Polypharmacy in Elderly- Dissertation Sample
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|S. No||Table of Contents||Page No|
|1.||Introduction & Literature Review|
1.3 Search Strategy
1.4 Polypharmacy in Elderly
1.5 Consequence of Polypharmacy
1.5.1 Increased Healthcare Costs
1.5.2 Adverse Drug Events
1.5.3 Drug Interaction
1.5.4 Medication Non Adherence
1.5.5 Functional Status
1.5.6 Cognitive Impairment
1.5.8 Urinary Incontinence
|2.||Methodological Issues in Research|
2.4 Research Questions
2.5.1 Qualitative Study
2.5.2 Quantitative Study
2.5.3 Quasi Experimental Study
2.6 Population, Sample and Sampling
2.6.1 Inclusion Criteria
2.6.2 Exclusion Criteria
2.7 Study Setting
2.8 Data Collection
2.9 Data Analysis
2.10 Pilot Study
2.12 Ethical Consideration
2.13 Limitation of Study
Chapter 1: Introduction & Review of Literature
Polypharmacy can be defined as the ill effects that may happen while consuming multiple medications simultaneously to manage the existing health problems like diabetes, hypertension and depression. Generally, polypharmacy becomes problematic, for instance when patients are prescribed too many drugs by different medical teams working independently of each other.
The commonly available over the counter drugs such as paracetamol, nurofen and antacids frequently result in adverse drug reactions in elderly patients. The more drugs a person consume, the risk of adverse reactions and drug interactions are more. The drug groups most commonly involved in adverse reactions are analgesics, cardiovascular agents, diuretics, hypoglycaemics, anticoagulants, steroids, anticholinergics, opioids benzodiazepines, and anti-depressants. (Sera & Mcpherson 2012)
The volume of the population aged over 65 years in Ireland is expected to double over the next 35 years. Statistics forecast that it may raise from 11% in 2006 to about 22% in 2041. Those over 65 years take the significant amount of medications in among the Western population (Families USA 2000), whereas Ireland accounts for around half of the prescription drugs distributed within the Health Service Executive’s Primary Care Reimbursement Service (HSE PCRS). The development of multiple medications among elderly result from increased life expectancy, multi morbidity, new drug treatments and indications. There are not many much eveidence to support prescription of polypharmacy in elderly due to exclusion of elderly particularly those with multi morbidity from drug trial. (Hilmer & Gnjidic 2008).
Richardson et al. (TILDA 2012) report that in Ireland 52% of the population are over 50 years of age who has a medical card, where the medicines are granted by the state for free. Out of these 79% are reported to have polypharmacy. Those without a medical card must pay for their medicines up to €120 per month maximum. During the collection of these information in 2010, medical cards were made accessible to those under 70 years of age with low incomes or for those whom the medical costs would bring about undue hardship. For those over 70 years, the income threshold was higher. Out of all age groups approximately 11% of the total healthcare budget is spent directly on medicines. Expenditure on those over 50 years of age accounts for two thirds of the medicine budget. In the last two decades the use of medicine has significantly increased in Ireland. It is vital for the nurses to be aware of what medications are being prescribed and administered. Only few research studies with regard to nurses’ knowledge and clinical experience on polypharmacy in elderly patients are available. Hence, the objective of this study was to determine the nurse’s knowledge of polypharmacy and to explore the clinical experience of polypharmacy in their practice in elderly care.
Polypharmacy can be defined as the simultaneous use of five or more medications and excessive polypharmacy may be defined as more than ten medications in a same patient at the same time (Fulton & Riley 2005). TILDA is also uniquely placed to study concomitant prescription, over-the-counter (OTC) medication, and food supplement use in the over 50s in Ireland, contributing to an under-studied source of potential drug interactions (Ernst, 2000).
