Oral medicine modification for older adults: a qualitative study of nurses

Aoife Mc Gillicuddy, Abina M Crean, Maria Kelly, Laura Sahm, Aoife Mc Gillicuddy, Abina M Crean, Maria Kelly, Laura Sahm

Abstract

Objective: Oral medicines are frequently modified (eg, tablets crushed) for older adults. However, these modifications can have clinical, legal and/or ethical implications. Nurses bear responsibility for medicine administration and hence, perform these modifications. The aim of this study was to investigate the knowledge, attitudes and beliefs of nurses about oral medicine modification for older adults.

Design: A qualitative study was conducted using semi-structured, face-to-face interviews with nurses providing care to older adults in acute and long-term care settings. Interviews were audio-recorded, transcribed verbatim and analysed thematically.

Settings: Sixteen purposively selected care settings; 4 acute-care and 12 long-term care settings were included. Nurses were recruited by convenience sampling at these sites.

Participants: Eighteen nurses participated (83% female, 67% long-term care, 33% acute-care, median age (IQR) 38 years (32.5-52.0)).

Results: Three major themes: modifying-a necessary evil, nurses' role as patient advocate and modifying-we are working very much as a team and two minor themes: fractional dosing, and covert administration emerged from the data. Nurses viewed oral medicine modifications as being a routine and necessary occurrence in geriatric patient care due to limitations of available formulations and the presence of age-related challenges in drug administration. Nurses' knowledge of residents' requirements ensured that they advocate for those with individualised formulation needs, however, nurses rely on pharmacists for information about modifications. Nurses expressed a desire for supports including increased education and ward-specific, pharmacist-developed recommendations on common modifications.

Conclusions: This study has provided useful insights into the views of nurses regarding oral medicine modification for older adults. The unique and varied formulation requirements of older adults must be acknowledged. Increased engagement by healthcare professionals, the pharmaceutical industry, regulatory agencies and policy-makers is required to facilitate the development of age-appropriate formulations. In the interim, practical interventions, informed by the findings of this study, are required.

Keywords: interviews; medicine administration; medicine modification; nurses; oral medicines; qualitative.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

