October 10, 2017
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Multistep tool reduced inappropriate medication use in nursing home residents

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An intervention including the Multidisciplinary Multistep Medication Review tool led to successful discontinuation of inappropriate medication use in nursing home residents without negatively affecting their well-being, according to data published in Annals of Internal Medicine.

Inappropriate prescribing is a well-known clinical problem in nursing home residents, but few interventions have focused on reducing inappropriate medication use,” Hans Wouters, PhD, from the University of Groningen in the Netherlands, and colleagues wrote.

Wouters and colleagues sought to improve prescribing in nursing home residents by evaluating successful discontinuation of inappropriate drug use. The researchers performed a randomized controlled trial in 59 Dutch nursing home wards for long-term care, while clustering by elder care physicians and their wards. They enrolled 426 nursing home residents who had a life expectancy greater than 4 weeks and consented to medication treatment and followed them for a mean of 144 days.

Nineteen elder care physicians from 33 wards performed the intervention — the Multidisciplinary Multistep Medication Review (3MR) — in 233 residents. The 3MR consisted of an evaluation of the patient’s perspective, medical history and use of medications; a meeting between the physician and pharmacist; and the execution of medication changes. In the control group, 16 elder care physicians from 26 wards followed standard procedures in 193 residents.

Results showed that successful discontinuation without relapse or severe withdrawal symptoms of at least one inappropriate medication was greater in the intervention group than the control group (39.1% vs. 29.5%; adjusted RR = 1.37; 95% CI, 1.02-1.75). Between baseline and 4 months of follow-up, there was no deterioration of clinical outcomes, such as neuropsychiatric symptoms, cognitive function and quality of life, in either group.

“Given the increasing prevalence of polypharmacy in older adults, our study provides timely and practical guidance on how to operationalize deprescribing in nursing home residents,” Wouters and colleagues concluded. “Our findings demonstrate the positive effects of the 3MR on decreasing inappropriate prescribing without compromising the well-being of vulnerable nursing home residents.”

In an accompanying editorial, Holly M. Holmes, MD, MS, from the University of Texas Health Science Center McGovern Medical School, Houston, and Greg A. Sachs, MD, from the Indiana University School of Medicine and Regenstrief Institute, Indianapolis, wrote that while these findings are positive, it is unknown whether they can be reproduced or generalized.

“Clinicians practicing in the nursing home setting should take important messages from this study,” the editorialists wrote. “Medication reconciliation can be a complex process requiring substantial expertise, but improvements in medication use can be facilitated by working closely with the multidisciplinary team, particularly the consultant pharmacist. Focusing on a specific set of criteria ... or a specific class of drugs ... might be the best first approach. Finally, a deprescribing process that incorporates the [Screening Tool of Older Persons' Potentially Inappropriate Prescriptions]-Frail criteria may be more appropriate for this population that is characterized by frailty, advanced dementia and reduced life expectancy.” – by Alaina Tedesco

Disclosures: Sachs reports receiving personal fees from CVS Caremark. The other authors report no relevant financial disclosures.