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Inappropriate Medication Prescribing in Residential
Care/Assisted Living Facilities
Philip D. Sloane, MD, MPH,* Sheryl Zimmerman, PhD,* Lori C. Brown, PharmD,‡Timothy J. Ives, PharmD, MPH,† and Joan F. Walsh, PhD*
To identify the extent to which inappro-
estimating equations, IPM use was associated with the
priately prescribed medications (IPMs) are administered to
number of medications received, smaller facility bed size,
older patients in residential care/assisted living (RC/AL)
moderate licensed practical nurse turnover, absence of de-
facilities and to describe facility and resident factors asso-
mentia, low monthly fees, and absence of weekly physi-
ciated with receipt of one or more IPMs.
Cross-sectional study of a stratified, representa-
IPMs remain a problem in long-term
tive sample of 193 facilities in four states.
care, but rates in these RC/AL settings compare favorably
We identified representative geographic re-
with those reported for other frail older populations, sug-
gions within Florida, New Jersey, North Carolina, and
gesting that use of medications with severe adverse effects
Maryland and drew from within them a stratified random
may be waning. Regular physician facility visits may im-
sample of 193 RC/AL facilities. Three subtypes of facilities
prove prescribing, as will attention to high-risk groups
were included in the sample: small homes (Ͻ16 beds),
such as individuals on multiple medications. J Am Geriatr
larger “new-model” homes, and larger “traditional” homes.
Soc 50:1001–1011, 2002.
Within each larger home, a random
Key words: medications; assisted living; long-term care
sample of residents aged 65 and older was approached for
consent; in smaller homes all residents were approached.
The overall enrollment rate was 92%; 2,078 residents
Questionnaires and on-site observa-
Adverse drug events are the most common medical er-
tions were used to gather data on facility administration
ror occurring in the United States today.1 Although
and staffing and resident characteristics. All prescription
older persons represent less than one-fifth of the U.S. pop-
and nonprescription medications taken at least 4 of the 7
ulation, they use more than one-third of all prescription
days before data collection were taken from medication
medications dispensed.2 As many as 18% of all outpatient
administration records and coded for analysis. IPM desig-
visits involve drug complications,3 which are implicated in
nation was based on modification of a list developed by
6% to 21% of older outpatient visits.4,5 Between 18% and
Beers et al. and currently used by nursing home surveyors.
24% of admissions of hospitalized older patients are at-
The majority of RC/AL patients were taking
tributable to adverse drug events. Persons aged 65 and
five or more medications; 16.0% of these patients were re-
older are particularly susceptible to adverse drug events
ceiving IPMs. The most common IPMs were oxybutynin,
because of high rates of medication use and physiological
propoxyphene, diphenhydramine, ticlopidine, doxepin, and
changes associated with aging. These factors are accentu-
dipyridamole. In multivariate analyses, using generalized
ated in long-term care facilities, where polypharmacy iscommon and the reported rates of adverse drug events areas high as 67% to 74%.8,9
Medication selection is an important factor influencing
the likelihood of adverse drug events. Advances in therapeu-
From the *Sheps Center for Health Services Research, and †School of Phar-
tics require that physicians update their prescribing prac-
macy and Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and ‡Kerr
tices when safer, superior alternatives to existing products
Drug EPCC, Greensboro, North Carolina.
become available. In addition, changes in patient medical
Financial support was provided by National Institute on Aging Grants R01
status over time can cause medications that have been used
chronically to become unsafe or ineffective. In clinical prac-
Address correspondence to Philip D. Sloane, MD, MPH, Sheps Center for
tice, drug selection involves a variety of biomedical and psy-
Health Services Research, University of North Carolina at Chapel Hill, 725
chosocial factors. For example, because of the limited fi-
Airport Road, CB 7590, Chapel Hill, NC 27599. E-mail: psloane@med. unc.edu
nances of many geriatric patients, physicians often choose
2002 by the American Geriatrics Society
SLOANE ET AL.
older, less-expensive medications rather than newer, more-
gion fall within 30% of the state mean on eight demo-
targeted alternatives.10 Thus, medication prescribing in-
graphic and health services measures (per capita income;
volves a process whereby the physician considers multiple
percentage of population aged Ն65, nonwhite, employed,
possible agents and selects one based on the individual pa-
and below poverty level; ratio per 1,000 persons aged Ն65
tient’s needs, medical status, and available resources.
