Professor of Primary Care Pharmacy School of Pharmacy, Queen’s University Belfast

Care homes for older people have a poor legacy in relation to quality of care issues. As institutions, they evolved from workhouses and poor houses, and have been variously described as ‘the waiting room for heaven’ or ‘a dumping ground for the elderly’. In terms of the population which inhabit nursing homes, residents can be described as vulnerable. The average age is over 80 years, over 70% are women and they tend to be more physically and mentally impaired than those living in their own homes (Hughes et al., 2000a). Residents of care homes are prescribed multiple medications, and studies have shown that they receive more medication compared to age-matched patients who live in the community (Stewart et al., 1989). Research conducted in the School of Pharmacy at Queen’s in Belfast over the past 12 years has identified and explored a number of influences on prescribing of medications and these may be described as control, context and culture.

Control is best exemplified by the legislative framework in place in the United States (US). Because of repeated reports of poor quality care in US nursing homes, Congress directed the Institute of Medicine to investigate what was happening in US nursing homes. This investigation culminated in the publication in 1986 of a seminal report entitled “Improving the quality of care in nursing homes” (Institute of Medicine, 1986). The report documented the widespread occurrence of the following: unsafe and unsanitary condition, abuse, neglect, malnutrition, medication errors, failure to provide prescribed drugs, excessive use of physical restraints, and the excessive use of chemical restraints; this latter term was coined to describe the inappropriate use of antipsychotics, hypnotics and anxiolytics. These medications were being used to sedate and subdue older residents. As a result of this damning report, the US Congress enacted a major piece of legislation in 1987 called the Omnibus Budgetary Reconciliation Act (OBRA 87) which was fully implemented in 1991 (Hughes et al., 1999). This legislation sought to improve the quality of care in US nursing homes via control through: regulations and standards, detailed inspections and enforcement procedure, with the ultimate sanction being closure of the nursing home. One regulation in particular related to the prescribing and it stated that “the resident has the right to be free from any psychoactive drug administered for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.”

Collaborative links between the School of Pharmacy at Queen’s University Belfast and the Center for Gerontology and Healthcare Research at Brown University facilitated an exploration of the impact of legislative control on prescribing through access to drug data from across US nursing homes (Hughes et al., 2000a). Furthermore, the Center had international links which also gave access to international data. The countries which had equivalent data, but did not have equivalent legislation were Denmark, Iceland, Italy, Japan and Sweden. The total number of residents included in this comparative study approached 500,000.

The descriptive statistics for this sample revealed that almost 70% of residents were female, over 40% were over the age of 80, at least 25% had severe activities of daily living impairment and were also cognitively impaired. At least one-third were receiving between 4-6 drugs per day, and in the USA, 30% were receiving between 7-10 drugs per days. The cross-national differences in prescribing of the psychoactive medications which are the focus of the OBRA legislation were stark as shown in Table 1. Using the US as the reference point, residents in nursing homes in all other countries were more likely to receive anxiolytics or hypnotics. For example, in Iceland, residents were almost nine times more likely to receive these medications compared to residents in US nursing homes. Similar trends were seen for anti-psychotic medication, but the differences were not so marked (Hughes et al., 2000). So our conclusion was that control, via legislation, can have a profound effect on certain aspects of care, and there is a plethora of other publications from the USA which have shown the differences in prescribing trends in US nursing homes before and after the introduction of OBRA.

Table 1 Effect of legislation on use of psychoactive medication in nursing homes (Hughes et al., 2000)

Country	% of residents using anti-anxiety/hypnotic drugs	Adjusted Odds ratio (95% CI)
Denmark Iceland Italy Japan Sweden USA	34.1 61.8 34.2 24.8 35.5 14.2	3.24 (2.99-3.51) 8.80 (7.80-9.93) 2.18 (1.89-2.52) 2.11 (1.83-2.42) 2.92 (2.49-3.42) 1.0 (referent)

The general consensus has been that this type of control (in the form of legislation) is a good thing. But it can be argued that control, by its very nature, is very controlling. which may conflict with choice. We have very little information about the extent to which residents are involved in any decisions about medication. We know that a number of residents will have dementia, but there are many who can make decisions. We are certainly aware of concerns about poor adherence in community dwelling patients, but very little has been published about what happens in the care home setting. What has been written has focussed on enforced compliance, particularly in relation to covert administration of medication (hidden in food or drink) (Kirkevold and Engedal, 2005). The opposite of that which could happen in care homes is erratic compliance, in which residents do not get their medications when they should. A qualitative study with residents, GPs and nursing home staff was undertaken in which some of these issues in either focus groups (nursing home staff) or semi-structured interviews (GPs and residents).

The over-arching finding of this study was the need for control (Hughes and Goldie, in press). In some situations, control was essential to ensure safe prescribing and administration of medications, but this control was sometimes adversely affected by lack of information, particularly poor medication records and the lack of regular medication review. However, what was also apparent was that the need for control created a tension with resident autonomy, and residents who were capable of making decisions seldom had the opportunity to do so. A GP in this study stated “Well, they don’t have much choice really. They have surrendered all their rights and personality and they just take their tablets and say nothing.” And one of the residents said: “I just take what I am given……. I believe in doing what I am told.”

