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In this series of articles Prescriber hasexamined a number of important issues

relating to polypharmacy, as originally high-lighted in the King’s Fund, Polypharmacyand Medicines Optimisation report.1 Thisseries began by looking at the epidemiol-ogy of polypharmacy,2 followed by the distinction between appropriate and prob-lematic pharmacy.3 We then moved on todiscuss the principles of medicines opti-misation,4 and then the issue of depre-scribing.5 In this final article, we considerthe specific case of polypharmacy in thecare home setting.

Why is the care home setting important?The Care of Elderly People UK MarketSurvey 2012–13 estimated that therewere around 432,000 UK care home res-idents, the vast majority of whom were

aged 65 years and over.6 This setting isof particular relevance to polypharmacyfor a number of reasons. The main rea-sons for requiring residential care are dis-eases related to ageing and associatedfrailty, so the care home population isolder and more often suffers from multi-ple long-term conditions. As a result,polypharmacy is common. The UK CareHomes’ Use of Medicines study (CHUMS)found UK care home residents to be tak-ing an average of eight medicationseach.7 A cross-sectional analysis of over4000 nursing home residents in eightEuropean countries found half of residents to be in receipt of five to ninedrugs, and a further quarter to be on 10 or more.8 Similar rates are seen inthose with advanced cognitive impair-ment.9 In a study in Canada 15 per centof long-term care home residents were inreceipt of nine or more drug therapies,increasing with the number of chronicconditions.10 This study also observed asubstantial three-fold variation in ratesacross homes.

More medicines means more adverseeffects; a US study found such events tooccur twice per 100-resident-months,11

with polypharmacy a major driving fac-tor.12 However, care home residents mayalso be particularly vulnerable due topharmacokinetic (“what the body does tothe drug”) and pharmacodynamic (“whatthe drug does to the body”) differenceswhen compared to younger, less frail indi-viduals. Patients are more likely to expe-rience reduced renal or hepatic function,reduced haemostatic reserve and haveincreased sensitivity of drug receptors.For example it has been estimated that,in an elderly population, two out of anaverage seven daily medicines shouldhave dose adjustment made for renalimpairment,13 and renal insufficiency is arecognised risk factor for adverse drugsreactions in the elderly.14 Reduced lean

Medicines optimisation in the care home settingRupert Payne PhD, FRCPE, MRCGP and Martin Duerden, BMedSci, FRCGP, DRCOG, DipTher, DPH

In this the fifth and final article in the series the focus is onmedicines optimisation in the care home setting and looks atthe particular challenges in this area.

Figure 1. Polypharmacy is common in the care home population

SPL

body mass, reduced body water andlower serum albumin may also alter drugdistribution. If not accounted for, theseissues may result in more frequent andmore serious adverse effects in analready vulnerable group.

Medication errorsAs with all cases of polypharmacy, errorsincrease with the number of drugs.CHUMS found two-fifths of care home res-idents to be affected by a prescribingerror, with common problems includingomission of strength or route (38 percent), unnecessary medication (24 percent), incorrect dose or strength (14 percent) and omitted drugs (12 per cent). Afurther 10 per cent of residents experi-ence monitoring errors.7 However, impor-tantly, a key difference between thisenvironment and patients’ own homes isthat medication administration is usuallyprovided by nursing and other care staff.Despite this supervision, administrationerrors are common and include residentsbeing given the wrong drug or dose, med-ications being administered at the wrongtime, or the drug being omitted com-pletely.7,15 One study of English carehomes found 90 per cent of all residentsto be exposed to at least one administra-tion error in a three month period; thesewere considered serious in over half ofcases.15 The CHUMS study differentiatedadministration and dispensing errors,finding 22 per cent and 37 per cent ofresidents to be affected respectively.7

A number of factors contribute to theoccurrence of medication errors in thecare home setting.7 Patient factors includeconfusion and lack of awareness of med-ications; this is particularly true for severedementia, despite complex medicationregimens being commonplace in thisgroup.9 Physical difficulties such as arthri-tis or swallowing may hamper drug admin-istration, as does simply locating a patientwhen the drug round is being carried out.A number of other factors relate to theprocesses of prescribing and drug admin-istration. This includes the availability orotherwise of computer support tools,access to the clinical record, lack of avail-ability of medication, absence of protocols,and inadequate staff experience. Althoughat first sight a monitored dosage system

(MDS) may be of value, it is essential theyare fit for purpose. An MDS can lead toomission of liquid medications if unable tohold such preparations, and staff may beunable to identify which individual drugswithin a single compartment may havebeen taken. Organisational factors mayalso lead to errors; examples include inac-curate drug administration charts, inade-quate communication between staff andteams, busy staff being interrupted, dis-tracted or conducting competing tasks,and a lack of co-ordinated managementoversight. These issues are all likely to becompounded by increasing degrees ofpolypharmacy and therapeutic complexity.