to primary care physicians, hospital beds, nursing home
Nevertheless, certain medications are rarely if ever in-
beds). Across all four states, only one variable deviated
dicated for older persons, because they are ineffective or
from the 30% limit in one state, and examination of that
because safer, effective alternatives exist. For example, al-
region indicated adequate dispersion of counties over high
pha-methyldopa and reserpine were once acceptable antihy-
pertensives, but newer agents have supplanted them. In the
Within each of the four regions, all licensed RC/AL fa-
early 1990s, the term inappropriate medications
cilities were identified using state licensure lists. The study
duced by Beers et al. to describe such drugs whose use in
definition of RC/AL included any licensed facility, not li-
older persons was no longer recommended.11,12 In 1999, the
censed as a nursing home, that provided room and board,
Health Care Financing Administration (HCFA) incorpo-
24-hour supervision, and assistance with activities of daily
rated a modification of this “potentially inappropriate med-
living. To maximize efficiency in enrolling older subjects,
ication” list into nursing home survey criteria.13 Investiga-
facilities that primarily served persons with mental retar-
tors have used modifications of the Beers list to report on
dation or developmental disabilities were excluded, as
potentially inappropriate medication use in skilled nursing
were facilities with fewer than 16 beds that housed fewer
facilities14 and by community-dwelling older people15 and
than four residents aged 65 and older and facilities with
homebound managed care plan participants.16
16 or more beds that housed fewer than 10 residents aged
One healthcare sector in which inappropriately pre-
scribed medicine (IPM) use has received little attention is
Eligible facilities were then divided into three strata to
residential care/assisted living (RC/AL). Spore et al. showed
adequately sample the range of facility types: small homes
that between 20% and 25% of residents in a 10-state sam-
(Ͻ16 beds); new-model large facilities (Ն16 beds; built af-
ple of board and care homes had at least one inappropri-
ter January 1, 1987, and fulfilling at least one of the fol-
ate prescription, raising concern about drug interactions
lowing criteria: at least two different private pay rates,based on resident’s service needs; 20% or more of resident
and adverse effects.17 This is of special concern because the
population requiring assistance in transfer; 25% or more
number of RC/AL facilities is growing rapidly; by 2005, it
of resident population incontinent daily; and a registered
is estimated that more persons will be housed in RC/AL fa-
nurse (RN) or a licensed practical nurse (LPN) on duty
cilities than in nursing homes.18 Compounding this, RC/AL
around the clock); and traditional large homes (Ն16 beds
facilities serve primarily older persons, a population that is
and not meeting the criteria for new-model facilities). One
typified by multiple disease states, polypharmacy, altered
hundred thirteen small facilities, 40 new-model, and 40
pharmacokinetics, and a high prevalence of drug-related
traditional facilities were enrolled in the four study states.
adverse events.19,20 In addition, the staff in RC/AL facilities
The facility refusal rate was 41%, but 44 nonrespondents
who administer medications are generally not nurses, and
(90% of those selected for sampling) completed a tele-
many have little or no training in medication administra-
phone survey, and participating and nonparticipating fa-
tion and effects. Finally, compared with nursing homes,
cilities were found to not differ in age; size; occupancy; orresident age, race, or ethnicity. Nonparticipating RC/AL
RC/AL facilities have less oversight by registered nurses
facilities differed from participating facilities in three of 42
items queried (hours worked by owners, number of rate
The analysis reported in this paper was performed to
determine the prevalence of IPM use among a representa-
Within each study home, a representative sample of
tive sample of more than 2,000 RC/AL residents in four
residents was enrolled as follows. In small homes, all resi-
states. In this study, the prevalence and distribution of IPMs
dents aged 65 and older were approached for participa-
are described, and resident and facility factors are identified
tion. In large facilities, random sampling of residents aged
that are associated with receipt of one or more IPMs.
65 and older was used to achieve target sample sizes(range 17–23 depending on stratum and state). Informed
consent was obtained from participating staff and resi-dents; proxies gave written consent for cognitively im-
paired residents, and the residents were required to assent
Data reported in this paper were collected as part of the
to in-person data collection. Two thousand seventy-eight
Collaborative Studies of Long-Term Care (CS-LTC), a
RC/AL residents were enrolled: 665 in small facilities, 765
multistate study of RC/ALs. The study was conducted in
in new model facilities, and 648 in traditional facilities.
