Percentage of Nursing Home Patients
| 20% | receive inappropriate drugs |
| 16% | receive drugs without prescription |
| 23% | don't receive prescribed drugs |
| 20% | receive drugs inappropriate for elderly |
| 21% | receive drugs that could interact with other drugs |
| 32% | receive more than one drug in the same class |
| 31% | patients' records insufficient to determine appropriateness of prescriptions |
Drugging the Nation's Elderly
Inspector General's Report on Nursing Home Drug Use The U.S. Department of Health and Human Services has released a report on Texas nursing homes, Prescription Drug Use in Nursing Home, based on investigations of Inspector General June Gibbs Brown of the Office of the Inspector General.
The primary purpose of the reports were to "describe the extent and appropriateness of drug use by Medicare and Medicaid residents of Texas nursing homes." In 1995, Medicaid paid $9.8 billion for prescription drugs in Texas. In that same year, Medicaid provided for 1.7 million Texans in nursing homes. With prescription costs ranging from $600 to $1,000 per resident per year, this equates to as much as $1.7 billion in drugs for the Texas nursing home elderly in 1995.
In the face of such enormous expenditures, the Inspector General examined the issue in three separate reports:
An Introduction Based on Texas assesses the extent of prescription drug use for Medicare and Medicaid nursing home residents using Medicaid data for Texas for calendar years 1992 through 1994 and the first six months of 1995. The report examines total program expenditures by year and total expenditures by drug class, offering a more detailed understanding of precisely what types of drugs are being used in nursing homes and in what volume they are being used. An Inside View by Consultant Pharmacists presents the results of a national survey of consultant pharmacists who perform federally-mandate monthly drug regimen reviews in nursing homes.
A Pharmaceutical Review and Inspection Recommendations discusses results from an independent review of drugs and medical records for a sample of Texas nursing home patients.
The first report, An Introduction Based on Texas, made some interesting discoveries:
"Some nursing home residents are receiving drugs which are potentially inappropriate or not medically necessary, raising cost and quality of care concerns. "In 1994 almost 20 percent, more than 16,600, of Texas' Medicaid and Medicare beneficiaries received at least one of twenty drugs considered by medical experts to be inappropriate for elderly use due to side effects or other consequences.
"Gastrointestinal drugs, drugs for cardiovascular and cardiac care, psychotherapeutics, and anti-infective drugs combine to total more than half of Medicaid payments for prescription drugs in this population.
"Total payments for drugs in these categories increased at very high rates, ranging from 60 percent to 94 percent, between 1992 and 1994.
"Almost 47 percent of the residents in our data set received at least one gastrointestinal drug in 1994; their total cost to Medicaid was over $15 million. This single drug class accounted for almost 17 percent of all Medicaid prescription drug payments in that year, a substantial increase over the 1992 share of 12 percent. This class of drugs is one of the most expensive, with average payments per beneficiary of nearly $385 and an average cost per day of $1.05.
"A 1992 study suggests that at least 40 percent of nursing home residents who receive these drugs are receiving them for conditions other than those indicated in the medical literature. Therefore, curtailing unnecessary or inappropriate use of gastrointestinal drugs could result in sizeable program savings."
The second report, An Inside View by Consultant Pharmacists, provides an inside look at what consultant pharmacists see when they perform federally-mandated drug utilization reviews in nursing homes:
"Ultimately, for nursing home patients, it is either the patient's attending physician or the facility's medical director who determines what is appropriate care "According to pharmacists, patients are experiencing numerous adverse reactions as a result of potentially inappropriate prescribing and inadequate administration or monitoring of the usage of medications.
"Adverse reactions reported by consultant pharmacists as occurring sometimes or often include constipation (reported by 81 percent); falls (66 percent); delirium (41 percent); depression (39 percent); and urinary incontinence (26 percent).
"Pharmacists have serious concerns about prescribing practices for antipsychotics, anxiolytics, sedatives/hypnotics, antidepressants, and other drugs.
