Original Study
Education to Reduce Potentially Harmful Medication Use Among Residents of Assisted Living Facilities: A Randomized Controlled Trial

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Abstract

Objectives

The objectives of this study were (1) to investigate the effect of nurse training on the use of potentially harmful medications; and (2) to explore the effect of nurse training on residents' health-related quality of life (HRQoL), health service utilization, and mortality.

Setting and participants

In total, 227 residents in 20 wards of assisted living facilities in Helsinki were recruited. The 20 wards were randomized into those in which (1) staff received two 4-hour training sessions on appropriate medication treatment (intervention group), and (2) staff received no additional training and continued to provide routine care (control group).

Intervention

Two 4-hour interactive training sessions for nursing staff based on constructive learning theory to recognize potentially harmful medications and corresponding adverse drug events.

Measurements

Use of potentially harmful medications, HRQoL assessed using the 15 dimensional instrument of health-related quality of life, health service utilization, and mortality assessed at baseline, and 6 and 12 months.

Results

During the 12-month follow-up, the mean number of potentially harmful medications decreased in the intervention wards [−0.43, 95% confidence interval (CI) −0.71 to −0.15] but remained constant in the control wards (+0.11, 95% CI −0.09 to +0.31) (P = .004, adjusted for age, sex, and comorbidities). HRQoL declined more slowly in the intervention wards (−0.038 (95% CI −0.054 to −0.022) than in the control wards (−0.072 (95% CI −0.089 to −0.055) (P = .005, adjusted for age, sex, and comorbidities). Residents of the intervention wards had significantly less hospital days (1.4 days/person/year, 95% CI 1.2–1.6) than in the control wards (2.3 days/person/year; 95% CI 2.1–2.7) (relative risk 0.60, 95% CI 0.49–0.75, P < .001, adjusted for age, sex, and comorbidities).

Conclusions

Activating learning methods directed at nurses in charge of comprehensive care can reduce the use of harmful medications, maintain HRQoL, and reduce hospitalization in residents of assisted living facilities.

Section snippets

Design and Context

This was a RCT in which 20 wards in assisted living facilities in Helsinki, Finland, were randomized to intervention and control arms.33 The intervention was staff training on harmful medication use using the principles of constructive learning theory. Assisted living facilities provide medical and nursing care to people who are unable to live independently in the community. The level of care is similar to that provided in traditional nursing homes or long-term hospital wards, but the

Results

Of 307 eligible residents, 227 residents or their proxies provided consent to participate (Figure 1). The intervention group included 118 residents and the control group included 109 residents. There was a moderate attrition rate, with 41 residents (18.1%) lost to follow-up at 6 months. The total study attrition at 12 months was 63 residents (27.8%). This included 63 deaths (39 intervention residents, 24 control residents). In addition, data collection was not possible for 3 residents at the

Discussion

This RCT demonstrated that a relatively light educational intervention in assisted living facilities reduced prescribing of potentially harmful medications, maintained HRQoL and reduced hospitalization. To our knowledge, this is the first RCT to demonstrate an educational initiative to reduce potentially harmful medication use was associated with maintenance of residents' quality of life and lower use of hospital services.

An important strength of this study was its pragmatic design. The light

Conclusions

It is possible to reduce the number of harmful medications in institutionalized settings by educating nurses to identify harmful medications and ADEs. Modern activating learning methods directed at nurses in charge of residents' comprehensive care can maintain HRQoL and reduce hospitalization. The education initiative did not have a detectable impact on mortality.

Acknowledgments

The authors thank Helsinki City Social Services Department for its support.

References (51)

  • G. Onder et al.

    Polypharmacy in nursing home in Europe: Results from the SHELTER Study

    J Gerontol A Biol Sci Med Sci

    (2012)
  • M.H. Beers et al.

    Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine

    Arch Intern Med

    (1991)
  • P.J. McLeod et al.

    Defining inappropriate practices in prescribing for elderly people: A national consensus panel

    Can Med Assoc J

    (1997)
  • D.M. Fick et al.

    Updating the Beers criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of experts

    Arch Intern Med

    (2003)
  • P. Gallagher et al.

    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)
  • Socialstyrelsen. Indikatorer för god läkemedelsterapi hos äldre. Artikelnr 2010–6-29. Socialstyrelsen 2010. Available...
  • 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)
  • M.M. Raivio et al.

    Use of inappropriate medications and their prognostic significance among institutionalized patients with and without dementia in Finland

    Drugs Aging

    (2006)
  • D.T. Lau et al.

    Potentially inappropriate medication prescriptions among elderly nursing home residents: Their scope and associated resident and facility characteristics

    Health Serv Res

    (2004)
  • A.C. Stafford et al.

    Inappropriate prescribing in older residents of Australian care homes

    J Clin Pharm Ther

    (2011)
  • E. Jano et al.

    Healthcare outcomes associated with Beers' criteria: A systematic review

    Ann Pharmacother

    (2007)
  • S. Borson et al.

    The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities

    Psychiatr Serv

    (1997)
  • L.S. Schneider et al.

    Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials

    JAMA

    (2005)
  • P.S. Wang et al.

    Risk of death in elderly users of conventional vs atypical antipsychotic medications

    N Engl J Med

    (2005)
  • S. Hartikainen et al.

    Medication as a risk factor for falls: Critical systematic review

    J Gerontol A Biol Sci Med Sci

    (2007)
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    Dr Pitkälä reports having professional cooperation including lecturing fees from pharmaceutical and other health care companies (including Lundbeck, Orion), and having participated in clinical trials funded by pharmaceutical companies. Dr Juola, Dr Kautiainen, Dr Soini, Dr Finne-Soveri, Dr Bell, and Dr Björkman have no competing interests. This study is supported by Sohlberg Foundation and Helsinki University Hospital development grant.

    Trial registration: ACTRN12611001078943.

    The authors declare no conflicts of interest.

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