Discontinuing Inappropriate Medication Use in Nursing Home Residents A Cluster Randomized Controlled Trial

Background:

Inappropriate prescribing is a well-known clinical problem in nursing home residents, but few interventions have focused on reducing inappropriate medication use.

Objective:

To examine successful discontinuation of inappropriate medication use and to improve prescribing in nursing home residents.

Design:

Pragmatic cluster randomized controlled trial, with clustering by elder care physicians and their wards. (ClinicalTrials.gov: NCT01876095)

Setting:

59 Dutch nursing home wards for long-term care.

Patients:

Residents with a life expectancy greater than 4 weeks who consented to treatment with medication.

Intervention:

Multidisciplinary Multistep Medication Review (3MR) consisting of an assessment of the patient perspective, medical history, critical appraisal of medications, a meeting between the treating elder care physician and the pharmacist, and implementation of medication changes.

Measurements:

Successful discontinuation of use of at least 1 inappropriate drug (that is, without relapse or severe withdrawal symptoms) and clinical outcomes (neuropsychiatric symptoms, cognitive function, and quality of life) after 4 months of follow-up.

Results:

Nineteen elder care physicians (33 wards) performed the 3MR, and 16 elder care physicians (26 wards) followed standard procedures. A total of 426 nursing home residents (233 in the intervention group and 193 in the control group) were followed for an average of 144 days (SD, 21). In an analysis of all participants, use of at least 1 inappropriate medication was successfully discontinued for 91 (39.1%) residents in the intervention group versus 57 (29.5%) in the control group (adjusted relative risk, 1.37 [95% CI, 1.02 to 1.75]). Clinical outcomes did not deteriorate between baseline and follow-up.

Limitations:

The 3MR was done only once. Some withdrawal symptoms or relapses may have been missed.

Conclusion:

The 3MR is effective in discontinuing inappropriate medication use in frail nursing home residents without a decline in their well-being.

Primary Funding Source:

Netherlands Organisation for Health Research and Development.

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