four states: Florida, Maryland, New Jersey, and North
The subject refusal rate was 8%. The Institutional Review
Carolina. The study states were chosen because each had a
Boards of the University of North Carolina at Chapel Hill
well-developed RC/AL industry, and the four represented
and the University of Maryland at Baltimore approved
a range of state regulatory approaches to the development
subject enrollment and data collection procedures. Further
of newer assisted living models. To increase efficiency of
details of the methods of the Collaborative Studies of
data collection, a purposive sample of counties (a sam-
Long-Term Care are published elsewhere.21
pling region) was selected within each state. Criteria forselection of a sampling region included that it contain at
Measures, Data Collection, Coding, and Analysis
least 15% of the state’s residential care facilities, that it
On-site interviewers, the majority of whom were RNs,
contain urban/suburban and rural areas, and that the re-
conducted baseline data collection between October 1997
INAPPROPRIATE MEDICATIONS IN RESIDENTIAL CARE
and November 1998. Questionnaires on the structure and
mines were excluded because they are considered at times
process of care were administered to facility staff, and ad-
to be appropriate treatment for allergies; (4) oral iron
ditional facility data were gathered using direct observa-
preparations and digoxin were excluded because their pre-
tion. Resident data were gathered using a combination of
scription’s appropriateness on Beer’s list depended on dos-
record review, patient or proxy interview, and direct ob-
age and the CS-LTC data did not include drug dosages; (5)
short-acting benzodiazepines (oxazepam, triazolam, loraze-
Data on the following facility factors were obtained
pam, temazepam, alprazolam, and zolpidem) were ex-
during interviews with facility administrators: bed size,
cluded because they are widely used for agitation in de-
profit/nonprofit status, affiliations with other facilities, the
mentia and for short-term treatment of insomnia in some
existence of separate levels of care in the same building, ser-
older people; they have a short half-life, leading to few
vices provided, monthly fees, staff hours actually worked in
problems with hangover and accumulation; and dosage
the previous week by nurses (LPNs and RNs) and nursing
was considered in the original criteria; and (6) trazodone
assistants, and turnover rates of LPNs, RNs, and nursing
was excluded because it is appropriately used in low doses
assistants. Data on the following resident characteristics
for sedation and agitation. The final list of IPMs used in
were gathered by interviews with the residents and the staff
the study, and recommended alternative medications, is
caregivers who knew the residents best: age, race, gender,
frequency of visits from friends/family, presence of moder-
Staff of the Cecil G. Sheps Center for Health Services
ate/severe dementia, payment source (e.g., Medicaid), and
Research Data coded, entered, cleaned, and analyzed data
dependency in six activities of daily living (eating, toileting,
using standard procedures and analytical software pack-
transferring, locomotion, dressing and bathing). Moderate
ages. To identify factors associated with resident’s receiv-
or severe dementia was determined to be present if the
ing one or more drugs on the IPM list, associations were
Mini-Mental State Examination (MMSE)22 score was below
studied between facility and resident variables known to
17, (when the MMSE was not available) if the Minimum
affect care provision in long-term care settings. The fol-
Data Set Cognition Scale23 score was greater than 3, or (in
lowing facility factors were studied as predictors of IPM
rare cases where neither was available) if a physician or
use: facility type (small facilities were the reference group),
nurse noted one or more of the following diagnoses on the
bed size, square of bed size, profit/nonprofit status, nurs-
medical record: Alzheimer’s disease, senile dementia, senile
ing home affiliation, whether a physician visited at least
dementia of the Alzheimer’s type, organic brain syndrome,
weekly, whether nursing services were provided at least
cerebral arteriosclerosis, multiinfarct dementia, subcortical
weekly, minimum monthly fee, nurse/resident ratio, nurs-
dementia, Binswanger’s disease, Pick’s disease, Creutzfeldt-
ing assistant/resident ratio, RN turnover, LPN turnover,
Jakob disease, Huntington’s disease, Lewy body disease, or
and nursing assistant turnover. The latter six variables
were trichotomized into low (Ͻ25th percentile), moderate
As part of each subject’s on-site data collection, re-
(25–75th percentile), and high (Ͼ75th percentile) and en-
search staff reviewed the Medication Administration Rec-
tered into the regression as dummy variables, with the
ord and wrote down the names of all prescription and
lowest percentile as the reference group. The following
nonprescription medications that had been administered
resident factors were included in the regression: dementia
to the subject on at least 4 of the previous 7 days. Informa-
(moderate or severe), race, gender, age (as four categories),
tion on dosage was not gathered. Drug names from the
frequency of family/friend visits (moderate ϭ 2–6 days/2
data collection forms were entered verbatim into data en-
weeks; high ϭ Ն7 days/2 weeks), Medicaid or state assis-
try fields. The resulting data files were cleaned and coded
tance (yes/no), dependency in activities of daily living
using an existing program to correct misspellings and to
(moderate ϭ assistance needed with one or two; heavy ϭ
code for recognized drugs using the American Hospital
assistance needed with three or more), and number of
Formulary Service system.24 A pharmacist (LCB) and a
medications (moderate ϭ 4–8; high ϭ Ն9). Bivariate asso-
geriatrician (PDS) reviewed each remaining uncoded drug
ciations were studied using t
tests (for continuous vari-
to determine what medication was represented and to as-
ables) or chi-square tests (for categorical variables).
sign a code. Of the 2,078 RC/AL residents in the study
To identify the relative contribution of resident and fa-
sample, 64 (3.1%) had data containing one or more medi-
cility factors to the likelihood of a resident receiving one or
cations that could not be coded because of illegibility or
more IPMs, multivariate regression was performed, using
misspellings. This paper reports on the 2,014 subjects for
generalized estimating equations to control for the cluster-
whom complete medication data were available.
ing effects of the study sample. Analyses were performed us-
IPMs were coded using an updated version of the list
ing PROC GENMOD in Statistical Analysis Systems, which
developed by Beers et al.11,12 (Dr. Beers was consulted
accounts for intrafacility correlation while weighting each
about revising the list during the course of our analyses
subject equally.25 The dichotomous dependent variable was
(March 21, 2000); he encouraged revision to reflect
whether a given resident’s medication list included one or
changes in pharmacotherapy.) For purposes of these anal-
more IPMs. The regression analysis excluded 29 residents
yses, the following medications were excluded from the
who were on no medications and 64 residents for which
Beers list:12 (1) flecainide, phenylbutazone and cyclande-
one or more medications could not be coded.
