Barricades and brickwalls--a qualitative study exploring perceptions of medication use and deprescribing in long-term care

Anna Palagyi, Lisa Keay, Jessica Harper, Jan Potter, Richard I Lindley, Anna Palagyi, Lisa Keay, Jessica Harper, Jan Potter, Richard I Lindley

Abstract

Background: The co-administration of multiple drugs (polypharmacy) is the single most common cause of adverse drug events in the older population, and residents of long-term care facilities (LTCFs) are at particularly high risk of medication harm. 'Deprescribing'--the withdrawal of an inappropriate medication with goal of managing polypharmacy and improving outcomes--may improve the quality of life of LTCF residents. The RELEASE study sought to explore perceptions of medication use and the concept of deprescribing in LTCFs.

Methods: Focus groups and interviews were conducted with General Practitioners (GPs), pharmacists, nursing staff, residents and their relatives within three LTCFs in the Illawarra-Shoalhaven region of NSW, Australia. Audiotapes were transcribed verbatim and, using the Integrative Model of Behaviour Prediction as a framework, thematic analysis of transcripts was conducted using QSR NVivo 10.

Results: Participants acknowledged the burden of too many medications (time to administer, physical discomfort, cost), yet displayed passivity towards medication reduction. Residents and relatives lacked understanding of medicine indications or potential harms. Willingness to initiate and accept medication change was dependent on the GP, who emerged as a central trusted figure. GPs preferred 'the path of least resistance', signalling systems barriers (poor uniformity of LTCF medical records, limited trained LTCF personnel); time constraints (resident consultations, follow-up with specialists and family); and the organisation of care (collaborating with LTCF staff, pharmacists and prescribing specialists) as obstacles to deprescribing.

Conclusions: Targeted engagement is required to raise awareness of the risks of polypharmacy in LTCFs and encourage acceptance of deprescribing amongst residents and their relatives. GPs are integral to the success of deprescribing initiatives within this sector.

Figures

Fig. 1
Fig. 1
An Integrative Model of Behaviour Prediction, adapted from Fishbein (2006). Themes emerging from the analysis were most clearly associated with five key elements: environmental factors, attitudes, control beliefs and self-efficacy, and skills and abilities
Fig. 2
Fig. 2
Major themes (in bold) and intermediate coding framework (boxed) emerging from discussions about medication use and deprescribing in long-term care facilities with participants of the RELEASE study. GP general practitioner, f female, F facility, LTCF long-term care facility, m male, RN registered nurse, y years

