To Örebro University

Background: The role of the registered nurse (RN) in the municipality regarding medication management in care for the elderly is rarely discussed. Organizational issues related to medication management often contribute more to the management than needs of the patients, nursing skills, and collaboration with the physician in primary care.

Objective: The aim of this study was to describe RNs’ perceptions of their professional role, especially regarding medication management in nursing of the elderly.

Design: The study is descriptive with a qualitative approach. Interviews with 16 RNs working at nursing homes were analysed by content analysis.

Results: The findings can be grouped into seven categories showing the RN in different roles while performing different aspects of her or his work: as controller, executer, messenger, supervisor, initiator, visionary and solitary worker. These themes were identified in the interviews and characterized the nurses’ own judgements and actions taken, especially regarding drug treatment. Overall, the RNs described nursing in elderly care as an undefined profession lacking leadership regarding medication management.

Conclusions: The study concludes that medication management ought to be promoted in care for the elderly. To handle the challenge and risks of polypharmacy there must be sufficient and adequate reporting based on the RNs’ nursing and skills to monitor and evaluate the drug treatment in teamwork with the physician. This requires leadership with understanding of the integration of services in care for the elderly, and of the medical processes and nursing skills involved.

Objective: The aim of the study was to assess the effect on prescription quality and quality of life after intervention with prescription reviews and promotion of patient participation in primary care. Design. A randomized controlled study with three groups: (A) controls, (B) prescription review sent to physician, and (C) as in B and with a current comprehensive medication record sent to the patient. Setting. The municipality of Ö rebro, Sweden (130 000 inhabitants). Intervention. The study focused on the easiest possible intervention to increase prescription quality and thereby increase quality of life. The intervention should be cost-effi cient, focus on colleague-to-colleague advice, and be possible to perform in the primary health care centre without additional resources such as a pharmacist.

Subjects: 150 patients recently discharged from hospital. Inclusion criteria were: 75 years, fi ve drugs and living in ordinary homes. Main outcome measures. Quality of life (EQ-5D index, EQ VAS) and quality of prescriptions.

Results: Extreme polypharmacy was common and persistent in all three groups and this was accompanied by an unchanged frequency of drug-risk indicators. There was a low EQ-5D index and EQ VAS in all three groups throughout the study. No statistically signifi cant differences were found anywhere between the groups.

Conclusion: The intervention seems to have had no effect on quality of prescriptions or quality of life. This underlines the major challenge of fi nding new strategies for improving prescription quality to improve patient outcome measures such as quality of life and reduce the known risks of polypharmacy for the elderly.

The general aim of this thesis was to examine the effect of interventions on the usage of inappropriate and hazardous multi-medication in the elderly ≥75 years with ≥5 drugs.

Methods: Paper I describes a cluster randomization of nursing homes, the outcomes were; number of drugs, health status and evaluations. A randomized controlled trial concerning elderly in ordinary homes was performed in paper II and the outcomes were; EQ-5D index, EQ VAS and prescription quality. In paper III a cohort study was carried out and the outcomes were; medication appropriateness index, EQ-5D index and EQ VAS. In paper IV, registered nurses from the nursing homes study were interviewed in a descriptive study with a qualitative approach.

Results:There was a significant reduction of number of drugs used per patient at the intervention nursing homes (p<0.05). Monitoring and evaluation of medications were significantly more frequent at the intervention homes (p<0.01). The registered nurses at the nursing homes described a self-made role in their profession and the leadership was not at sight. Drug treatment seems to be a passive process without own reflection. Extreme polypharmacy was persistent in all three groups of elderly living in ordinary homes and there was an unchanged frequency of drug-risk indicators. In the cohort study a lower medication quality was shown to be associated with a lower quality of life. EQ-5D index was statistically significantly different among the groups as was EQ VAS.

Conclusion: The nursing home study showed an extreme shortage of monitoring of health status and surveillance of the effects of drugs in the elderly. More attention must be focused on the complexity of the nursing process; medication management must be promoted in teamwork with the physician. The resistance to change prescriptions in accordance with the intervention underlines the need of new strategies for improving prescription quality. Since medication quality is related to the patients’ quality of life, there is immense reason to continuously evaluate every prescription and treatment in shared decision with the patient.

Background: Modern drugs have made large contributions to better health and quality of life. Increasing proportions of negative side effects due to extensive pharmacological treatment are however observed especially among elderly patients who have multiple health problems. The aim of our study was to see if there is an association between medication quality and quality of life.

Methods: 150 patients discharged from hospital. Inclusion criteria were: living in ordinary homes, ≥ 75 years and ≥ 5 drugs. Home visits were performed to all, including prescription reviews and calculation of medication appropriateness index. The patients were divided into three groups depending on index score and followed for 12 months. The validated and recognized EQ-5D and EQ VAS instruments were used to assess quality of life.

Results: A lower medication quality was associated with a lower quality of life. EQ-5D index was statistically significantly different (declining for each group) among the groups (p = 0.001 at study start, p = 0.001 at 6 months and p = 0.013 at 12 months) as was EQ VAS (p = 0.026 at study start, p = 0.003 at 6 months and p = 0.007 at 12 months).

Conclusions: This study has shown the validity of the basic principle in prescribing: the more appropriate medication the better quality of life. Since drug quality is related to the patients’ quality of life, there is immense reason to continuously evaluate every prescription and treatment. The evaluation and if possible deprescribing should be done as a process where both the patient and physician are involved.

Purpose To examine whether patient focused drug surveillance was associated with a higher quality of drug treatment at nursing homes.

Methods An intervention study in four nursing homes in Sweden and four other nursing homes served as controls. At the intervention nursing homes physicians focused on patients' health status as a baseline for further ongoing medication. The outcomes were mortality, health care consumption, and number of drugs, health status and evaluations as parameters for "quality of drug treatment".

Results There were no significant differences in mortality rates. Healthcare consumption and polypharmacy were extensive in both groups. There was a significant reduction of number of drugs used per patient at the intervention homes during the study (p < 0.05). Monitoring and evaluation of the effects of medications were significantly more frequent at the intervention homes (p < 0.01).

Conclusions The intervention resulted in significant positive results in relation to "quality of drug treatment", a shift in health care utilization with concomitant use of fewer drugs. The study showed an extreme shortage of monitoring of health status and surveillance of the effects of drugs in the elderly. Copyright (C) 2009 John Wiley & Sons, Ltd.

The role of the municipal registered nurse (RN) is rarely discussed with regard to multimedication. The aim of this study was to describe RNs’ perceptions of their professional role especially regarding medication management in elderly care. The study is descriptive with a qualitative approach. Interviews with 16 RNs at nursing homes for the elderly were analysed. The RNs described an undefined profession lacking leadership. The findings can be categorized into seven roles showing different aspects of their work: controller, executer, messenger, supervisor, initiator, visionary and solitary worker. Health assessment and medication management should be promoted in elderly care. There must be sufficient and adequate reporting based on the RNs’ nursing and medical skills to monitor and evaluate the drug treatment in teamwork with the physician. This requires leadership with understanding of the integration process in care of the elderly, of the medical processes and nursing skills involved.