References

    1. An Bord Altranais. Guidance to nurses and midwives on medication management. Dublin: An Bord Altranais, 2007.
    1. Elliott M, Liu Y. The nine rights of medication administration: an overview. Br J Nurs 2010;19:300–5. 10.12968/bjon.2010.19.5.47064
    1. United Nations Department of Economic and Social Affairs Population Division. World population ageing 2013, 2013. ST/ESA/SER.A/348.
    1. United Nations Department of Economic and Social Affairs Population Division. World population prospects: the 2015 revision, key findings and advance tablets, 2015. Working Paper No. ESA/P/WP.241.
    1. World Health Organisation. World report on ageing and health, 2015.
    1. Sabaté E. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization, 2003.
    1. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 2007;5:345–51. 10.1016/j.amjopharm.2007.12.002
    1. Stegemann S, Ecker F, Maio M, et al. . Geriatric drug therapy: neglecting the inevitable majority. Ageing Res Rev 2010;9:384–98. 10.1016/j.arr.2010.04.005
    1. Topinková E, Baeyens JP, Michel JP, et al. . Evidence-based strategies for the optimization of pharmacotherapy in older people. Drugs Aging 2012;29:477–94. 10.2165/11632400-000000000-00000
    1. Aslam M, Vaezi MF. Dysphagia in the elderly. Gastroenterol Hepatol 2013;9:784–95.
    1. Chen PH, Golub JS, Hapner ER, et al. . Prevalence of perceived dysphagia and quality-of-life impairment in a geriatric population. Dysphagia 2009;24:1–6. 10.1007/s00455-008-9156-1
    1. Steele CM, Greenwood C, Ens I, et al. . Mealtime difficulties in a home for the aged: not just dysphagia. Dysphagia 1997;12:43–50. 10.1007/PL00009517
    1. Hämmerlein A, Derendorf H, Lowenthal DT. Pharmacokinetic and pharmacodynamic changes in the elderly. Clinical implications. Clin Pharmacokinet 1998;35:49–64. 10.2165/00003088-199835010-00004
    1. Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2004;57:6–14. 10.1046/j.1365-2125.2003.02007.x
    1. Mercovich N, Kyle GJ, Naunton M. Safe to crush? A pilot study into solid dosage form modification in aged care. Australas J Ageing 2014;33:180–4. 10.1111/ajag.12037
    1. Caussin M, Mourier W, Philippe S, et al. . [Crushing drugs in geriatric units: an "handicraft" practice with frequent errors which imposed recommendations]. Rev Med Interne 2012;33:546–51. 10.1016/j.revmed.2012.05.014
    1. Fischbach MS, Gold JL, Lee M, et al. . Pill-splitting in a long-term care facility. CMAJ 2001;164:785–6.
    1. Mc Gillicuddy A, Kelly M, Sweeney C, et al. . Modification of oral dosage forms for the older adult: An Irish prevalence study. Int J Pharm 2016;510:386–93. 10.1016/j.ijpharm.2016.06.056
    1. Haw C, Stubbs J. Covert administration of medication to older adults: a review of the literature and published studies. J Psychiatr Ment Health Nurs 2010;17:761–8. 10.1111/j.1365-2850.2010.01613.x
    1. Kirkevold Ø, Engedal K. Concealment of drugs in food and beverages in nursing homes: cross sectional study. BMJ 2005;330:20 10.1136/bmj.38268.579097.55
    1. National Institute for Health and Care Excellence. Medicines management in care homes, 2015.
    1. Mental Welfare Commission for Scotland. Good practice guide-covert medication, 2013.
    1. Liabeuf S, Gras V, Moragny J, et al. . Ulceration of the oral mucosa following direct contact with ferrous sulfate in elderly patients: a case report and a review of the French National Pharmacovigilance Database. Clin Interv Aging 2014;9:737–40. 10.2147/CIA.S58394
    1. Schier JG, Howland MA, Hoffman RS, et al. . Fatality from administration of labetalol and crushed extended-release nifedipine. Ann Pharmacother 2003;37:1420–3. 10.1345/aph.1D091
    1. Verrue C, Mehuys E, Boussery K, et al. . Tablet-splitting: a common yet not so innocent practice. J Adv Nurs 2011;67:26–32. 10.1111/j.1365-2648.2010.05477.x
    1. James A. The legal and clinical implications of crushing tablet medication. Nurs Times 2004;100:28–9.
    1. Wright D, Chapman N, Foundling-Miah M, et al. . Consensus guideline on the medication management of adults with swallowing difficulties. Berkhamsted: Medenium Group Publishing, 2006.
    1. Griffith R, Davies R. Tablet crushing and the law: the implications for nursing. Prof Nurse 2003;19:41–2.
    1. Paradiso LM, Roughead EE, Gilbert AL, et al. . Crushing or altering medications: what’s happening in residential aged-care facilities? Australas J Ageing 2002;21:123–7. 10.1111/j.1741-6612.2002.tb00432.x
    1. Braun V, Clarke V. Successful qualitative research: a practical guide for beginners: Sage, 2013.
    1. Kelly J, D’Cruz G, Wright D. A qualitative study of the problems surrounding medicine administration to patients with dysphagia. Dysphagia 2009;24:49–56. 10.1007/s00455-008-9170-3
    1. Kelly J, D’Cruz G, Wright D. Patients with dysphagia: experiences of taking medication. J Adv Nurs 2010;66:82–91. 10.1111/j.1365-2648.2009.05145.x