late were not included because they are no longer mar-keted; (2) haloperidol and thioridazine were excluded be-cause they may be appropriate for some indications, even
though they may cause sedation, extrapyramidal effects,
Table 1 presents the characteristics of the 193 study facili-
and sedation in some patients; (3) nonsedating antihista-
ties and 2,014 subjects used in these analyses. The major-
SLOANE ET AL.
ity of facilities (58.5%) were small, but the number of sub-
4.0% in traditional homes. The most common categories
jects was relatively equally divided between the three
of medications received across all strata were cardiovascu-
facility types (31.8% in small, 37.0% in new-model, and
lar drugs (received overall by 53% of subjects); diuretics/
31.1% in traditional). Facility staffing data indicate a de-
potassium (40%); laxatives/antacids (37%); vitamins/min-
pendency on unlicensed staff, with few nursing hours per
erals (37%); pain medications such as nonsteroidal anti-
week (0.6 hours per resident for RNs and 1.2 hours per
inflammatory medications, aspirin, and acetaminophen
resident for LPNs). Residents tended to be female, very old
(over half were Ն85), and impaired in at least one activity
Three hundred sixty-nine of the 11,649 prescriptions
of daily living and to pay privately.
in the sample (3.2%) were IPMs. Across the three types of
Most study subjects had taken at least one medication
homes, the percentage of prescriptions that involved IPMs
on 4 or more of the 7 days before data collection. The
was similar: 3.3% in small homes, 3.2% in new-model
mean number of medications taken regularly was 5.1 in
homes, and 2.9% in traditional homes. Three hundred
small homes, 6.1 in new-model homes, and 5.6 in tradi-
twenty-two (16.0%) of the 2,014 study subjects received
tional homes. Few residents were on no medications:
at least one IPM, ranging from 15.5% in traditional
6.0% in small homes, 3.4% in new-model homes, and
homes to 16.9% in new-model homes (Table 2). The most
Table 1. Descriptive Characteristics of the Study Sample
Staffing ratio (expressed as weekly hours per resident—census at data collection)
Turnover (per 6 months: n left/n current FTE)
*Excludes observations that had missing data for specific variables.
†Fewer than 16 beds.
RC/AL ϭ residential care/assisted living; ADL ϭ activities of daily living; FTE ϭ full time equivalent.
INAPPROPRIATE MEDICATIONS IN RESIDENTIAL CARE
common IPMs were oxybutynin, propoxyphene, amitrip-
older people received a potentially inappropriate drug. Al-
tyline, ticlopidine, doxepin, and dipyridamole (Table 3).
though any generalization based on these results must be
Table 4 displays the results of the generalized estimat-
made with caution, these findings are reassuring in that
ing equation regression of facility and resident factors on
they suggest that RC/AL settings do not have higher rates
the probability of having one or more IPMs. The facility
than other settings, in spite of employing fewer nurses.
factors that were independently associated with an in-
As with all studies of medication use in long-term
creased probability of a resident being on an IPM included
care, potential sources of error exist. One is the potential
smaller bed size, low minimum monthly fees for residents,
that over-the-counter, complementary/alternative, and other
moderate LPN turnover, and absence of a weekly physi-
medications were brought in by families and administered
cian visit. Resident factors associated with an increased
to residents without being recorded on the medication ad-
probability of being on an IPM were number of medica-
ministration record. No estimate of the extent of this miss-
tions received and absence of moderate/severe dementia.
ing data is available, but data collectors who interviewedresidents as part of the study did not feel that this consti-
tuted a problem. Another source of missing data is the
The data presented here indicate that polypharmacy is
3.1% of medication that could not be coded because of il-
prevalent in RC/AL facilities. The majority of residents in
legibility or misspellings; this is higher than the 1.6% rate
this sample were taking at least five medications, and use
of missing data reported by Hanlon et al. in a community
of 10 or more medications was not unusual. Furthermore,
study.26 In addition, this study assessed appropriateness in
according to an updated version of Beer’s “potentially in-
terms of efficacy only, because data on indication, dose,
appropriate” medication list, 16.0% of study subjects
duration, comorbid diseases, and potential interactions
were receiving one or more IPMs, and between 2.9% and
with other medications were not collected. Thus, this
3.3% of RC/AL medications fell into the IPM category.
study likely underestimated the presence of “inappropri-
Although these numbers are not unusual for a group of
ate” medications in RC/AL facilities. Finally, the cross-sec-
older patients, the normalcy of such numbers should not
tional design limits the ability to derive causal inferences.
