medication prescribing and administration in - age and ageing

Age and Ageing 1998; 27: 385-392

Medication prescribing andadministration in nursing homesMICHAEL S. ROBERTS, MICHELLE KING, JUUE A. STOKES, TERESA A. LYNNE, CHRISTOPHER J. BONNER,

SEAN MCCARTHY, ANDREW WILSON1, PAUL GLASZIOU1, W. JOHN PUGH2

Department of Medicine, University of Queensland, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia4102'Department of Social and Preventive Medicine, University of Queensland, Herston, Queensland, Australia2Welsh School of Pharmacy, Cardiff, UK

Address correspondence to: M. S. Roberts. Fax: (+61) 7 3240 5806. E-mail: [email protected]

AbstractObjective: to examine the key determinants of pharmaco-epidemiology in Australian nursing homes.Design: a cross-sectional survey of medication use in 998 residents in 15 nursing homes in Southern Queenslandand Northern New South Wales.Results: the total, laxative, digoxin/diuretic, benzodiazepine and psycholeptic medication prescribed andadministered to residents of nursing homes was affected to differing extents by age and gender, the nursing home,resident functional disability and medical practitioner. Resident Classification Instrument (RCI) category andnursing home were the dominant determinants for prescribing and administration of the total drugs, laxative,benzodiazepine and psycholeptic medications. In contrast, the resident use of digoxin and/or diuretics wasdependent on the resident age and on the functional disability (RCI category) of the resident but not medicalpractitioner or nursing home. Approximately 30% of medications were prescribed on a pro re nata (p.r.n.) basisand administered at the discretion of registered nurses.Conclusion: nursing home culture is a major determinant of the variability in medication use between residents,particularly for those medications often prescribed for p.m. use. The nursing home does not account for variationin the use of digoxin and/or diuretics which are prescribed on a non-discretionary basis.

Keywords: cross-sectiona/ studies, decision making drug prescriptions, drug utilization, frail eldehy people, pharmaco-epidemiology,

physician's practice patterns, nurses, nursing homes

IntroductionThe use of medication, particularly psychotropic drugs,by elderly residents of nursing homes has been thesubject of a number of studies. The mean number ofmedications prescribed for elderly patients in nursinghomes ranges from six to eight per patient in the USA[1] to two to six in Ireland and the UK [2]. Studies havealso examined aspects of psychotropic drug use [3 - 5]which, in Australian nursing homes, is amongst thehighest in the world [5]. Medication affects quality oflife. The number of medications prescribed may lead toiatrogenic complications [6] and specific impairmentsin mobility and cognition [7] in older patients. Thedeterminants of prescribing and administration patternsfor nursing home residents are not well understood.Identification of factors influencing the patterns ofmedication use in nursing homes could lead to

development of strategies to optimize medication usewith consequent improvement in residents' quality oflife.

The present study defines the pharmaco-epidemiol-ogy of residents in a number of nursing homes. Theinfluence of nursing home, medical practitioner andresident characteristics (age, gender and functionalstatus) were considered. The difference in the pharmaco-epidemiology of prescribed and administered medica-tions was of particular interest. One US study hassuggested that the number of medications administeredto a resident is about half of the medications prescribed[1], reflecting the high frequency of prescription onan 'as needed' [pro re nata (p.m.)] or discretionarybasis.

This study was the first phase of the Quality ofMedication Care Project and is based on prescribingand administration information obtained on 998

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M. S. Roberts et al.

residents from 15 nursing homes. The Quality ofMedication Care Project sought to examine, using arandomized, controlled design, whether an interven-tion based on team-building, education and medicationreview could improve drug use outcomes. It wasconducted at the University of Queensland in conjunc-tion with the Pharmaceutical Education Scheme of theAustralian Government.

Methods

Study sample

Randomly selected, non-government nursing homeswith more than 20 beds in Southern Queensland andNorthern New South Wales were invited to enrol in thestudy. Government-run nursing homes were excludedbecause they used a different drug supply system anddid not use the care needs assessment instrument usedby non-government homes. To conserve resources,nursing homes with less than 20 beds were excluded.Sixteen homes with a total of 1022 residents consentedto participate. Nursing home managers were asked forpermission to gain access to records which were theproperty of the nursing homes because of thedifficulties of obtaining informed consent from resi-dents, many of whom had significant cognitive impair-ment. The study protocol including the consentprocess, was approved by two separate and indepen-dent medical research ethics committees and reviewedby a third.