The term ‘total institution’ has sometime been used to describe these types of facilities and has been defined as one in which daily life is organised and regulated according to a predetermined schedule and all aspects of an occupant’s existence are provided for by that institution (Andrews et al., 2005). The concept of the ‘total institution’ also raises one of the interesting dichotomies about care homes. At its best, a care home will try to be home-like, but this identity is quite schizophrenic. A care home represents a dual environment. A care home is where someone lives. But a care home is also a health care environment and has the characteristics of such an environment-it will have nursing and care staff, doctors come and go, the facilities will vary in size, and they will vary in terms of ownership and profit status. So, again, collaborative work between researchers in Northern Ireland and the USA have explored if any of these contextual factors have an impact on prescribing?

The first study focused on antipsychotics in which we used data from about 17,000 care homes in the US-this represents about 96% of all homes in the USA ( Hughes et al., 2000b) . The main finding from this study was that in those homes classified as being for-profit, residents were more likely to receive an anti-psychotic drug compared to residents in other types of nursing homes (i.e. not-for-profit, or those which are owned by the government) (Hughes et al., 2000b). This finding seemed to be explained by nurse staffing levels. We found that in the for-profit environment, there was an increasing care assistant-to-nurse ratio which in turn led to greater likelihood of these drugs being used. By increasing this ratio, professional nurse contact is decreased (which is more expensive, and may well be a consideration in for-profit homes). This could result in a lack of supervision of nurse assistants and a shortage of specialised nursing care for some residents, which in turn can lead to the inappropriate use of anti-psychotics.

And the importance of staffing had previously been identified by the original Institute of Medicine report in 1986 which noted that “Understaffed facilities may make excessive use of antipsychotic drugs to substitute for inadequate numbers of nursing staff,” (Institute of Medicine, 1986). We have also looked at some of these contextual factors in relation to depression. We chose to look at this category of drugs as the literature had reported that depression was probably under-treated in care homes. Again, staffing proved to be very important: if there were more nurses present on staff, there was greater use of antidepressants (Lapane and Hughes, 2004). We thought that this might suggest that if there were more nurses on staff, they were more likely to identify depression. This seemed to be borne out by another finding in this study; in larger homes, there was less treatment with antidepressants and we suggested that because of the size of larger homes, depression may be harder to identify (Lapane and Hughes, 2004).

Control and context have helped to explain some of the prescribing trends that we have observed in care homes. But these two factors do not appear to explain the whole story. And in many of the epidemiological studies that have been conducted by ourselves and others, it has been clear that there are marked differences between care homes. Control in the form of legislation and the contextual factors such as the size of the home, staffing complement and the profit status of the home did not affect prescribing uniformly, and it would be naïve to think that this would be the case. There appear to be other factors at work and this has become more apparent in recent years.

There have been two studies which have given us food for thought. In 2005, Becky Breisacher and colleagues reported the highest level of antipsychotic use in US nursing homes in 10 years (28%), and this is despite the presence of OBRA (Briesacher et al., 2005). It was noted that these drugs (primarily the atypical antipsychotics) were being prescribed outside of prescribing guidelines for the management of the behavioural and psychological symptoms of dementia. Then in 2006, a Canadian group reported a point prevalence for antipsychotic use of 32.4% (Rochon et al., 2007). It was also reported that there was marked variation between homes in the prescribing of these drugs and this is something that we had also observed in some of our studies. In the discussion section of the latter paper, the authors noted “….some environments being more permissive about antipsychotic use” (Rochon et al., 2007). So this has led us to think about why some care homes are more ‘permissive’ than others. One publication a number of years ago mentioned ‘nursing home culture appears to influence prescribing’ but with no explanation of what this meant (Roberts et al., 1998). So we have now started to move beyond control and context and look at culture, specifically organisational culture and how it may affect the quality of health care performance (Hughes et al., 2007).

The term ‘culture’ has entered common vernacular, but it does have a precise meaning in sociological terms. It has been described as the way things are understood, judged and valued. It encompasses the shared beliefs, attitudes, values and norms of behaviour within an organisation (Schein, 1995). A lay definition which is sometimes used to explain organisational culture is ‘the way we do things around here (Davies et al., 2000). Ongoing work is examining the impact of culture and its impact on prescribing (Donnelly et al., 2008). We have been doing some survey work using a questionnaire which allows us to classify care homes into three categories of organisational culture: resident-centred, traditional or ambiguous, based on previous American work (Svarstad et al., 2001). This will be followed up by observational work in which we will attempt to describe these cultures in more detail.

Prescribing of medicines is one of the most common interventions experienced by older people, and in care homes for older people, this intervention is particularly prevalent. Practitioners in this setting should be aware of the range of factors which can influence the use of medicines, and consider what is most appropriate for individuals in this frail population.

 

References

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