Can further reductions be achieved? Multivariate
Strict comparison of these findings with other pub-
analyses to identify facility and resident factors associated
lished studies is not possible for a number of reasons.
with IPMs provide insight into potential intervention tar-
First, other published studies have used somewhat differ-
gets. As noted in Table 4, the strongest predictor of IPM
ent criteria for inappropriateness; in this study, modifica-
use is the number of medications a patient receives. This
tion was made to reflect prescribing practices at the time
finding is intuitive, but it emphasizes that quality monitor-
of the study and to account for the absence of dosage in-
ing efforts should concentrate on patients with the longest
formation. Second, the potential for secular trends to in-
medication lists. The finding that frequent physician visits
fluence results exists because of differences in the dates of
were associated with fewer inappropriate prescriptions
data collection across studies. Finally, the extent to which
suggests that quality may be improved by encouraging
nonprescription drugs were included in published stud-
stronger linkages between RC/AL facilities and physicians
ies is unclear, but the rate of potentially inappropriate
who make regular visits. The association between moder-
medication use from this study appears lower than that
ate LPN turnover and high levels of inappropriate pre-
previously reported in board and care homes17 and in
scriptions suggests that minimal levels of nursing oversight
homebound older people,16,26 suggesting that use of these
may be inadequate, but the lack of a consistent association
medications is decreasing or that the RC/AL facilities sur-
between other nursing turnover, or of nurse staffing levels,
veyed expose their residents less frequently to these drugs.
and inappropriate medication use suggests the need for
Thus, when analyses are adjusted to remove medications
further research in this area. Finally, increased oversight
not included in this study’s list, the findings of Golden et
by consultant pharmacists, although not assessed in this
al.16 showed that 8% of prescriptions used by homebound
study, may be able to further reduce IPMs. In nursing
older people were inappropriate, of Beers et al.14 that
homes, consultant pharmacists review medications monthly,
4.9% of nursing home prescriptions were inappropriate;
but for RC/AL facilities the timing and extent of pharmacy
and of Wilcox et al.15 that 23.5% of community-dwelling
review varies and is generally less frequent.
Table 2. Frequency and Number of Inappropriately Prescribed Medications (IPMs), by Facility Type
RC/AL ϭ residential care/assisted living.
SLOANE ET AL.
Table 3. Number of Study Subjects (N
؍ 2,014) Regularly
Table 4. Facility and Resident Factors Influencing Likelihood
Receiving Each Inappropriately Prescribed Medication (IPM),
of a Residential Care/Assisted Living Resident Having One or
by Facility Type
More Inappropriately Prescribed Medications
The following medications on the “potentially inappropriate” list were not
received by any study subjects: belladonna, buprenorphine, butorphanol, chlor-propamide, chlorzoxazone, dezocine, isoxsuprine, meperidine, meprobamate, me-
thocarbamol, minoxidil, nalbuphine, and reserpine.
RC/AL ϭ residential care / assisted living.
Other associations noted in the multivariate analyses
are more difficult to interpret. Facility size and monthly
fee may have indirect effects as proxies for resources such
as nursing oversight. The fact that increases in the mini-
mum monthly fee are associated with parallel decreases in
the likelihood of IPMs suggests that some kind of socio-
economic effect is present, a finding that was also identi-fied by Wilcox et al.15 The finding of an independent rela-
Analysis was performed using Generalized Estimating Equations (GEE).
tionship between dementia and absence of IPMs is puzzling;
*Odds ratios are adjusted for all other variables in the model. The scale parameterfor GEE was computed as the square root of the normalized Pearson’s chi-square.
perhaps it arose because some common IPMs are used to
RNϭ registered nurse; LPN ϭ licensed practical nurse; PCA ϭ patient care assis-
treat conditions or symptoms rarely voiced by persons with
tant; ADL ϭ activities of daily living.
dementia. For example, this may be true of propoxyphenebecause persons with dementia tend to request and receivefewer pain medications than persons with similar condi-
known. In the CS-LTC study, observations of patient som-
nolence at a standard time in the midafternoon were not
The extent to which these “potentially inappropriate”
correlated with IPM use (2 ϭ 1.35, P
ϭ .24). Other po-
medications result in adverse resident outcomes is un-
tential outcomes, such as hospitalization, morbidity, mor-
INAPPROPRIATE MEDICATIONS IN RESIDENTIAL CARE
tality, and disability will be studied in a longitudinal fol-
8. Cooper JW. Probable adverse drug reactions in a rural geriatric nursing
low-up of the cohort, but, given the distribution of the use
home population: A four-year study. J Am Geriatr Soc 1996;44:194–197.
9. Cooper JW. Adverse drug reactions and interactions in a nursing home. Nurs
of individual medications in the study (Table 3), it is un-
likely that this list constitutes a strong predictor of adverse
10. Beers MH, Fingold SF, Ouslander JG et al. Characteristics and quality of pre-
scribing by doctors practicing in nursing homes. J Am Geriatr Soc 1993;41:
Physicians’ prescribing patterns are changing, and
11. Beers MH, Ouslander JG, Rollinger I et al. Explicit criteria for determining
many of yesterday’s “inappropriate” medications (those
inappropriate medication use in nursing home residents. Arch Intern Med
with the most severe adverse drug events) have been elimi-
nated from practice through manufacturer’s withdrawal,
12. Beers MH. Explicit crieria for determining potentially inappropriate medica-
regulatory efforts, or voluntary changes in physician pre-
tion use by the elderly: An update. Arch Intern Med 1997;157:1531–1536.