Data collected

Medication data for a 7-day period and demographicdetails were collected from medication charts andnursing home documentation for 1022 residentsduring the period February to March 1994. Anymedication order that was valid (where medicationwas able to be legally administered from the order) forpart or all of the collection period was recorded anddenned as 'prescribed' medication. Medications weredefined as being 'administered' where the administra-tion of at least one dose was recorded at some timeduring the 1-week data collection period (medicationwas either given or it was not). Medications wereidentified as 'discretionary' if 'p.m.' or equivalent waswritten on the prescription or the order was written inthe p.m. section of the medication chart. Thisdefinition maximizes the extent of administration ofdiscretionary medication.

The medication data collected included the brandname of the drug (or generic name if written as such),strength, route of administration, directions, drugcommencement date, number of doses usually takenper day, times of administration and the number ofdoses given in the 7-day period. All data collectors were

familiar with drug names, prescribing abbreviationsand the interpretation of medication orders.

Demographic information included the resident'sdate of birth, date of admission, gender, medicalpractitioner, health care entitlement number/s, dispen-sing pharmacy, hospital admissions in the previous 12months, adverse incident reports in the previous 3months, patient clinical assessments in the previous 3months, and the Australian Resident ClassificationInstrument (RCI) together with its elements.

The RCI classifies resident functional ability and caredependence on a five-point scale and is based on theweighted assessment of 14 elements associated withnursing care [8]. It is a standardized instrument used tocalculate payments made to nursing homes by thegovernment for the care of each resident, and isaudited by nursing home surveyors. Residents assignedan RCI rating of 1 are generally severely incapacitatedand bed-bound; those with a rating of 2 also tend to bebed-bound but require less nursing care. With increas-ing RCI rating, nursing care needs decrease andmobility increases, so that residents with the maximumrating of 5 are able to perform most of the activities ofdaily living fairly independently.

Data analysisAll data •were entered into Microsoft Access 2.0 usingthe Australian Pharmaceutical Benefits Scheme drugidentification codes for drug form, strength, and brandwherever possible. Other drugs were allocated projectcodes. Drug codes were linked and analysed using theWorld Health Organisation Nordic Anatomical, Ther-apeutic and Chemical (ATQ code classification valid atJanuary 1994 (outlined in Table 1). Data were analysedusing the Minitab and SAS statistical packages. One-wayanalysis of variance (ANOVA) was used to test theseparate effects of age, gender, RCI rating, nursinghome, nursing home size or medical practitioner(those who visited four or more residents) on medica-tion prescribing and administration. Multiple linearregression was used to estimate the adjusted effects ofage, gender, nursing home size and RCI rating. Two-way ANOVA was used to assess the variation inprescribing and administration due to medical practi-tioner after accounting for the effects due to nursinghome. The level of significance was taken to be P <0.05. Data and figures are presented as mean ± 95%confidence interval (CI), where appropriate.

Results

On 1 March 1994 the mean age of the sample (1022residents) was 838 years, ranging from 37.9 to 105.2years with an interquartile range of 79-1 - 90 years; 71% ofthe sample were female. At the time of data collection,the average length of stay was 3-3 years for the 995residents for whom admission dates were available.

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Medication prescribing and administration in nursing homes

Table I. Outline of the Worid Health Organisation Nordic Anatomical, Therapeutic and Chemical code classification(January 1994)

Code Category name and relevant sub-categories

A Alimentary tract and metabolism(A06: laxatives)

B Blood and blood-forming organsC Cardiovascular system

(C01AA05 or C03: digoxin and/or diuretics)D DermatologicalG Genitourinary system and sex hormonesH Systemic hormonal preparations excluding sex hormonesJ General anti-infectives for systemic useL Antineoplastic and immunomodulating agentsM Musculo-skeletal systemN Nervous system

(N05: psycholeptics; N05A: antipsychotics; NO5BA/NO5CD: anxiolytic/hypnotic benzodiazepines)P Antiparasitic products, insecticides and repellentsR Respiratory systemS Sensory organsV Various

Complete medication data were available for 998residents in 15 nursing homes. The number ofmedications prescribed per patient was 6.57 (95% CI6.34-6.80), range 0-22, while the mean number ofmedications actually administered was 4.75 (95% CI4.56-4.94), range 0-18 (Figure 1). Sixteen residents(1.6%) had no medication prescribed and 78 (7.8%) hadnone administered. Overall, 72% of drugs prescribedper person were administered. Of the total, 69% were

I•5

10 16 20

Number of Drugs

25 30

Figure I. Frequency distribution of prescribed (•) andadministered (O) medication use.

for non-discretionary medications with 87% beingadministered at least once in the week of datacollection. 31% (2.02 items/person) of total prescrip-tions were ordered as p.m. Of the discretionarymedication, 41% was administered at least onceduring the week of data collection. The proportion oftotal items prescribed as p.m. that were administeredwas not significantly different between nursing homes.

