Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

An educational program reduced the use of psychoactive drugs in nursing homes

ACP J Club. 1992 Nov-Dec;117:92. doi:10.7326/ACPJC-1992-117-3-092


Source Citation

Avorn J, Soumerai SB, Everitt DE, et al. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992 Jul 16;327:168-73.


Abstract

Objective

To evaluate the effectiveness of an educational program in geriatric psychopharmacology for health care providers in reducing the excessive use of psychoactive drugs in nursing homes.

Design

Randomized controlled trial of 5 months duration.

Setting

12 nursing homes in eastern Massachusetts. Facilities with atypically high or low levels of psychoactive drug use were excluded.

Patients

823 residents of 12 nursing homes. 678 residents (82%) remained in the nursing homes at follow-up.

Intervention

The 12 nursing homes were grouped into 6 pairs matched on size, type of ownership, and level of drug use. One home in each pair was randomized to an experimental group where physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology.

Main outcome measures

Type and quantity of drugs received by all residents were assessed during 30-day periods before and after the intervention. Using these data, a psychoactive drug use score was calculated based on points assigned for the use of a nonrecommended drug, for high doses, or for both. Level of functioning was also assessed.

Main results

The mean psychoactive drug use score was reduced by 27% in the experimental group compared with 8% in the control group (P = 0.02). Antipsychotic drugs were discontinued for 32% of baseline users in the experimental group compared with 14% in the control group (difference -18%, CI -33% to -3%, P = 0.02). Shifts to no drug or to an acceptable drug occurred more frequently among residents in the experimental group receiving long-acting or other benzodiazepines (20% vs 9%, mean difference -11%, CI -38% to 15%) and the nonrecommended hypnotic agent diphenhydramine (45% vs 21%, mean difference -24%, CI -54% to 5%), but the differences did not attain significance. In the experimental homes, baseline antipsychotic users had less deterioration of memory than similar control home residents, but they were more likely to report depression. Baseline users of benzodiazepines or antihistamine hypnotic agents in experimental homes reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups.

Conclusion

An educational program in geriatric psychopharmacology for physicians, nurses, and aides reduced the use of psychoactive drugs in nursing homes.

Source of funding: John A. Hartford Foundation.

For article reprint: Dr. J. Avorn, Program for the Analysis of Clinical Strategies, Gerontology Division, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA.


Commentary

If current trends continue, one half of us will spend some time in a nursing home. Unfortunately, ample evidence shows that quality of care in this setting is often low. One of the more troublesome and persistent problems is the extensive use of anti-psychotic and other psychoactive drugs. Despite their high risk for toxicity in frail elderly patients, these drugs have been prescribed for the convenience of care providers without trials of safer alternatives. This practice has led to regulatory changes in the United States that are designed to sharply curtail such use.

Avorn and colleagues show that a comprehensive educational outreach program can improve the quality of psychoactive drug use in the nursing home. Their intervention decreased antipsychotic drug use by 18% among baseline users, with a concomitant improvement in memory, but reports of depressive symptoms also increased. Another effect of the intervention is more controversial. Some patients receiving diphenhydramine were switched to intermediate half-life benzodiazepines, possibly leading to the deterioration in memory among baseline users of hypnotics or anxiolytics. This finding highlights the dilemma faced by clinicians treating the frequent problem of sleep disorders in older patients, for which benzodiazepines, sedating antihistamines, low-dose sedating antidepressants, and other drugs have all been recommended. Unfortunately, all of these have a relatively high incidence of adverse effects, and few comparative quantitative data are available to guide clinical choice.

This study should re-invigorate the debate on how to improve quality of care in the nursing home. Current approaches are predominantly regulatory; witness the expanding set of rules that govern many aspects of therapeutics in this setting. Restrictive policies, however, may fail to achieve their goals and indeed have unintended negative effects. Although recently enacted nursing home rules clearly motivate change, their clinical effects have not been rigorously evaluated. Ultimately, the optimal method may be synergism between regulation and educational programs of the type developed by Avorn and colleagues.

Wayne Ray, PhD
Vanderbilt UniversityNashville, Tennessee, USA