    1. Barnes L, Cheek J, Nation RL, et al. . Making sure the residents get their tablets: medication administration in care homes for older people. J Adv Nurs 2006;56:190–9. 10.1111/j.1365-2648.2006.03997.x
    1. Mc Gillicuddy A, Kelly M, Crean AM, et al. . The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: A systematic review of the qualitative literature. Res Social Adm Pharm 2017;13 10.1016/j.sapharm.2016.09.004
    1. Central Statistics Office Central Statistics Office. Census 2016 Small Area Population Statistics. (accessed 22 Aug 2017).
    1. Marshall MN. Sampling for qualitative research. Fam Pract 1996;13:522–6. 10.1093/fampra/13.6.522
    1. Nursing Homes Ireland. Nursing Home Directory. (accessed 2 Feb 2016).
    1. Cahill S, O’Caheny D. Specialist Care Units for People with Dementia in Ireland: A Guide for Family Caregivers and Health Service Professionals. Dublin: The Dementia Services Information and Development Centre, St. James’s Hospital, 2014.
    1. Department of Health. Review of the nursing homes support scheme, a fair deal, 2015.
    1. Bourdenet G, Giraud S, Artur M, et al. . Impact of recommendations on crushing medications in geriatrics: from prescription to administration. Fundam Clin Pharmacol 2015;29:316–20. 10.1111/fcp.12116
    1. Fodil M, Nghiem D, Colas M, et al. . Assessment of clinical practices for crushing medication in geriatric units. J Nutr Health Aging 2017;21:904–8. 10.1007/s12603-017-0886-3
    1. Francis JJ, Johnston M, Robertson C, et al. . What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health 2010;25:1229–45. 10.1080/08870440903194015
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. 10.1191/1478088706qp063oa
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159–74. 10.2307/2529310
    1. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19:349–57. 10.1093/intqhc/mzm042
    1. Serrano Santos JM, Poland F, Wright D, et al. . Medicines administration for residents with dysphagia in care homes: A small scale observational study to improve practice. Int J Pharm 2016;512:416–21. 10.1016/j.ijpharm.2016.02.036
    1. Wong IC, Basra N, Yeung VW, et al. . Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child 2006;91:686–8. 10.1136/adc.2006.093724
    1. Mc Gillicuddy A, Crean AM, Sahm LJ. Older adults with difficulty swallowing oral medicines: a systematic review of the literature. Eur J Clin Pharmacol 201672 10.1007/s00228-015-1979-8
    1. Hurst K. How much time do nurses spend at the bedside? Nurs Stand 2010;24:14 10.7748/ns.24.52.14.s20
    1. Zolnierek CD. An integrative review of knowing the patient. J Nurs Scholarsh 2014;46:3–10. 10.1111/jnu.12049
    1. Radwin LE. ’Knowing the patient': a review of research on an emerging concept. J Adv Nurs 1996;23:1142–6. 10.1046/j.1365-2648.1996.12910.x
    1. Suhonen R, Papastavrou E, Efstathiou G, et al. . Patient satisfaction as an outcome of individualised nursing care. Scand J Caring Sci 2012;26:372–80. 10.1111/j.1471-6712.2011.00943.x
    1. Hendrich A, Chow MP, Skierczynski BA, et al. . A 36-hospital time and motion study: how do medical-surgical nurses spend their time? Perm J 2008;12:25–34. 10.7812/TPP/08-021
    1. Strachan I, Greener M. Medication-related swallowing difficulties may be more common than we realise. Pharm Pract 2005;15:411–4.
    1. Schiele JT, Quinzler R, Klimm H-D, et al. . Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms. Eur J Clin Pharmacol 2013;69:937–48. 10.1007/s00228-012-1417-0
    1. Greener M. Dealing with dysphagia. Geriatric Medicine 2008;38:539–42.
    1. Arnet I, Hersberger KE. Misleading score-lines on tablets: facilitated intake or fractional dosing? Swiss Med Wkly 2010;140:105-10
    1. Food and Drug Administration. Guidance for Industry Tablet Scoring: Nomenclature, Labeling and Data for Evaluation. 2013.
    1. European Medicines Agency. Guideline on pharmaceutical development of medicines for paediatric use. 2013.
    1. Messina R, Becker R, van Riet-Nales DA, et al. . Results from a preliminary review of scientific evidence for appropriateness of preparations, dosage forms and other product design elements for older adult patients. Int J Pharm 2015;478:822–8. 10.1016/j.ijpharm.2014.10.052
    1. Stegemann S, Gosch M, Breitkreutz J. Swallowing dysfunction and dysphagia is an unrecognized challenge for oral drug therapy. Int J Pharm 2012;430:197–206. 10.1016/j.ijpharm.2012.04.022
    1. Greenhalgh T, Snow R, Ryan S, et al. . Six ‘biases’ against patients and carers in evidence-based medicine. BMC Med 2015;13:200 10.1186/s12916-015-0437-x
    1. Takase M. The relationship between the levels of nurses’ competence and the length of their clinical experience: a tentative model for nursing competence development. J Clin Nurs 2013;22:1400–10. 10.1111/j.1365-2702.2012.04239.x

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