13. Eans TL. New HCFA drug-prescribing criteria for nursing homes and sug-
scribing. In addition, the pharmaceutical industry has re-
gested alternate prescribing to avoid care deficiencies. Ann Long-Term Care
sponded in some cases to toxic drug effects by reformulat-
ing their products. For example, one of the most frequently
14. Beers MH, Ouslander JG, Fingold SF et al. Inappropriate medication pre-
used “inappropriate” medications on this study’s list is
scribing in skilled nursing facilities. Ann Intern Med 1992;117:684–689.
15. Wilcox SM, Himmelstein DU, Woolhandler S. Inappropriate drug prescrib-
oxybutynin. Since the time of data collection, oxybutynin
ing for community dwelling elderly. JAMA 1994;272:292–296.
has been reformulated as a sustained-release product, with
16. Golden AG, Preston RA, Barnett SD et al. Inappropriate medication prescrib-
evidence of reduced adverse effects.29,30
ing in homebound older adults. J Am Geriatr Soc 1999;47:948–953.
Given the possibility that the most clearly “inappro-
17. Spore DL, Mor V, Larrat P et al. Inappropriate drug prescriptions for elderly
residents of board and care facilities. Am J Public Health 1997;87:404–409.
priate” medications are prescribed less frequently, regula-
18. Meyer H. The bottom line on assisted living. Hosp Health Network 1998;7:
tory efforts may need to refocus, as is expected when a
quality improvement effort is successful.31 Thus, facility
19. Williams L, Lowenthal DT. Drug therapy in the elderly. South Med J 1992;
medical directors, consultant pharmacists, and HCFA sur-
20. Blanchette K. New Directions for State Long-term Care Services, Volume III:
veyors may achieve little clinical improvement by trying to
Supportive Housing. Washington DC: Public Policy Institute, American As-
eliminate medications whose appropriateness depends on
dose, duration, or indication. Instead, a broader examina-
21. Zimmerman SI, Sloane PD, Eckert JK et al. Overview of the collaborative
tion of medication use may be needed and other indicators
studies of long-term care. In: Zimmerman SI, Sloane PD, Eckert JK, eds. As-sisted Living: Long-Term Care in Transition. Baltimore, MD: Johns Hopkins
of prescribing problems sought. Measures that may be
helpful include patient-adjusted doses (to account for pa-
22. Folstein MF, Folstein S, McHugh PR. “Mini-Mental State”. A practical
tient factors, such as weight and renal function); frequency
method for grading the cognitive state of patients for the clinician. J Psychiatr
of administration; presence of pharmacotherapy without
23. Hartmaier SL, Sloane PD, Guess HA et al. The MDS Cognition Scale: A valid
indication; the presence of possible adverse effects; and use
instrument for identifying and staging nursing home residents with dementia
of over-the-counter medications, social drugs (e.g., alco-
using the minimum data set. J Am Geriatr Soc 1994;42:1173–1179.
hol), and complementary/alternative therapies. In addi-
24. McEvoy JK. AHFS Drug Information 2001. Bethesda, MD: American Soci-
tion, underprescribing may be emerging as a significant
ety of Health-System Pharmacists, 2001.
25. Stokes ME, Davis CS, Koch GG. Categorical Data Analysis Using the SAS
problem as more therapeutic options are available for a
System. Cary, NC: SAS Institute Inc., 2000.
variety of chronic conditions. The most critical issues in
26. Hanlon JT, Fillenbaum, GG, Schmader KE et al. Inappropriate drug use
pharmacotherapeutics in long-term care change over time,
among community-dwelling elderly. Pharmacotherapy 2000;20:575–582.
and monitoring efforts must account for these changes.
27. Cariaga J, Burgio L, Flynn W et al. A controlled study of disruptive vocaliza-
tions among geriatric residents in nursing homes. J Am Geriatr Soc 1991;39:501–507.
28. Sengstaken EA, King SA. The problems of pain and its detection among geri-
The Collaborative Studies of Long-Term Care involves a
atric nursing home residents. J Am Geriatr Soc 1993;41:541–544.
team of investigators, data collectors, and support staff
29. Gleason DM, Susset J, White C et al. Evaluation of a new once-daily formu-
lation of oxbutynin for the treatment of urinary urge incontinence. Ditropan
from the University of North Carolina at Chapel Hill and
XL Study Group. Urology 1999;54:420–423.
the University of Maryland at Baltimore. Special apprecia-
30. Goldenberg MM. An extended-release formulation of oxybutynin chloride
tion is extended to the staff and residents of the cooperat-
for the treatment of overactive urinary bladder. Clin Ther 1999;21:634–642.
31. Schnelle JF, Ouslander JG, Osterweil D et al. Total quality management: Ad-
ministrative and clinical applications in nursing homes. J Am Geriatr Soc1993;41:1258–1266.
32. Hass WK, Easton JD, Adams HP Jr et al. A randomized trial comparing
ticlopidine hydrochloride with aspirin for the prevention of stroke in high-
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a
risk patients. Ticlopidine Aspirin Study Group. New Engl J Med 1989;321:
Safer Health System. Washington, DC: National Academy Press, 2000.