Prescribing and administration of the differentanatomical classes (ATC codes) of drugs are shown inFigure 2. The drugs used were mainly in the alimentary,cardiovascular and nervous system groups. Few of thecardiovascular medications (7%) were associated withdiscretionary or p.r.n. prescribing. In contrast, 38% ofalimentary and 46% of nervous system prescriptionswere ordered as p.m., and 43 and 39% of these wereadministered. For benzodiazepines, 39% of orders werefor p.m. use, of which 43% were administered. Ofantipsychotic prescriptions, 38% were for p.r.n. useand 32% administered. When the 10 most frequentlyprescribed medications are considered, the lowproportion of prescribed drugs that were administeredfor six of these items (a rate of less than 85%) reflectedtheir p.r.n. use (see Table 2). Furthermore, the drugsmost frequently prescribed were relatively inexpen-sive. The mean cost for the maximum pharmaceuticalbenefits scheme quantity for these 10 items was $AUS7.53 (£360)—about half the average cost of apharmaceutical benefits scheme prescription of $AUS16.78 (£8.05) for 1993 [9].

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Q

C D G H J L M N P R S V

Drug Category

Figure 2. Prescribed (•) and administered (D) medica-tion use according to World Health Organisation NordicAnatomical, Therapeutic and Chemical classificationcodes.

Table 3 summarizes the determinants of the pre-scribing and administration of total, laxative, digoxinand/or diuretics, benzodiazepine and psycholepticmedications (the ATC psycholeptic category includesantipsychotics, anxiolytics, and hypnotics and seda-tives not antidepressant, analgesic, antiparkinsonian oranti-epileptic agents). Prescribing and administrationof digoxin/diuretics increases -with age while prescrib-ing of psycholeptics decreases. Significant genderdifferences in medication use were limited to theprescribing of laxatives and benzodiazepines.

RCI was a significant determinant of the prescribingand administration of total drugs and of the druggroups examined. Figure 3 shows the relationshipsbetween RCI and prescribed and administered drugsper person for total drugs, laxatives, digoxin/diuretics,benzodiazepines and psycholeptics. Prescribing and

administration of laxatives were greater for bed-boundresidents (RCI category 2) than in more ambulatoryresidents (RCI categories 3-5). Conversely, the use ofdigoxin/diuretics, benzodiazepines and psycholepticsincreased with RCI rating—that is, for more mobileresidents less dependent on nursing care.

The individual nursing home accounted for asignificant amount of the variation in total drugprescribing and administration (see Table 3). Thisvariation was largely due to differences in laxatives,benzodiazepines and psycholeptics, which were oftenprescribed for p.m. use. Figure 4 shows that home sizeappeared to influence total drug administration (P<0.05) and the use of some drug groups: laxativeprescribing and administration (P< 0.001), benzodia-zepine prescribing and administration (P< 0.05) andpsycholeptic administration (P< 0.05). While an appar-ently linear relationship was observed between sizeand total drug use, this consistent trend was not seenfor the drug groups.

Mutual adjustment for the effects of age, gender, RCIcategory and nursing home size by multiple linearregression did not affect the interpretation of theresults.

Significant differences were observed in the pre-scribing and administration of medications betweenmedical practitioners (Table 3). As very few medicalpractitioners treated residents in more than one home,the variation in medication use between medicalpractitioners •was likely to be due, in part, todifferences between nursing homes. This was borneout by two-way ANOVA using nursing home andmedical practitioner as factors, which showed thatmedical practitioner had no significant effect on theprescribing or administration of total drugs, laxatives,digoxin/diuretics and benzodiazepines, or on theprescribing of psycholeptics. The influence of medicalpractitioner was significant only for the administrationof psycholeptics (P = 0.03).