"Because legislation prescribes certain limitations on antipsychotics, anxiolytics, and sedatives/hypnotics, there is concern that from 21 to 44 percent of pharmacists report some patients are receiving medically inappropriate prescriptions of these drugs. Other drugs, not necessarily legislated for scrutiny, which also seriously concern consultant pharmacists include H2 antagonists (reported by 65 percent); non-steroidal anti-inflammatory drugs (47 percent); narcotics (46 percent); digoxin (40 percent); antibiotics and anti-infectives (39 percent) and gastrointestinals (36 percent). Moreover, according to 15 percent of the consultant pharmacists, some physicians are prescribing medically inappropriate antidepressants. One-third say antidepressants are sometimes prescribed without an appropriate diagnosis and that few or not physicians ensure their maintenance at appropriate levels.
"A number of medication administration problems which may put patients at risk also concern pharmacists. These include absence of specific usage directions; incomplete orders; failure to update medication administration records with dosage or schedule changes; physicians signing orders that are not current or correct; failure to include orders on the medication administration record; misplaced medications; and continuation of a medication in disregard of stop orders. Further, medications are sometimes administered by
ursing staff at the wrong time, in non-optimal dosages, for inappropriate durations, or the medication may be inappropriately altered (crushing, dilution, etc.).
"Pharmacists conduct some reviews without consulting important medical records and without having patients' diagnoses or laboratory reports. More than half of the reviews do not consider the resident's assessment (65 percent) or plan of care (56 percent). Other records not consulted by pharmacists include facility incident and accident reports (20 percent ) and specialists' notes and nutritional plans (13 percent). Fully one-third say they have difficulty obtaining a patient's diagnosis and necessary lab reports."
The third report, A Pharmaceutical Review and Inspection Recommendations, presents results from an independent review of drugs and medical records for a sample of Texas nursing home patients. The final report summarizes the findings of all three inspections: "Contracted medication reviews revealed potentially serious concerns with residents' drug regimens.
"20 percent of the reviewed patient records identified patients receiving at least one drug judged inappropriate for their diagnoses. Additionally, patients' records indicated some residents were taking medications potentially contraindicated by their diet requirements, plans of care, or assessments. "16 percent of patients were receiving, without a prescription in their records, drugs for which prescriptions are generally required. Further, 23 percent of the patients were prescribed medications for which the records showed no orders or receipts to indicate the patient actually received the medication.
"Approximately 20 percent of residents received at least one drug considered by experts to be inappropriate for use by the elderly.
"Some patients' records indicate they may be experiencing unnecessary adverse medication reactions as a result of inadequate monitoring.
"21 percent of patients were receiving drugs which may sometimes negatively interact with other drugs in their regimen.
"Nearly one-third of patients were receiving more than one drug from the same class, sometimes a potential hazard. Drugs from the same class may produce similar side effects which can be additive and need to be carefully managed. Yet, 19 percent of all records indicate no monitoring of efficacy.
"Resident medication records are often incomplete, making it difficult or impossible to identify or confirm potential drug regimen problems.
"31 percent of patients' records were not sufficiently complete to allow contract pharmacists to make determinations concerning the appropriateness of medications prescribed for patients' diagnoses.
"Contract pharmacists identified several patients whose prescribed medications may have contributed to falls, depression, and constipation. However, due to insufficient records, they were unable to pinpoint or eliminate the patient's drug regimen as the cause.
"Often the contract pharmacists were unable to determine whether a patient had received a monthly drug regimen review during the sampled time period.
"Contract pharmacists' reviews averaged 50 minutes, which is considerably longer than the times consultant pharmacists expend doing medication reviews (averaged 5-10 minutes per monthly review with initial reviews taking 15-20 minutes).
"The contract pharmacists identified medication problems or concerns for 20 percent of the patients which had not been identified by the nursing home consultant pharmacists' reviews.
"Medication problems and concerns raised collectively by the three coordinated reports of this inspection demonstrate the need for stronger monitoring and more positive enforcement of existing regulations and required reviews of medication usage in nursing homes."
This information should be shared with all patients in nursing homes, and those who have family in nursing homes. The dangers are rampant. The only safeguards to prevent these abuses are to critically examine every drug prescribed; to verify that they are absolutely necessary; that they are appropriate for elderly patients; that they are not in harmful combination with other drugs; that they are recorded in the health records and correctly administered by the nursing home staff.
Because every drug has side effects, these should be well understood and monitored. Ultimately, the best solution to these problems is for the elderly to continue to lead a drug-free life as much as possible.
Without a knowledgeable, forceful family member on guard, nursing home residents are likely to end up victims of one or more of these statistics.