InterventionsThe issues discussed above highlight anumber of potential areas which might betargeted in an effort to reduce theadverse consequences of polypharmacyin the care home setting. Some of theseare highlighted in Table 1. NICE has pub-lished recommendations on the manage-ment of medicines in care homes.16

One approach is to focus on optimis-ing prescribing by doctors. This might

involve improved training for GPs, and theprovision of dedicated medicationreviews. Many medication optimisationissues will be pertinent to all cases ofpolypharmacy, but certain aspects areparticularly relevant in the care home set-ting. End-of-life care will probably beencountered more frequently, and thebenefits of long-term preventative thera-pies may be less likely to be realised.Opportunities to reduce or stop medica-tions should not be overlooked.5 Cognitiveimpairment is a common problem, whichhas the potential to hinder identificationof adverse effects or patient concerns,and may result in inappropriate medica-tion use by confused patients. Cliniciansalso need to be aware of the increasedrisk of adverse reactions, and rememberto make appropriate dose adjustments,as well as being wary of potential interac-tions which might usually be dismissed inother patients. Doctors should takeadvantage of the opportunity for usingfeedback from care home staff to informdecision making; this may be particularlyrelevant in terms of medication adher-ence or adverse effects. Finally, remote

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Table 1. Medicines optimisation in care homes

A number of aspects of organisation and medicines optimisation may improvepatient safety and the quality of prescribing in the care home setting. Suggestedapproaches include:• A lead GP for each care home in the practice area. This could also be organised

at “cluster” or CCG level• A nominated clinical pharmacist having overall oversight for medicines use in

the care home• All patient’s medication to be regularly reviewed by a pharmacist• Regular review of the use and accuracy of medication administration records• Putting in place adequate staff training and suitable protocols• Timing of medication administration to prevent interruption (for example, not

at meal times)• Regular, appropriate monitoring of patients on specific higher-risk medicines

(such as ACE inhibitors and angiotensin-II receptor blockers), including blood tests• Monitoring of omitted doses and ordering systems. Checking for waste• Remote access to the medical record. Electronic administration systems; use

of barcodes• As much as possible, involving the resident and their family in the medicine

optimisation process• Where appropriate, enabling self-administration of medicines to capable

residents• Adherence aids such as monitored dosage boxes or “pill organisers” are widely used

in care homes. They may be inflexible in the care home setting and careful adminis-tration of medicines by trained staff (nurses in nursing homes) may be preferable.Regular audit of prescribing and root cause analysis if errors are identified.

access to computerised clinical systems,such as prescribing decision support toolsand the electronic medical records, mayhelp reduce inappropriate prescribing.

Improve documentationInterventions based around nursinghome staff themselves are also worthconsidering. This could include trainingin matters such as safe and appropriatedrug administration, or awareness ofadverse effects. Improving documenta-tion would be of value, ideally using com-puterised systems to facilitate audit, torecord problems or concerns, and toimprove communication between staff.Such systems should also extend torecording of drug administration andmedication stock control, ideally linked tomedical and nursing records. Barcodemedication administrative systems havealso been explored as ways to reduceadministration errors.15

Clinical pharmacists are almost cer-tainly underused in the care home set-ting. They can be an indispensible sourceof advice on both prescribing and drugadministration issues, conducting med-ication reviews alongside nursing staff,and potentially contributing to staff train-ing programmes and the development ofsupport tools. The Royal PharmaceuticalSociety has recommended pharmacistshaving overall responsibility for medi-cines in care homes, as well as leadingmedication reviews in this setting, andhas suggested one community pharmacyand one GP surgery should be associatedwith each home to improve coordinationand standards of care.17 Other experts inmanagement of polypharmacy may alsobe of use; for example, there is evidencethat care facilities with access to a geri-atrician have lower rates of excessivepolypharmacy.9