The effect of the number of residents treated by

Table 2. The 10 most frequently prescribed items in the nursing homes studied

Item % of residents prescribed

ParacetamolSenna/senna combinationsBisacodylTemazepamFnisemide"ThioridazineAspirin (low dose)a

Digoxin*Potassium chloride3

Diazepam

57363227262019181410

% of prescribed items administered

41744473948293979756

"Items usually prescribed for non-discretionary administration.

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Tab

le 3

. Sig

nifi

canc

e of

dif

fere

nces

for

var

ious

det

erm

inan

ts o

f m

edic

atio

ns p

resc

ribe

d an

d ad

min

iste

red

in n

ursi

ng h

omes

[T

he e

stim

ate

of e

ffec

t ca

n be

see

nas

the

diff

eren

ce b

etw

een

the

low

est

and

high

est v

alue

s (s

how

n in

par

enth

esis

) of

the

mea

n nu

mbe

r of

dru

gs p

er p

erso

n pe

r ca

tego

ry o

f a

give

n de

term

inan

t.]

Det

erm

inan

t"

All

drug

sP

resc

ribe

dA

dmin

iste

red

Lax

ativ

esP

resc

ribe

dA

dmin

iste

red

Dig

oxin

/diu

reti

csP

resc

ribe

dA

dmin

iste

red

Ben

zodi

azep

ines

Pre

scri

bed

Adm

inis

tere

d

Psy

chol

epti

csP

resc

ribe

dA

dmin

iste

red

Sign

ific

ance

(P

)

Age

(ye

ars)

NS

NS

NS

NS

<0.

001

(<6

0/>

90

year

s: 0

.2/0

.7)

<0.

001

(<6

0/>

90

year

s: 0

.2/0

.7)

NS

NS

<0.

05 (

<6O

/^9O

yea

rs:

1.3/

0.8)

NS

Gen

der"

NS

NS

<0.

05 (

M/F

: 0.

8/1.

0)N

S

NS

NS

<0.

03 (

M/F

: 0.

8/1.

0)N

S

NS

NS

Rcr

=

<0.

001

(5.9

, 7.5

)<

0.00

1 (4

.2, 5

.5)

<0.

001

(0.6

, 1.

1)<

0.00

1 (0

.4, 0

.8)

<0.

001

(0.4

, 0.8

)<

0.00

1 (0

.4, 0

.8)

<0.

03 (

0.3,

0.6

)<

0.00

3 (0

.3,

0.5

)

<0.

001

(0.8

, 1.

1)<

0.00

1 (0

.6, 0

.9)

Nur

sing

hom

ed

<0.

001

(3.7

, 10

.7)

<0.

001

(2.7

, 7.2

)

<0.

001

(0.2

, 2.2

)<

0.00

1 (0

.1, 1

.3)

NS

NS

<0.

001

(0.2

, 1.

2)<

0.00

1 (0

.1,

0.7

)

<0.

001

(0.6

, 1.6

)<

0.00

1 (0

.3, 0

.6)

Med

ical

pra

ctit

ione

rc

<0.

001

(1.6

, 1

1.2

)<

0.00

1 (0

.5, 8

.4)

<0.

001

(0,

2.3

)<

0.00

1 (0

, 1.3

)

NS

NS

NS

<0.

01 (

0, 1

.0)

<0.

001

(0.2

, 2.0

)<

0.00

1 (0

, 1.6

)

Medic 5' 3 1/1 n 2. o; 0Q 3 a s. 3!"

"Num

ber

of c

ateg

orie

s: "

6; b

2; C

5; d

15; C

64 (

whe

re f

our

or

mor

e re

side

nts

visi

ted

by a

med

ical

pra

ctit

ione

r).

NS,

no

t si

gnif

ican

t; R

C1,

Res

iden

t C

lass

ific

atio

n In

stru

men

t.O 3

oo sO

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M. S. Roberts et of.

•02

RCI Category

Figure 3. The effect of Resident Classification Instru-ment (RCI) on medication prescribing (—) andadministration (....) for a total drugs, b laxatives (•,• ) and digoxin/diuretics ( • , O) and c benzodiaze-pines (A, A) and psycholeptics (•, O). The residentnumbers in each category were RCI 1 (16), RCI 2 (371),RCI 3 (394), RCI 4 (152), RCI 5 (46) and missing (19).

aa.

Q

is

I

aa.

