Drug-Related Problems in the transitional care of the elderly from hospital to home

Valente, Silvia Helena; Barbosa, Sara Maria; Ferro, Denise; Fabriz, Luciana Aparecida; Schönholzer, Tatiele Estefani; Pinto, Ione Carvalho

doi:10.1590/0034-7167-2018-0848

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Revista Brasileira de Enfermagem

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Sumário

REVIEW • Rev. Bras. Enferm. 72 (suppl 2) • Nov 2019 • https://doi.org/10.1590/0034-7167-2018-0848 copy

Drug-Related Problems in the transitional care of the elderly from hospital to home

Problemas Relacionados com los Medicamentos en la transición de ancianos del hospital para casa

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To identify the knowledge produced on Medication-Related Problems in the transitional care of the elderly from hospital to home.

Method:

Integrative review of the literature data, organized in six stages: guiding question; establishment of inclusion and exclusion criteria; extraction of data; analyze; interpretation of results; and presentation of the review. Articles were considered among 2002 and 2017, in Portuguese, English, and Spanish, in the databases LILACS, MEDLINE, CINAHL and EMBASE.

Results:

10 studies were selected and analyzed. They were categorized by subject and identified in three themes: Medication Discrepancy and Reconciliation (40%); Adhesion to Medication (30%); and Adverse Drug Events (30%).

Final considerations:

Drug-Related Problems in the transitional care of the elderly from hospital to home, were presented as a relevant theme for nursing, involving complex issues related to care. Drug reconciliation was evidenced as a coherent and effective strategy in home care transitions for the elderly.

Descriptors:
Transitional Care; Medication Therapy Management; Patient Care Planning; Health of the Elderly; Nursing Care

Databases	Search Strategy	Articles Found
MEDLINE	Descritors (MeSH) and keywords - aged OR elderly OR senior OR older people AND transition care OR continuity of patient care OR patient discharge AND medication errors OR medication adherence OR medication reconciliation OR drug-related side effects and adverse reactions.	239
LILACS	Descritors (DeCS) and keywords in Portuguese - idoso AND cuidado transicional OR alta do paciente OR continuidade do cuidado AND erros de medicação OR adesão à medicação OR reconciliação de medicamento OR efeitos colaterais e reações adversas relacionadas a medicamentos.	13
EMBASE	Emtree terms and keywords - aged AND chronic disease AND transition care; aged AND chronic disease AND transition care AND medication errors; aged AND chronic disease AND transition care AND medication adherence; aged AND chronic disease AND transition care AND medication reconciliation; aged AND chronic disease AND transition care and drug-related side effects and adverse reactions.	48
CINAHL	CINAHL titles and keywords - aged OR elderly OR senior OR older people AND transition care OR continuity of patient care OR patient discharge AND medication errors OR medication adherence OR medication reconciliation OR drug-related side effects and adverse reactions.	58

Level of Evidence	Evidence Source
Level I	Evidence regarding the systematic review or meta-analysis of randomized controlled trials.
Level II	Evidence from well-outlined randomized clinical trial.
Level III	Evidence obtained from well-outlined controlled trials without randomization.
Level IV	Evidence from well-outlined cohort study and/or control case.
Level V	Evidence of systematic reviews of descriptive and qualitative studies;
Level VI	Evidence from a single descriptive or qualitative study.
Level VII	Evidence from the opinion of authorities and/or reports from expert committees.