2. Mueller C, Schur C, O’Connell J. Prescription drug spending: The impact of
33. Gent M, Glakely JA, Ellis DJ et al. The Canadian American Ticlopidine
age and chronic disease status. Am J Public Health 1997;87:1626–1629.
Study (CATS) in thromboembolic stroke. Lancet 1989;1:1215–1220.
3. Gandhi TK, Burstin HR, Cook EF et al. Drug complications in outpatients. J
34. Steinhubl SR, Tan WA, Foody JM et al. Incidence and clinical course of
thrombotic thrombocytopenic purpura due to ticlopidine following coronary
4. Schneider JK, Mion LC, Frengley JD. Adverse drug reactions in an elderly
stenting. EPISTENT Investigators. Evaluation of Platelet IIb/IIIa Inhibitor for
outpatient population. Am J Hosp Pharm 1992;49:90–96.
5. Veehof LJG, Stewart RE, Meyboom-de Jong B et al. Adverse drug reactions
35. Tisdale JE. Antiplatelet therapy in coronary artery disease: Review and up-
and polypharmacy in the elderly in general practice. Eur J Clin Pharmacol
date of efficacy studies. Am J Health Syst Pharm 1998;55:S8–S16.
36. Green D, Podrazik P. Key references: Antiplatelet drugs in the elderly. J
6. Mannesse CK, Derkx FHM, de Ridder MAJ et al. Contribution of adverse
Thromb Thrombolysis 2000;9:115–116.
drug reactions to hospital admission of older patients. Age Ageing 2000;29:
37. Hogan DB. Revisiting the O complex: Urinary incontinence, delirium and
polypharmacy in elderly patients. Can Med Assoc J 1997;157:1071–1077.
7. von Renteln-Kruse W, Thiesemann N, Thissemann R et al. Does frailty predis-
38. Katz WA. Pharmacology and clinical experience with tramadol in osteoar-
pose to adverse drug reactions in older patients? Age Ageing 2000;29:461–462.
SLOANE ET AL.
39. Forman WB. Opioid analgesic drugs in the elderly. Clin Geriatr Med 1996;
58. Kadowaki T, Hagura R, Kajinuma H et al. Chlorpropamide-induced hy-
ponatremia: incidence and risk factors. Diabetes Care 1983;6:468–471.
40. Miller RR. Evaluation of the analgesic efficacy of ibuprofen. Pharmacother-
59. Tanay A, Firemann Z, Yust I et al. Chlorpropamide-induced syndrome of inap-
propriate antidiuretic hormone secretion. J Am Geriatr Soc 1981;29:334–336.
41. Pearce V, Robson PJ. Double-blind crossover trial or oral meptazinol, penta-
60. Bassotti G, Whitehead WE. Biofeedback, relaxation training, and cognitive
zocine and placebo in the treatment of pain in the elderly. Postgrad Med J
behaviour modification as treatments for lower functional gastrointestinal
disorders. Q J Med 1997;90:545–550.
42. Mallet L, Kuyumjian J. Indomethacin-induced behavioral changes in an el-
61. McDowell BJ, Engberg S, Sereika S et al. Effectiveness of behavioral therapy
derly patient with dementia. Ann Pharmacother 1998;32:201–203.
to treat incontinence in homebound older adults. J Am Geriatr Soc 1999;47:
43. Johnson AG. NSAIDs and blood pressure. Clinical importance for older pa-
tients. Drugs Aging 1998;12:17–27.
62. Appell RA. Clinical efficacy and safety of tolterodine in the treatment of
44. Johnson AG, Seidemann P, Day RO. NSAID-related adverse drug interac-
overactive bladder: A pooled analysis. Urology 1997;50:90–96.
tions with clinical relevance: An update. Int J Clin Pharmacol Ther 1994;32:
63. Zorzitto ML, Holliday PJ, Jewett MA. Oxybutynin chloride for geriatric uri-
nary dysfunction: A double-blind, placebo-controlled study. Age Ageing
45. Hoppmann RA, Peden JG, Ober SK. Central nervous system side effects of
nonsteroidal anti-inflammatory drugs. Aseptic meningitis, psychosis, and
64. Burgio KL, Locher JL, Goode PS et al. Behavioral vs drug treatment for urge
cognitive dysfunction. Arch Intern Med 1991;151:1309–1313.
urinary incontinence in older women: A randomized controlled trial. JAMA
46. Brooks PM, Kean WF, Kassam Y et al. Problems of antiarthritic therapy in
the elderly. J Am Geriatr Soc 1984;32:229–234.
65. Pritchard JF, Bryson JC, Kernodle AE et al. Age and gender effects on on-
47. Ray WA. Psychotropic drugs and injuries among the elderly: A review. J Clin
dansetron pharmacokinetics: Evaluation of healthy aged volunteers. Clin
48. Darcourt G, Pringuey D, Salliere D et al. The safety and tolerability of zolpi-
66. Isah AO, Rawlins MD, Bateman DN. The pharmacokinetics and effects of
dem–an update. J Psychopharmacol 1999;13:81–93.
prochlorperazine in elderly female volunteers. Age Ageing 1992;21:27–31.
