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DOI 10.1007/s11096-013-9811-y
RESEARCH ARTICLE
Received: 15 March 2013 / Accepted: 14 June 2013 / Published online: 28 June 2013
Springer Science+Business Media Dordrecht 2013
Impacts on practice
Introduction
A. Chan
Department of Pharmacy, Faculty of Science, National
University of Singapore, Singapore, Singapore
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806
123
Method
Study design and setting
This was a cross-sectional study conducted in the private,
non-profit Caritas Meng Fai Nursing Home in Macao. The
study protocol was approved by the review committee at
the Macao Polytechnic Institute. All data were de-identified
and a waiver for informed consent was obtained. Caritas
Meng Fai Nursing Home is currently the largest long-term
care facility in Macao, with a bed capacity of 168 [12]. It is
also the only skilled nursing facility with an in-house
medical team consisting of a physician, nurses, a physical
therapist, and an occupational therapist. The medical team
provides around-the-clock care to the residents who are
mostly of poor health or disabled, although the residents
are also managed by other specialized physicians outside of
the nursing home. All medications and supplements are
required to be stored in the in-house pharmacy and dispensed by nurses. Residents are not allowed to keep any
drug or supplement in their own rooms.
Inclusion and exclusion criteria
The study population comprised all residents who were
65 years or older, and consumed at least one scheduled
prescription or over-the-counter medication. All medications consumed on an as-needed basis, vitamin or mineral
supplements, drugs for topical use, and herbal medicines
were not counted in this study. The residents were excluded
if their medication administration records were unavailable
or incomplete.
Data collection
Eligibility screening and data collection were performed on
a single day (1 August 2011). All data were obtained from
806
123
Method
Study design and setting
This was a cross-sectional study conducted in the private,
non-profit Caritas Meng Fai Nursing Home in Macao. The
study protocol was approved by the review committee at
the Macao Polytechnic Institute. All data were de-identified
and a waiver for informed consent was obtained. Caritas
Meng Fai Nursing Home is currently the largest long-term
care facility in Macao, with a bed capacity of 168 [12]. It is
also the only skilled nursing facility with an in-house
medical team consisting of a physician, nurses, a physical
therapist, and an occupational therapist. The medical team
provides around-the-clock care to the residents who are
mostly of poor health or disabled, although the residents
are also managed by other specialized physicians outside of
the nursing home. All medications and supplements are
required to be stored in the in-house pharmacy and dispensed by nurses. Residents are not allowed to keep any
drug or supplement in their own rooms.
Inclusion and exclusion criteria
The study population comprised all residents who were
65 years or older, and consumed at least one scheduled
prescription or over-the-counter medication. All medications consumed on an as-needed basis, vitamin or mineral
supplements, drugs for topical use, and herbal medicines
were not counted in this study. The residents were excluded
if their medication administration records were unavailable
or incomplete.
Data collection
Eligibility screening and data collection were performed on
a single day (1 August 2011). All data were obtained from
807
Endpoints
Results
Demographics
PIM use
Fifty-three subjects used at least one PIM, accounting for
46.5 % of the study population. Among these subjects, 21
(40 %) consumed two or more PIMs. The most common
PIMs, as determined by STOPP, were duplicate drug
classes, the use of benzodiazepines in patients with a fall
history, and the use of dipyridamole as monotherapy for
cardiovascular secondary prevention (Table 1).
Factors associated with PIM use
Among the subject characteristics, an increased number of
drugs used (p \ 0.001) and the use of psychotropic drugs
(p = 0.025) were significantly associated with the use of
PIMs. No associations were found between PIM use and
age, gender, or certain chronic medical conditions such as
hypertension, diabetes, dementia, Parkinson disease, and
stroke history (all with p [ 0.05). The multivariate logistic
regression analysis demonstrated that the more medications
an elderly subject consumed, the more likely the subject
would use PIMs (OR 1.28, 95 % CI 1.111.47) (Table 2).