Title	Year/Country	Outlining/Patients number	Interventions	Outcomes
Multiple medication use in older patients in post-acute transitional care: a prospective cohort study⁽¹⁸18 Runganga M, Peel NM, Hubbard RE. Multiple medication use in older patients in post-acute transitional care: a prospective cohort study. Clin Interv Aging [Internet]. 2014[cited 2017 Oct 24];(9):1453-62. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158998/pdf/cia-9-1453.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2014 Australia	Prospective Observational n= 351	Comprehensive geriatric assessment, performed at admission and discharge, using the InterRAI Home Care assessment tool. Outpatient abstracts were coded using the World Health Organization's Anatomical Therapeutic Chemical (ATC) Classification System.	Polypharmacy was observed in 46.7%, and hyperpolypharmacy in 39.2% of patients. Increased numbers of medications have been associated with a greater number of chronic conditions, such as Diabetes Mellitus, heart disease, lung disease and dizziness. The most common drugs were analgesics (56.8%) and gastric protectors (52.7%). The most common potentially inappropriate drugs were tertiary tricyclic antidepressants.
Adverse Drug Events Post-Hospital Discharge in Older Patients: Types, Severity, and Involvement of Beers Criteria Medications⁽¹⁹19 Kanaan AO, Donovan JL, Duchin NP, Field TS, Tjia J, Cutrona SL, et al. Adverse drug events post-hospital discharge in older patients: types, severity, and involvement of beers criteria medications. J Am Geriatr Soc [Internet]. 2013[cited 2017 Oct 20];61(11):1894-99. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446728/pdf/nihms517947.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2013 United States	Cross-Sectional Retrospecti ven = 1000	Comprehensive analyzes of medical records to identify possible drug-related incidents during the 45-day post-hospital discharge period.	At least one ADE was identified during the 45-day period in 18.7% of participants. Of the 115 ADEs identified, 35% were considered avoidable. 32% were characterized as severe and 5% as life threatening. More than half of all ADEs occurred within the first 14 days after hospitalization.
Predictors of medication adherence post-discharge: the impact of patient age, insurance status and prior adherence⁽²⁰20 Cohen MJ, Shaykevich S, Cawthon C, Kripalani S, Paasche-Orlow MK, Schnipper JL. Predictors of medication adherence post-discharge: the impact of patient age, insurance status and prior adherence. J Hosp Med [Internet]. 2012 [cited 2017 Oct 16];7(6):470-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575732/pdf/nihms434410.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2012 United States	Randomized Controlled Study n = 646	Survey of medical records and interview for sociodemographic data collection, cognition, health literacy level, medicine in use, and adherence to medication prior to admission. New telephone interview 30 days post-discharge for application of structured questionnaire to measure the level of adherence to the medication.	The mean post-discharge adhesion index was 95%. For each increase of 10 years of age, there was an absolute increase of 1% in adhesion. Patients with private insurance were 4.5% less adherent. Health literacy was not an independent predictor of post-discharge adherence.
Relationship of Health Literacy to Intentionaland Unintentional Non-Adherence of HospitalDischarge Medications⁽²¹21 Lindquist LA, Go L, Fleisher JV, Jain N, Friesema E, Baker DW. Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications. J Gen Intern Med [Internet]. 2011[cited 2018 Jan 02];27(2):173-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270238/pdf/11606_2011_Article_1886.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2011 United States	Correlational n=254	Interviews with patients before and after discharge; application of the S-TOFHLA tool; extraction of data from discharge medical records; and coding of drug discrepancies.	56% presented a discrepancy between discharge instructions and home use 48 hours post-discharge. Subjects who did not receive guidelines showed no adherence (47.7%) and those oriented were less likely to non-adherence (73.3%). Another common cause of discrepancies was incomplete instructions (39.3%).
Nurse Identified Hospital to Home Medication Discrepancies: Implications for Improving Transitional Care⁽²²22 Corbett CF, Setter SM, Daratha KB, Neumiller JJ, Wood LD. Nurse Identified Hospital to Home Medication Discrepancies: Implications for Improving Transitional Care. Geriatr Nurs [Internet]. 2010 [cited 2018 Jan 02];31(3):188-96. Available from: https://www.sciencedirect.com/science/article/pii/S0197457210002028 https://www.sciencedirect.com/science/ar... ⁾	2010 United States	Randomized Prospective n = 101	Application of the electronic version of the Medication Discrepancy Tool (MDT).	94% of participants had at least one drug discrepancy. The contributing causes were related to the patient, with emphasis on non-intentional medication adherence (39.6%), with emphasis on incomplete/inaccurate/illegible discharge instructions (46.5%).
