NurseWeek: Industry Pulse - Drug misuse, overuse common in nursing homes, report says

Drug misuse, overuse common in nursing homes, report says

By Gary R. Ilminen, RN
September 27, 2001

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Gary R. Ilminen, RN, has worked in health
care for more than 20 years starting in 1981 as a volunteer emergency medical technician in southern Wisconsin. He has been a registered nurse since 1987.

He is employed as a nurse consultant for the State of Wisconsin Department of Health
and Family Services Bureau
of Managed Health Care Programs, as a legal nurse consultant in private practice and as a free-lance writer. He also is the author of Consumer Guide to
Long-term Care
published by the University of Wisconsin Press.

For more information on the OIG report, visit www.os.dhhs.gov/oig.

One out of five nursing home residents in the nation received at least one drug judged to be inappropriate for the diagnoses in their records, according to a series of studies by the Office of Inspector General, Department of Health and Human Services. Of these, 32 percent received three or more inappropriate drugs and 5 percent took seven or more.

The use of drugs generally considered inappropriate for the residents' conditions was one of many widespread problems identified by the OIG in a three-part report, "Prescription Drug Use in Nursing Homes" (OEI-06-96-00080, OEI-06-96-00081, OEI-06-96-00082).

The report looked at drug use in nursing homes through a nationwide survey of consultant pharmacists who conduct drug regimen reviews in nursing homes on a monthly basis, as well as a sample review of medical records of Texas nursing home residents.

The study also found that:

16 percent of residents had no prescription in their records to support one or more of the drugs in their regimen for which a prescription generally is required. Additionally, 14 percent of residents were taking over-the-counter medications without physician orders.
17 percent of residents were taking medications inappropriate for their dietary requirements.
8 percent of residents were given drugs inappropriate for their plan of care and 6 percent received drugs judged inappropriate based on their physical assessments.
23 percent of patient records indicated patients having been prescribed medications for which the records showed no orders or receipts to indicate the patient actually received the medication.
20 percent of residents' records indicated use of at least one drug generally considered to be inappropriate for the elderly. (Several of the drugs among those considered inappropriate are psychoactive drugs, including certain antidepressants; anti-anxiety drugs; sedative and hypnotic drugs.) Of these, 21 percent had more than one of such drugs in use.

The report also identified that some residents may experience unnecessary adverse side effects and drug interactions as a result of inadequate monitoring of medications.

Misuse of drugs is not the only problem besetting nursing home residents. Data indicate overuse of even the most stringently regulated drugs as well.

Since the passage of the Nursing Home Reform Act of 1987, federal regulations have required that psychoactive drugs be used only when absolutely necessary to treat an appropriate diagnosis or severe symptoms and only for as long as necessary. Despite the regulations, use of psychoactive drugs in nursing homes has soared from 26.4 percent of all residents in 1991 to 50.3 percent in 1999.

The continued escalation of drug use among nursing home residents in the past three years is surprising because the OIG issued its report in November 1997.

The department made 14 recommendations intended to address the problems they found in nursing home medication management.

Unfortunately, few of the OIG recommendations have been implemented by the state or federal government. The department's recommendations largely were overlooked in the federal government's 1998 Nursing Home Initiative.

In July 1999, the Health Care Financing Administration issued a revised state operations manual for surveys of long-term care facilities. It includes new listings of medications that may be inappropriate for elderly individuals and resident conditions and drug combinations that have the potential for serious adverse outcomes.

New rules were added on the use of drugs considered to be chemical restraints but no new requirements were added for physicians to follow in prescribing.

The ineffectiveness of the new regulations may be indicated by Minimum Data Set Quality Indicator data.

According to the latest available data, the percentage of residents nationwide who exceeded the quality indicator "trigger" level for receiving psychoactive drugs in the absence of an appropriate diagnosis actually has increased since the new regulations went into effect.

In the first quarter of 2000, 35.2 percent of residents triggered, but by the year's fourth quarter, the percentage rose to 35.6 percent. Similarly, the percentage of residents exceeding the Quality Indicator trigger for receiving nine or more drugs increased in the same time period from 41.3 percent to 42.8 percent.