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Frailty and potentially inappropriate medication use at nursing home transition

Maclagan LC, Maxwell CJ, Gandhi S, Guan J, Bell CM, Hogan DB, Daneman N, Gill SS, Morris AM, Jeffs L, Campitelli MA, Seitz DP, Bronskill SE. J Am Geriatr Soc. 2017; 65(10):2205-12. Epub 2017 Jul 28.

Background/Objectives — To estimate the prevalence of potentially inappropriate medication (PIM) use among older adults with cognitive impairment or dementia prior to and following admission to nursing homes and in relation to frailty.

Design — Retrospective cohort study using health administrative databases.

Setting — Ontario, Canada.

Participants — 41,351 individuals with cognitive impairment or dementia, aged 66+ years newly admitted to nursing home between 2011 and 2014.

Measurements — PIMs were defined with 2015 Beers Criteria and included antipsychotics, H2 -receptor antagonists, benzodiazepines, and drugs with strong anticholinergic properties. Medication information was obtained at nursing home admission and in the subsequent 180 days. Multivariable Cox proportional-hazards models were used to assess the impact of frailty status (determined by a 72-item frailty index) on the hazard of starting and discontinuing PIMs.

Results — At admission, 44% of residents with cognitive impairment or dementia were on a PIM and prevalence varied by frailty (38.7% non-frail, 42.8% pre-frail, and 48.1% frail, P < .001). Following admission, many residents discontinued PIMs (23.5% for antipsychotics, 49.3% benzodiazepines, 32.2% anticholinergics, and 30.9% H2 -receptor antagonists). However, PIMs were also introduced with 10.9% newly started on antipsychotics, benzodiazepines (10.1%), anticholinergics (6.6%), and H2 -receptor antagonists (1.2%). After adjustment for other characteristics, frail residents had a similar risk of PIM discontinuation as non-frail residents except for anticholinergics (HR = 1.21, 95% CI 1.06-1.39) but were more likely to be newly prescribed benzodiazepines (HR = 1.32, 95% CI 1.20-1.44), antipsychotics (HR = 1.36, 1.23-1.49), and anticholinergics (HR = 1.34, 95% CI 1.20-1.50).

Conclusions — Many residents with cognitive impairment or dementia enter nursing homes on PIMs. PIMs are more likely to be started in frail individuals following admission. Interventions to support deprescribing of PIMs should be implemented targeting frail individuals during the transition to nursing home.