References

    1. Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J. A national census of medicines use: a 24-h snapshot of Australians aged 50 years and older. Med J Aust. 2012;196(1):50–3. doi: 10.5694/mja11.10698.
    1. Cheek J, Gilbert A, Ballantyne A, Penhall R. Factors influencing the implementation of quality use of medicines in residential aged care. Drugs Aging. 2004;21(12):813–24. doi: 10.2165/00002512-200421120-00005.
    1. Stafford AC, Alswayan MS, Tenni PC. Inappropriate prescribing in older residents of Australian care homes. Journal of Clinical Pharmacy & Therapeutics. 2011;36(1):33–44. doi: 10.1111/j.1365-2710.2009.01151.x.
    1. Somers M, Rose E, Simmonds D, Whitelaw C, Calver J, Beer C. Quality use of medicines in residential aged care. Aust Fam Physician. 2010;39(6):413–6.
    1. Khalil H. A review of pharmacist recommendations in an aged care facility. Aust J Prim Health. 2011;17(1):35–9. doi: 10.1071/PY10044.
    1. Johnell K, Klarin I. The relationship between number of drugs and potential drug-drug interactions in the elderly: a study of over 600,000 elderly patients from the Swedish Prescribed Drug Register. Drug Saf. 2007;30(10):911–8. doi: 10.2165/00002018-200730100-00009.
    1. Field TS, Gurwitz JH, Avorn J, McCormick D, Jain S, Eckler M, et al. Risk factors for adverse drug events among nursing home residents. Arch Intern Med. 2001;161(13):1629–34. doi: 10.1001/archinte.161.13.1629.
    1. Lu WH, Wen YW, Chen LK, Hsiao FY. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study. CMAJ. 2015;187(4):E130–7. doi: 10.1503/cmaj.141219.
    1. Runciman WB, Roughead EE, Semple SJ, Adams RJ. Adverse drug events and medication errors in Australia. Int J Qual Health Care. 2003;15(Suppl 1):i49–59. doi: 10.1093/intqhc/mzg085.
    1. Brandt NJ, Zarowitz BJ. Aligning care initiatives to reduce medication adverse effects in nursing homes. J Gerontol Nurs. 2015;41(1):8–13. doi: 10.3928/00989134-20141219-01.
    1. Handler SM, Wright RM, Ruby CM, Hanlon JT. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264–72. doi: 10.1016/j.amjopharm.2006.09.011.
    1. Poudel A, Peel NM, Nissen L, Mitchell C, Gray LC, Hubbard RE. Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities. Ann Pharmacother. 2014;48(11):1425–33. doi: 10.1177/1060028014548568.
    1. Elliott RA, Tran T, Taylor SE, Harvey PA, Belfrage MK, Jennings RJ et al. Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open. 2012;2(3). doi:10.1136/bmjopen-2012-000918.
    1. Reeve EG, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of “deprescribing” with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015; doi:10.1111/bcp.12732.
    1. Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust. 2014;201(7):390–2. doi: 10.5694/mja14.00146.
    1. Australian Government Department of Health and Ageing. Guidelines for a Palliative Approach in Residential Aged Care. Enhanced version. Canberra (Australia): Commonwealth of Australia, 2006. Accessed 19 May 2015.
    1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31. doi: 10.1111/j.1532-5415.2012.03923.x.
    1. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83. doi: 10.5414/CPP46072.
    1. Naugler CT, Brymer C, Stolee P, Arcese ZA. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharm. 2000;7(2):103–7.
    1. Gnjidic D, Le Couteur DG, Abernethy DR, Hilmer SN. A pilot randomized clinical trial utilizing the drug burden index to reduce exposure to anticholinergic and sedative medications in older people. Ann Pharmacother. 2010;44(11):1725–32. doi: 10.1345/aph.1P310.
    1. Spinewine A, Dumont C, Mallet L, Swine C. Medication appropriateness index: reliability and recommendations for future use. J Am Geriatr Soc. 2006;54(4):720–2. doi: 10.1111/j.1532-5415.2006.00668_8.x.
    1. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–34. doi: 10.1001/jamainternmed.2015.0324.
    1. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648–54. doi: 10.1001/archinternmed.2010.355.
    1. Reeve E, Andrews JM, Wiese MD, Hendrix I, Roberts MS, Shakib S. Feasibility of a patient-centered deprescribing process to reduce inappropriate use of proton pump inhibitors. Ann Pharmacother. 2015;49(1):29–38. doi: 10.1177/1060028014558290.
    1. Reeve E, M.D. W, Hendrix I, Roberts MS, Shakib S. People’s Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe. J Am Geriatr Soc. 2013;61(9):1508–14. doi:10.111/jgs.12418. Epub 2013 Aug 26.
    1. Beer C, Loh PK, Peng YG, Potter K, Millar A. A pilot randomized controlled trial of deprescribing. Ther Adv Drug Saf. 2011;2(2):37–43. doi: 10.1177/2042098611400332.
    1. Lindstrom K, Ekedahl A, Carlsten A, Martensson J, Molstad S. Can selective serotonin inhibitor drugs in elderly patients in nursing homes be reduced? Scand J Prim Health Care. 2007;25(1):3–8. doi: 10.1080/02813430600958427.
    1. Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG. Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging. 2008;25(12):1021–31. doi: 10.2165/0002512-200825120-00004.
    1. Kutner JS, Blatchford PJ, Taylor DH, Jr, Ritchie CS, Bull JH, Fairclough DL, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med. 2015;175(5):691–700. doi: 10.1001/jamainternmed.2015.0289.
    1. Schuling J, Gebben H, Veehof LJG, Haaijer-Ruskamp FM. Deprescribing medication in very elderly patients with multimorbidity: the view of Dutch GPs. A qualitative study. BMC Fam Pract. 2012;13:56. doi: 10.1186/1471-2296-13-56.
    1. Reeve E, To J, Hendrix I, Shakib S, Roberts MS, Wiese MD. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging. 2013;30(10):793–807. doi: 10.1007/s40266-013-0106-8.
    1. Faugier J, Sargeant M. Sampling hard to reach populations. J Adv Nurs. 1997;26(4):790–7. doi: 10.1046/j.1365-2648.1997.00371.x.
    1. Fishbein M, Cappella JN. The role of theory in developing effectiveness health communications. J Commun. 2006;56:S1–17. doi: 10.1111/j.1460-2466.2006.00280.x.
    1. Yzer M. The Integrative Model of Behavioral Prediction as a Tool for Designing Health Messages. In: Cho H, editor. Health Communication Message Design. Thousand Oaks: SAGE Publications, Inc; 2012.
    1. Scott IA, Le Couteur DG. Physicians need to take the lead in deprescribing. Intern Med J. 2015;45(3):352–6. doi: 10.1111/imj.12693.
    1. Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list: Appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician. 2012;41:12.
    1. Leydon GM, Rodgers L, Kendrick T. A qualitative study of patient views on discontinuing long-term selective serotonin reuptake inhibitors. Fam Pract. 2007;24(6):570–5. doi: 10.1093/fampra/cmm069.
    1. Australian Medical Association & Royal Australian College of General Practitioners. GP Services to Residential Aged Care: A Joint Proposal. 27 September 2006. Accessed 19 May 2015.
    1. Barter G, Cormack M. The long-term use of benzodiazepines: patients' views, accounts and experiences. Fam Pract. 1996;13(6):491–7. doi: 10.1093/fampra/13.6.491.
    1. Roe D, Goldblatt H, Baloush-Klienman V, Swarbrick M, Davidson L. Why and how people decide to stop taking prescribed psychiatric medication: exploring the subjective process of choice. Psychiatr Rehabil J. 2009;33(1):38–46. doi: 10.2975/33.1.2009.38.46.
    1. Kilinc S, Campbell C. The experience of discontinuing antiepileptic drug treatment: an exploratory investigation. Seizure. 2008;17(6):505–13. doi: 10.1016/j.seizure.2008.01.002.
    1. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549–55. doi: 10.1046/j.1532-5415.2003.51185.x.
    1. Spinewine A, Swine C, Dhillon S, Franklin BD, Tulkens PM, Wilmotte L, et al. Appropriateness of use of medicines in elderly inpatients: qualitative study. BMJ. 2005;331(7522):935. doi: 10.1136/bmj.38551.410012.06.
    1. Denneboom W, Dautzenberg MG, Grol R, De Smet PA. Comparison of two methods for performing treatment reviews by pharmacists and general practitioners for home-dwelling elderly people. J Eval Clin Pract. 2008;14(3):446–52. doi: 10.1111/j.1365-2753.2007.00900.x.
    1. Morris CJ, Cantrill JA, Weiss MC. GPs’ attitudes to minor ailments. Fam Pract. 2001;18(6):581–5. doi: 10.1093/fampra/18.6.581.
    1. Australian Institute of Health and Welfare . Residential aged care in Australia 2010–11: a statistical overview. Canberra: AIHW; 2012.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner