the elderly. A few other drugs were also considered as IDU, according to the National board of Health and Welfare, and Swedish Agency for Health Technology Assessment and Assessment of Social Services (other benzodiazepines [2], SSRI [18,20] and neuroleptics [18,21]).
Statistics
T-test was used when analysing differences in age, number of secondary diagnoses and number of drugs, and was calculated using SPSS statistics 22. P-values ≤ 0.05 were considered statistically significant. The programme Confidence Interval Analysis (CIA) was used for calculating differences in proportions, a method described by Newcombe & Altman [27]. 95% confidence intervals (95%CI) were used to report these results, and were considered statistically significant if the 95%CI did not include zero.
Ethics
The head of the department of Geriatric medicine approved the quality study. No ethical approval was required from the Ethics Committee. However, cautious managing of personal data was required and the data was de-identified after it had been collected.
RESULTS
During the two-month period, 64 patients were admitted to Tullhuset, however, four patients were excluded due to not fulfilling the age criterion and three patients were excluded due to arriving from their households. A total of 57 patients were larger proportion of the included patients had diagnoses in three or more organ systems, compared to the excluded patients (32% difference, 95% CI: 3; 65). A larger proportion of the included patients were women, but the difference was not significant (63% compared to 43%, 20% difference, 95%CI: -14; 50). Before the included 57 patients were admitted to the hospitals, a majority were living in their ordinary houses, however, when admitted many patients were in need of assistance in daily life activities. Further details are given in table 1.
DISCUSSION
The aim of this study was to investigate the number of drugs and the IDU among patients admitted to Tullhuset, and to evaluate the occurrence of a valid indication for each patient with IDU. Furthermore, the study intended to investigate potential differences between patients with inappropriate drugs and patients without.
Many previous studies have shown that polypharmacy remains a significant problem [11,16,22,28,29], and this study was no exception. A total of 96% fulfilled the criterion for polypharmacy and 56% for excessive polypharmacy. The prevalence of polypharmacy has in a previous Swedish systematic literature study been found to range from 46-84% in hospital care patients [29], and in another study the prevalence was 51.7% for polypharmacy and 14.2% for excessive polypharmacy [16]. The frequency of polypharmacy in our study is more pronounced compared to previous studies. This is in keeping with another study showing that the prevalence of polypharmacy appears to increase over time [28]. However, it is important to keep in mind that the ageing process itself is a major factor affecting the frequency of polypharmacy as well. Moreover, the population in our study consists of quite old multimorbid elderly patients, admitted to a special institution, and therefore are not representative of the whole Swedish elderly population.
There may be several reasons for increasing prevalence of polypharmacy in society. One explanation is the occurrence of inadequate documentation, especially since many health care providers have different systems for recording medical information. Furthermore, the number of new available drug therapies is constantly increasing and it is also common that adverse events give rise to new symptoms, which further on give rise to a prescribing cascade [15]. Moreover, it is often a greater challenge to stop a medication than continuing an established drug regimen, for example due to the risk that the original condition could flare or the possibility of withdrawal symptoms [30]. Furthermore it is possible that the recommended prescriptions for different types of drugs are modified over time, changing the original indication [28]. An additional aspect is that the number of prescribers available in each care giving process has been shown to increase the number of prescribed drugs [15,24], due to lack of continuity. These factors combined may affect the frequency of polypharmacy. Nevertheless, it is of great relevance that polypharmacy affects quality of drug therapy, which further on affects quality of life [31].
Previous studies have suggested that polypharmacy increases the risk inappropriate drug treatments [11,16]. In our study the number of drugs seemed to be higher in the group with IDU compared to the patients with no IDU, especially when comparing those exposed to excessive polypharmacy, however this was not statistically significant.
Almost half of the patients included in the study were exposed to IDU. In a previous Swedish systematic literature study the prevalence of IDU was found to range from 27% to 56% [29], and in other previous studies with similar age criterions it ranged from 17% to 74% [16,22,24,25,32]. Our prevalence of 49% seems to be in line with this. However, it is difficult comparing the prevalence of IDU between various studies, due to different definitions of IDU, which further on might cause the discrepancy of IDU frequency. Conversely, it is possible to compare the frequency of some specific inappropriate drugs. A total of 7% were using long-acting benzodiazepines in this study and 11% anticholinergics, this is in accordance with previous Swedish studies, in which it ranged from 4.4% to 13.5% and 6.1% to 20.2%, respectively [16,22,25,32]. The results indicate that there is room for improvements to optimise drug therapies of the elderly in Örebro.
There may be many factors affecting the prevalence of IDU and why it appears to be a common problem among elderly patients in today’s society. For example there seems to be an association between the number of drugs and the risk for IDU [11,16], and the high prevalence of polypharmacy has already been discussed. Furthermore, institutionalization has been indicated to affect the risk for IDU [32]. Moreover, it has been shown that education and information to the physician and other medical staff affect the quality of drug therapies [2]. In our study there is a possibility that discharging doctors unknowingly were influenced by the fact that the patient was being transferred to a geriatric clinic, and therefore did not seek to optimising each patient’s list of medications as thoroughly as the general population. In general, it is often easier assigning someone else the responsibility for the patient’s drug therapy, than dealing with the problem yourself.
Table of contents :
ABSTRACT
Introduction
Aim
Methods
Results
Conclusion
INTRODUCTION
Aim of the study
MATERIAL AND METHOD
Statistics
Ethics
RESULTS
DISCUSSION
Strengths and limitations
Future improvements
Conclusion
REFERENCES
Ethical consideration
Cover letter
Populärvetenskaplig sammanfattning