Finally, it is important to consider therole of patients and their families. A sub-stantial proportion of care home resi-dents have both the capacity and desireto make decisions about their medicines,and patients’ wishes are an importantreason for cessation of treatment.18 Yetshared decision making often does nothappen; health professionals’ time is onekey barrier, as may be the misconceptionthat residents are generally incapable of

making such decisions. NICE recom-mends residents being involved when-ever possible in their medication use, notjust in decision-making processes, butalso in terms of self-administration.16 Thelatter helps empower patients, and ismore “homely”, but complexity of treat-ment regimens in this population must beconsidered, and there is the potential toadd to the complexity of medicationrecording systems.

Unfortunately, the evidence for effec-tive strategies for optimising care homeprescribing and polypharmacy is relativelypoor and this area needs furtherresearch. A Cochrane systematic reviewwas published in 2013 examining theefficacy of eight randomised interven-tions to improve prescribing for older (≥65years) people in care homes.19 Thesewere complex interventions, heteroge-neous in nature, and included multidisci-plinary care conferences, education forcare home staff and computerised clini-cal decision support. Seven of the inter-ventions had a medication reviewcomponent. Overall, these interventionsled to improved identification and resolu-tion of medication-related problems, but there was limited evidence of costeffectiveness, and no evidence of areduction in adverse drug events, hospi-talisation or mortality.

ConclusionPolypharmacy is an extremely commonissue in residential and nursing carehomes, and is a critical factor contributingto adverse effects and medication errorsin this environment. Importantly, patientsin this setting are especially vulnerable tomedication problems. Furthermore,administration of drugs by nursing staffraises particular issues around dispens-ing, administration and monitoring oftreatment, as well as staff training.Approaches to address the adverse con-sequences of polypharmacy in the carehome setting are likely to be multifacetedin nature although, to date, the cost effec-tiveness and efficacy of such programmesremains unproven. Nevertheless, thepotential problems of polypharmacy inthis setting need to be highlighted to GPs,appropriate training for nursing staff mustbe encouraged, informatics solutions

should be more widely employed, andadvantage should be taken of the expert-ise of clinical pharmacists and other spe-cialist clinicians to optimise medicationregimens in these patients.

References1. Duerden M, et al. Polypharmacy and medi-cines optimisation: Making it safe and sound.Kings Fund, 2013.2. Duerden M, Payne RA. Prescriber 2014;25:44–7.3. Payne RA, Duerden M. Prescriber 2015;26:31–4.4. Duerden M, Payne RA. Prescriber 2015;26:40–43.5. Duerden M, Payne RA. Prescriber 2015;26:24–26.6. Care of Elderly People UK Market Survey2012–13; LaingBuisson, London 2013.7. Barber ND, et al. Quality & Safety in HealthCare 2009;18:341–6.8. Onder G, et al. J Gerontol A Biol Sci Med Sci2012;67:698–704.9. Vetrano DL, et al. Alzheimers Dement2013;9:587–93.10. Bronskill SE, et al. J Am Med Dir Assoc2012;13:309.e15–21.11. Gurwitz JH, et al. Am J Med 2000;109:87–94.12. Field TS, et al. Arch Intern Med2001;161:1629–34.13. Karsch-Völk M, et al. BMC Geriatr2013;13:92.14. Corsonello A, et al, (GIFA) Investigators.Arch Intern Med 2005;165:790–5.15. Szczepura A, et al. BMC Geriatr2011;11:82.16. NICE. Managing medicines in care homes.London 2014.17. Pharmacists improving care in carehomes. Royal Pharmaceutical Society, London2014.18. Shine 2012 final report: a clinico-ethicalframework for multidisciplinary review of med-ication in nursing homes. Health Foundation,London 2014.19. Alldred DP, et al. Cochrane Database SystRev 2013;2:CD009095.

Declaration of interestsNone to declare.

Dr Payne is clinical lecturer in generalpractice, University of Cambridge, andhonorary consultant clinical pharmacol-ogist, and Dr Duerden is a part-time GPin North Wales, and clinical senior lec-turer, Bangor University

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