DDIs
One hundred and eleven elderly subjects were eligible for
the DDI analysis (Fig. 1). Considerable variations were
observed in the results between the two compendia. Based
on the preset criteria of Lexi-Interact, 488 potential DDIs
were recognized. In contrast, 168 potential DDIs were
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808
Total number
of residents
n=156
65 years of
age
n=118
< 65 years of
age
n=38
Medication
users
n=114
Medication
non-users
n=4
Taking 1
medication
n=114
With PIM(s)
n=53
Taking 2
medications
n=111
Without PIMs
n=61
With DDI(s)
n=42
Without DDIs
n=69
12.3% (14)
13.2% (15)
12.3% (14)
11.4% (13)
12.0%
12.3% (14)
% of study population
(number of residents)
10.0%
8.0%
7.0% (8)
6.1% (7)
6.0%
4.4% (5)
4.4% (5)
6.1% (7)
4.4% (5)
4.0%
2.6% (3)
0.9% (1)
1.8% (2)
0.9% (1)
2.0%
0.0%
1
10
11
12
13
14
15
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809
Rank
Criterion (concern)
Frequency
(% total PIMs)
1st
22 (25.3)
2nd
Benzodiazepines in patients who are prone to falls (sedative, may cause reduced
sensorium and impair balance)
11 (12.6)
11 (12.6)
3rd
9 (10.3)
4th
8 (9.2)
Neuroleptic drugs in patients who are prone to falls (may cause gait dyspraxia
and parkinsonism)
8 (9.2)
Proton pump inhibitors for peptic ulcer disease at full therapeutic dosage for
[8 weeks (earlier discontinuation or dose reduction for maintenance/
prophylactic treatment of peptic ulcer disease, esophagitis or gastroesophageal
reflux disease as indicated)
3 (3.4)
3 (3.4)
5th
Total PIMs identified = 87
PIM potentially inappropriate
medication
Table 2 Bivariate analysis and multivariate logistic regression analysis to identify the independent factors associated with PIM use
Characteristic
Bivariate analysis
Multivariate analysis
81.7 (9.4)
81.4 (7.2)
Gender
p value
OR (95 %CI)
p value
0.887
0.507
22 (36.1)
39 (63.9)
16 (30.2)
37 (69.8)
38 (62.3)
30 (56.6)
0.537
41 (67.2)
41 (77.4)
0.229
17 (27.9)
18 (29.5)
20 (37.7)
16 (30.2)
0.262
0.937
2 (3.3)
3 (5.7)
0.662
24 (39.3)
32 (60.4)
0.025c
2.20 (0.994.90)
0.052
5.9 (3.1)
8.0 (2.8)
\0.001c
1.28 (1.111.47)
0.001c
CI confidence interval, OR odd ratio, PIM potentially inappropriate medication, SD standard deviation
a
Students t test;
statistically significant; all of the others were done by using Chi Square test
Discussion
This is the first study that evaluated the prevalence of drugrelated problems among elderly nursing home residents in
Macao. Our findings suggested that 46.5 % of elderly nursing home residents used PIMs and 37.8 % were exposed to
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810
Potential DDI
Drug-Reax
Lexi-Interact
Severity
Evidence
Severity
Evidence
Frequency
(% total DDIs)
1st
Clopidogrel
Amlodipine
Major
Excellent
Moderate
Fair
6 (7.8)
2nd
Clopidogrel
Nifedipine
Major
Excellent
Moderate
Fair
3 (3.9)
Aspirin
Enalapril
Moderate
Excellent
Moderate
Excellent
3 (3.9)
3rd
Clopidogrel
Esomeprazole
Major
Excellent
Major
Fair
2 (2.6)
Clopidogrel
Cilostazol
Major
Fair
Moderate
Fair
2 (2.6)
Amlodipine
Simvastatin
Major
Good
Major
Fair
2 (2.6)
Amlodipine
Furosemide
Diltiazem
Captopril
Moderate
Moderate
Good
Good
Moderate
Moderate
Good
Good
2 (2.6)
2 (2.6)
Furosemide
Celecoxib
Moderate
Good
Moderate
Excellent
2 (2.6)
Furosemide
Digoxin
Moderate
Good
Moderate
Fair
2 (2.6)
Levodopa
Phenytoin
Moderate
Good
Moderate
Fair
2 (2.6)
Allopurinol
Theophylline
Moderate
Fair
Moderate
Good
2 (2.6)
Bivariate analysis
Multivariate analysis
82.1 (8.2)
80.2 (8.7)
Gender
p value
OR (95 %CI)
p value
0.251
0.498
24 (34.8)
45 (65.2)
30 (71.4)
37 (53.6)
31 (73.8)
0.034c
4.26 (1.3913.05)
0.011c
39 (92.9)
5.03 (1.1222.66)
0.035c
2.46 (0.867.01)
0.093
1.53 (1.251.86)
\0.001c
42 (60.9)
12 (28.6)
\0.001
15 (21.7)
22 (52.4)
0.001
19 (27.5)
14 (33.3)
0.517
2 (2.9)
3 (7.1)
0.365
39 (56.5)
5.9 (2.4)
17 (40.5)
8.8 (3.0)
0.101
\0.001c
32 (46.4)
21 (50.0)
0.711
CI confidence interval, DDI drugdrug interaction, OR odd ratio, PIM potentially inappropriate medication, SD standard deviation
a
Students t test;
statistically significant; all of the others were done by using Chi Square test
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811
Conclusion
STOPP-related PIM use and potential DDIs were highly
prevalent among elderly Chinese nursing home residents in
Macao. Polypharmacy was shown to be an issue for the
elderly residents in this setting, which might increase the risk
of drug-related problems. However, the use of PIMs as
determined by STOPP did not increase the likelihood of
potential DDIs. It is imperative to conduct further studies to
assess the clinical outcomes of pharmacist interventions for
the elderly residing in long-term care facilities in Macao.
Acknowledgments The authors gratefully acknowledged the medical and administrative staff of Caritas Meng Fai Nursing Home for
their assistance.
Funding This study was financially supported by the Macao Polytechnic Institute.
Conflicts of interest
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