Q

1 1 - » [20-39 40-69 60-79 80-99 100-120

20-39 40-59 60-79 80-99 100-120

1.15

0.1520-39 40-59 60-79 80-99 100-120

Nursing Home Size Categories

Figure 4. The effect of nursing home size (number ofbeds) on prescribing (—) and administration (....) for atotal drugs, b laxatives (•, • ) and digoxin/diuretics( • ,O) and c benzodiazepines (A, A) and psycholep-tics (•, O).

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Medication prescribing and administration in nursing homes

individual medical practitioners on drug use wasequivocal—only total drug and laxative prescribingand administration showed significant effects. The totaldrug prescribing and administration for medicalpractitioners treating three to nine residents was onlyslightly lower (but statistically significant) than medicalpractitioners who treated one to two or more than nineresidents (prescribing: P<0.005, range 6.1-7.0 drugs/person; administration: P< 0.05, range 4.5-5.0 drugs/person). Laxative prescribing and administration wasalso lowest for medical practitioners treating three tonine residents (prescribing: P< 0.01, range 0.8-1.0drugs/person; administration: /><0.05, range 0.5-0.6drugs/person). A linear relationship between drug useand number of residents treated by individual medicalpractitioners was not evident.

Discussion

A more rational approach to prescribing in nursinghomes is needed [2]. The extent of medication usefound in our study is similar to that reported elsewhere.The average numbers of medications prescribed (6.6)and administered (4.8) are almost identical to thosefrom the data of Beers et al. [1]. In this study,prescribing was conservative in terms of cost anddrug selection. All of the medications in the 'top 10' listhave been in use for more than 20 years (Table 2). Thisreflects both a conservative approach to drug therapyof the older person (the use of medications whoseeffects in the elderly are better known) and the cost-controlling effects of the formulary of the pharmaceu-tical benefits scheme. Our data indicate that cardiovas-cular drugs, especially digoxin/diuretics are seldomprescribed on a discretionary basis and are generallyadministered (90 and 96% of orders were administeredfor cardiovascular drugs and digoxin/diuretics respect-ively). The administration rate is slightly less than 100%because of the small contribution of nitrates andhaemorrhoidal preparations to this group. As expected,given the decrease in cardiac function with age, theprescribing and administration of digoxin/diureticsincreases with age. In addition (Figure 3b), thedigoxin/diuretic group is prescribed more frequentlyfor ambulatory residents than for the bed-bound.

The administration of alimentary and nervous systemmedications—the other two main groups used (Figure2)—differs substantially from the amount actuallyprescribed. As administration is denned as at leastone dose taken during the week of data collection, theeffective administration may be lower than is apparentin our study. In our view, the finding that a highproportion of prescriptions for these medications arediscretionary (Table 2, Figure 2) is, in principle, a goodthing when the appropriate use of discretionarymedications is understood—the administration oflaxative and psycholeptic medication for individual

residents is at the discretion of the health carers whoassess and monitor residents on a daily basis. Theappropriateness of drug use was not evaluated in thisstudy. However, given the link between psychotropicagents and falls [10], the increasing use of psycholepticsand benzodiazepines with increasing resident mobility,as indicated by RCI category (Figure 3c), is a cause forconcern.

The prescribing of antipsychotic medication issimilar to that reported by Snowdon et al [5]. In1988 Beers et al [1] observed that 42% of allprescribing of antipsychotic drugs in nursing homesin the USA was for discretionary medication, with only11% of the prescriptions being administered. We find asimilar rate of prescription (38%) but the rate ofadministration at 32% is three times that in the USsurvey. This observation may be more apparent thanreal since Beers' study defined administration as medi-cation being given at least 5 times/month. Contrary tothe findings of Nolan and O'Malley [2], who noteddecreasing antipsychotic drug use with increasingnursing home size, there was no clear relationshipbetween psycholeptic drug use and nursing homesize.

A combination of factors such as organizationalenvironment and staff training or knowledge give riseto different nursing home cultures which appear toinfluence drug use. The prescribing and administrationof total medications varied significantly betweenindividual nursing homes (where each home was acategory in ANOVA). This was also observed for thelaxative, benzodiazepine and psycholeptic classes.These groups were often prescribed for p.r.n. use.Nursing home culture did not influence the use ofdigoxin/diuretics which were rarely prescribed forp.m. use, nor did home size or medical practitioner.Beers et al. [1] have voiced concern about the undueemphasis on discretionary medication prescribing andthe devolution of responsibility to nursing staff,quoting a report of an adverse effect on patient care[11]. Whether education of Australian nursing homestaff can further improve appropriateness of drug useis currently the subject of a separate study.