49. Dashevsky BA, Kramer M. Behavioral treatment of chronic insomnia in psy-
67. Hulme A, MacLennan WJ, Ritchie RT et al. Baclofen in the elderly stroke pa-
chiatrically ill patients. J Clin Psychiatry 1998;59:693–699.
tient: Its side-effects and pharmacokinetics. Eur J Clin Pharmacol 1985;29:
50. Freeman C. Drug treatment of insomnia in the elderly. Conn Med 1992;56:
68. Urba SG. Nonpharmacologic pain management in terminal care. Clin Geriatr
51. Dommisse CS, DeVane CL. Buspirone: A new type of anxiolytic. Drug Intell
69. Fishback DB. An approach to the treatment of hypertension in the aged. An-
52. Hart RP, Colenda CC, Hamer RM. Effects of buspirone and alprazolam on
the cognitive performance of normal elderly subjects. Am J Psychiatry 1991;
70. Ganzini L, Walsh JR, Millar SB. Drug-induced depression in the aged. What
can be done? Drugs Aging 1993;3:147–158.
53. Smith M, Buckwalter KC. Medication management, antidepressant drugs,
71. Blom MW, Sommers DK. Placebo substitution for methyldopa in geriatric
and the elderly: An overview. J Psychosoc Nurs Ment Health Serv 1992;30:
hypertensive patients. S Afr Med J 1993;83:335–336.
72. Thompson TL 2d, Filley CM, Mitchell WD et al. Lack of efficacy of hydergine in
54. Schweizer E, Rickels K, Hassman H et al. Buspirone and imipramine for the
patients with Alzheimer’s disease. N Engl J Med 1991;324:197–198.
treatment of major depression in the elderly. J Clin Psychiatry 1998;59:175–183.
73. Rogers SL. Perspectives in the management of Alzheimer’s disease: Clinical
55. Roberto V, Vitaliano B, Donnatella P et al. Disopyramide pharmacokinetics
profile of donepezil. Dement Geriatr Cogn Disord 1998;9:29–42.
in the elderly after single oral administration. Pharmacol Res Commun 1988;
74. Shintani EY, Uchida KM. Donepezil: An acetylcholinesterase inhibitor for
Alzheimer’s disease. Am J Health Promot 1997;54:2805–2810.
56. Connolly SJ. Evidence-based analysis of amiodarone efficacy and safety. Cir-
75. Katz IR, Jeste DV, Mintzer JE et al. Comparison of risperidone and placebo
for psychosis and behavioral disturbances associated with dementia: A ran-
57. Krentz AJ, Ferner RE, Bailey CJ. Comparative tolerability profiles of oral an-
domized, double-blind trial. Risperidone Study Group. J Clin Psychiatry
tidiabetic agents. Drug Safety 1994;11:223–241.
INAPPROPRIATE MEDICATIONS IN RESIDENTIAL CARE
aspirin allergy or those who have failed
effects (dizziness, confusion), which may
Efficacy is questionable; low-dose aspirin
More anticholinergic activity than other
Toxic metabolite may accumulate in older
Mixed agonist/antagonist agents should be
may lead to frontal headaches; may cause
antihypertensive effect of beta-blockers;
risk of psychosis in dementia patients.
Appendix 1. Potentially Inappropriately Prescribed Medications Studied and Possible Alternative Treatments
SLOANE ET AL.
delirium, sedation, postural hypotension
Use of agents with long half-lives leads to
Potent negative inotrope; may induce heart
Long half-life drug, therefore more likely to
Appendix 1 (Continued)
INAPPROPRIATE MEDICATIONS IN RESIDENTIAL CARE
potential for benefit; avoid long-term use;
otential for toxic reactions greater than
potential for benefit; highly anticholinergic;
people; can aggravate peptic ulcers.
Potential for toxic reactions greater than
Not effective for incontinence and detrusor
May cause extrapyramidal adverse events;
Therapeutically ineffective; extrapyramidal
nonsteroidal antiinflammatory drug.
Appendix 1 (Continued)
Theoretical Foundations of Chemical Engineering, Vol. 39, No. 2, 2005, pp. 200–203. From Teoreticheskie Osnovy Khimicheskoi Tekhnologii, Vol. 39, No. 2, 2005, pp. 216–219. Original English Text Copyright © 2005 by Haghi. A Study of Heat and Mass Transfer in Porous Material under Equilibrium Conditions1 A. K. Haghi The University of Guilan, P.O. Box 3756, Rasht, Iran Abstract —
13. MEDICATION PROTOCOLS FOR CO-INFECTIONS Babesia Of all the co-infections, Babesia has the most distinct regimen of medica- tions because it is a protozoal parasitic infection, not a bacterial infection as are Borrelia, Bartonella and Ehrlichia. Until recent years, the usual treatment regimen was clindamycin plus quinine; however, this regimen has been abandoned due to the unaccept