Drug related problems after discharge from an Australianteaching hospital⁽²³23 Ellitt GR, Engblom E, Aslani P, Westerlund T, Chen TF. Drug related problems after discharge from an Australian teaching hospital. Pharm World Sci [Internet]. 2010 [cited 2018 Jan 02];(32):622-30. Available from: https://link.springer.com/content/pdf/10.1007%2Fs11096-010-9406-9.pdf https://link.springer.com/content/pdf/10... ⁾	2010 Australia	Documentary Retrospective Research n = 76	Documentary research and data grouping from discharge summary analysis, home drug review reports and home drug review.	DRPs were identified in 71 patients (93.3%), with 398 problems and an average of 5.6 problems / patient. The most frequent problems were uncertainty about the drug's goal, potential interactions and adverse reactions.
Adherencia al tratamiento farmacológico en pacientes ancianos tras el alta hospitalaria⁽²⁴24 Castellano-Muñoz P, Miranda-Ruiz A, Sojo-González G, Perea-Milla E, García-Alegría JJ, Santos-Rubio MD. [Pharmacological treatment adherence by older patients after hospital discharge]. Enferm Clin. 2008;18(3):120-26. Spanish.⁾	2008 Spain	Cross-Sectional Study n = 70	Two home interviews (3 and 20 days post-discharge) for the application of a questionnaire containing quantitative and qualitative data (sociodemographic data and related to the use of prescribed drugs).	85% of the medicines are used incorrectly, mainly more than the prescribed ones (67%). The causes for misuse were forgetfulness and lack of knowledge. The risk factors were: male gender, live with children and more prescribed drugs.
Relationship of In-Hospital Medication Modifications of Elderly Patients to Postdischarge Medications, Adherence, and Mortality⁽²⁵25 Mansur N, Weiss A, Beloosesky, Y. Relationship of in-hospital medication modifications of elderly patients to postdischarge medications, adherence, and mortality. Sage J[Internet]. 2008[cited 2018 Jan 02];42(6):783-9. Available from: https://journals.sagepub.com/doi/pdf/10.1345/aph.1L070 https://journals.sagepub.com/doi/pdf/10.... ⁾	2008 Israel	Retrospective Prospective Cohort Study n=212	Clinical and demographic data, post-discharge drug modifications, and adherence were prospectively obtained through patient interviews. Modifications of the in-hospital drug regimen were obtained retrospectively through medical records. Professionals were occasionally interviewed to clarify the reasons for drug modifications.	The rate of modification of the drug regimen was 49.8%. Cognitively normal patients who were admitted with polypharmacy and were discharged home experienced fewer drug modifications. Three months after discharge, 17 patients died and 50 were readmitted. The main risk factors were impaired cognition and chronic disease.
Continuity and Adherence to Long-Term Drug Treatment by Geriatric Patients after Hospital Discharge⁽²⁶26 Mansur N, Weiss A, Hoffman A, Gruenewald T, Beloosesky Y. Continuity and adherence to long-term drug treatment by geriatric patients after hospital discharge: a prospective cohort study. Drugs Aging. 2008;25(10):861-70. doi: 10.2165/00002512-200825100-00005 https://doi.org/10.2165/00002512-2008251... ⁾	2008 Israel	Cohort Prospective n=198	Clinical, demographic and drug data were recorded for all patients, applying the Mini-Mental State Examination (MMSE) scale and pre-discharge interview. After one month, the patient, caregiver or doctor were interviewed regarding the extent and reasons for changes in the regimen of medication and adherence to the treatment.	An average post-discharge month, 36.7% of patient medications had been modified in comparison to the discharge prescription. To improve adherence to the drug regimen, patients should be encouraged to return to health services.
Posthospital medication discrepancies: prevalence and contributing factors⁽²⁷27 Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med [Internet]. 2005 [cited 2018 Jan 02];165(16):1842-7. Available from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/486693 https://jamanetwork.com/journals/jamaint... ⁾	2005 United States	Intervention Research n= 375	Application of the Medication DiscrepancyTool (MDT).	14.1% of the patients presented one or more discrepancies. The discrepancy factors were 50.8% associated with the patient and 49.2% associated to the system. 14.3% of the patients who suffered discrepancies were rehospitalized in 30 days.

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[1] Corresponding Author: Silvia Helena Valente. E-mail: silvia.h.valente@gmail.com