One of the successes of improvements in health and social care in the developed world is the increase in survival of people into old age. However, increased longevity is associated with an increased burden of disease and therefore an associated increase in years of life with disability and illness for some people. As such, many of the frailest in society will spend some of the final months or years of life in a care home.
In England between 300,000 and 400,000 people over 65 years of age live in care homes with or without nursing in England [NHS Information Centre, 2010
; Comas-Herrera et al. 2001
]. The average length of time spent in a care home is 26.8 months for residential homes or 11.6 months for nursing care homes [Bebbington et al. 2001
]. Thus, the focus of care for many residents is often very different compared with that for fit and active older people living independently in the community.
As already discussed, most drug reactions in the elderly are predictable and therefore potentially avoidable. Given this information, one might expect that prescribing for a patient group with multiple chronic conditions and barriers to compliance that include mental and physical health problems, might result in greater levels of consideration as to the true benefits and risk of prescribing, and to the monitoring of effect. However, evidence seems to indicate the contrary [Gurwitz et al. 2007
; Crotty et al. 2004b
; Spore et al. 1997
]. Similarly, it seems intuitive that a detailed medication review considering all indication, interaction, evidence for use and risk/benefit would be advantageous to the individual concerned. As such, there are many recommendations regarding the methodology and frequency with which medication reviews should be carried out for older people. In the UK, the recommendation of the National Service Framework for Older People
[Department of Health, 2001
] is that anyone taking four or more medications should have a medication review every 6 months, although the nature of the review (e.g. whether or not the patient has to be seen by the healthcare practitioner performing the review) is not laid down.
There are several studies investigating and identifying particular drug classes that are frequently associated with unwanted effects in frail older people, for instance, long-acting benzodiazepines and tricyclic antidepressants [Nishtala et al. 2009
]. Estimates of the frequency with which potentially inappropriate drugs such as these are prescribed for older care-home residents are between 17.5% and 25% [Zhan et al. 2001
; Spore et al. 1997
]. However, all drug classes are responsible for contributing to data for ADRs. This includes antibiotics, antihypertensives, nonsteroidal anti-inflammatory drugs, antiplatelet drugs and anticoagulants, and antineoplastic agents, this collection of drugs is responsible for up to 60% of ADRs [Wu et al. 2010
; Patel et al. 2007
; Wiffen et al. 2002
Most studies of the possible benefits of medication review discussed thus far have started from an assumption that a reduction in the number of drugs prescribed for an individual is universally desirable [Kaur et al. 2009
; Garcia, 2006
; Schmader et al. 2004
; Furniss, 2002
]. Others have pointed out that a review may also benefit a patient if it identifies drugs with potential therapeutic effect that are not prescribed [Parikh et al. 2009
; Wright, 2007
; Quilliam and Lapane, 2001
]. Examples are osteoporosis treatments in patients at risk of fracture, or patients in atrial fibrillation who are not prescribed warfarin or aspirin. Nevertheless, an enthusiasm for treatment needs to be counter-balanced against an awareness that the evidence for the benefit of drug treatments has been gathered in a very different population from those who live in care homes. Similarly relevant is that the life expectancy of residents is limited; thus, preventative drugs that may require months or years of treatment before benefit accrues may not be indicated. The potential risks of polypharmacy have already been described: thus, the decision whether or not to prescribe additional medication for a care-home resident must always be a ‘patient-centred’ and individualized decision. Special circumstances may factor into this decision-making such as residents with swallowing problems or dementia who may have difficulty in physically taking medication, and those who are fed via nasogastric or percutaneous enterostomy tubes who may have limitations regarding the preparations they can tolerate.