The medical practitioner was a significant factor fordifferences in prescription and administration of totaldrugs, laxatives, benzodiazepines and psycholeptics.These differences were not linearly related to thenumber of residents seen per practitioner. Thissuggests that prescribing by medical practitionerswho visit many residents and who might be thoughtto have an interest in geriatrics, is little different fromthat of medical practitioners seeing smaller numbers ofresidents. Nursing home culture appears to influenceprescribing. This is illustrated by the prescribingof benzodiazepines where the difference was notsignificant between medical practitioners but wassignificant between nursing homes. Indeed, variationin prescribing and administration due to nursing home

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culture accounted for most of the effea attributed tomedical practitioner.

Many initiatives to improve drug use have advocatedrational prescribing. However, the present studyindicates that nursing home culture exerts a majorinfluence over prescribing and administration ofmedications. The establishment and implementationof satisfactory prescribing and administration policiesor systems in nursing homes may well be moreeffective than pharmaceutical interventions directedtowards individual medical practitioners or residents.

Conclusion

It is clear from this study that the resident's disabilityclassification and the culture of the nursing homeare the major determinants of prescribing and admin-istration of medication, in particular for laxatives,benzodiazepines and psycholeptics which are oftenprescribed for p.r.n. use. Medication prescribing andadministration patterns in nursing homes are relativelyunaffected by medical practitioner, or by resident ageor gender.

Key points• Nursing home culture is a major determinant of

medication use, especially for laxative and psycho-leptic medications which are often prescribed as'pro re nata' and administered at the discretion ofregistered nurses.

• Medical practitioner prescribing in Australian nursinghomes is conservative in cost and consistent in theprescribing of medication for which administrationis non-discretionary such as digoxin and diuretics.

• Medication use is also related to the functionaldisability of the resident and, to a lesser extent, theirage: laxative use is significantly higher when residentsare less mobile, while cardiovascular medication useis more common in the more mobile and olderresidents.

Acknowledgements

We acknowledge the assistance provided by David

Purdie in statistical analysis. This study was supportedin part by the Commonwealth Pharmaceutical EducationFund, the Upjohn Pharmaceutical Education Schemeand the Pharmacy Guild of Australia.

References

1. Beers M, Avorn J, Soumerai SB, Everitt DE, Sherman DS,Salem S. Psychoactive medication use in intermediate-carefacility residents. JAMA 1988; 260: 3016-20.

2. Nolan L, O'Malley K. The need for a more rationalapproach to drug prescribing for elderly people in nursinghomes. Age Ageing 1989; 18: 52-6.

3. Avorn J, Soumerai SB, Everitt DE et al. A randomised trialof a program to reduce the use of psychoactive drugs innursing homes. N Engl J Med 1992; 327: 168-73.

4. Beers MH, Ouslander JG, Fingold SF et al. AmericanCollege of Physicians. Inappropriate medication prescribingin skilled-nursing facilities. Ann Intern Med 1992; 117:686-9.

5. Snowdon J, Vaughan R, Miller R, Burgess EE, Tremlett P.Psychotropic drug use in Sydney nursing homes. Med J Aust1995; 163: 70-2.

6. Steel, K, Gertman PM, Crescenzi C, Anderson J. Iatrogenicillness on a general medical service at a university hospital.N Engl J Med 1981; 304: 638-42.

7. Owens NJ, Fretwell MD, Willey C, Murphy SS. Distinguish-ing between the fit and frail elderly, and optimisingpharmacotherapy. Drugs Aging 1994; 4: 47-55.

8. Aged and Community Care Division, CommonwealthDepartment of Human Services and Health. The NursingHome Manual. Australia: Commonwealth Department ofHuman Services and Health, 1995.

9. Anon. Financial survey of Australian community pharmacyperformance. In: Guild Digest. Australia: The Pharmacy Guildof Australia, July 1994.

10. Yip YB, Cumming RG. The association between medica-tions and falls in Australian nursing home residents. Med JAust 1994; 160: 14-8.

11. Howard JB, Strong KE Sr, Strong KE Jr. Medicationprocedures in a nursing home: abuse of P.R.N. orders. J AmGeriatrSoc 1977; 25: 83-4

Received 26 February 1997

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