1.3 Search strategy:
The search terms used were polypharmacy in elderly, nurse’s knowledge on polypharmacy. The databases searched were CINAHL, Medline and PUBMED. Limits applied were, year of publication 2009-2014, peer reviewed, English language, research articles. Few additional documents like research text books obtained from library were searched. A total of 21 articles were found and used. All articles accessed were international studies based in Ireland, U.K, USA, Australia, Canada and few other European countries.
1.4 Polypharmacy in elderly:
A few components add to polypharmacy among patients over age 65. Clinicians may be recommending a larger number of medications for their elderly patients. This may be due to availability of more medications for treating these patients.
1.5 Consequences of Polypharmacy:
1.5.1 Increased Healthcare Costs:
Polypharmacy directly relates to the health care costs to both the patient and the healthcare system. A reflective cohort study discovered that polypharmacy was associated with an increased risk of conceiving a potentially improper medication and an extended risk of outpatient visits, and hospitalization with an almost 30% increase in medical expenses (Akazawa et al. 2010).
1.5.2 Adverse Drug Events:
It was estimated that more than 4.3 million human services visits were ascribed to Adverse Drug Events(ADE) (Bourgeois et al. 2010). It has been calculated that up to 35% of outpatients and 40% of hospitalized elderly experience an ADE. In addition, about 10% of emergency departments visits are resulted from an ADE (Hohl et al. 2001). In a quantitative study, outpatients taking 5 or more medications had an 88% increased risk of experiencing an ADE compared to those who were taking less number of medications (Bourgeois et al. 2010). In nursing home residents, the rates of ADEs have been found to be doubled in patients taking 9 or more medications compared to those taking less (Nguyen 2006). One more study assessing unexpected hospitalizations in elderly patients observed that taking they were more than 5 meds was approximately 4 times as prone to be hospitalized from ADE (Marcum et al. 2012). The very common drug classes associated with ADEs are such as anticoagulants, NSAIDs, cardiovascular medications, diuretics, antibiotics, anticonvulsants, benzodiazepines, and hypoglycemic medications (Marcum et al. 2012).
Elderly patients who are on polypharmacy are at high risks for drug interactions (Mallet et al. 2007). The chances of drug interactions are more with the number of medications. For example, a patient taking 5-9 medications had a 50% chance whereas the risk increased to 100% when a patient was prescribed 20 or more medications (Doan 2013). In an another study of hospitalized elder adults taking 5 or more medications, the occurrence of a possible hepatic cytochrome enzyme-mediated, drug-drug interaction was 80%. In a study of community-living elderly adults, almost 50% of patients had a potential drug-drug interaction (Bjorkman et al. 2002). Drug-drug interactions are most common cause of preventable ADEs and medication-related hospitalizations (Juurlink et al. 2003). This results in prescribers to be cautious in prescribing medications for their patients especially elderly. Researches shows that the occurrence of drug-disease interactions is approximately 15-40% in weak elderly patients. Risk of drug-disease interactions are usually higher with the usage of increased numbers of medications (Juurlink et al. 2003). Healthcare providers have to be very careful in prescribing multiple drugs for elderly patients with chronic disease conditions in the view of drug interactions.
1.5.4 Medication Non-adherence:
Among elderly patients, non-adherence with drugs are always one of the major issues. Such non-adherence is related with complicated medication regimens and polypharmacy. Non-adherence rates in community living elderly adults has been reported to be between 43-100% (Vik et al. 2004). There is a large difference in the nonadherence rates with drugs. This may be as a result of different methods, tools, and thresholds for classifying adherence as well as the variety of populations studied. A study shows that the rate of patient nonadherence was 35% when a patient was taking 4 or more medications. Medication nonadherence is directly related to potential disease progression, treatment failure, hospitalization, and ADEs, all of which could be life-threatening (Rollason & Vogt 2003).
1.5.5 Functional Status:
Polypharmacy has been related to reduction in functionalities in older patients. In a detailed study of community-dwelling older adults, increase in prescribed medications use was significantly associated with reduced ability to perform instrumental activities of daily living (IADLs) and decreased physical functioning (Magaziner et al. 1989). Data from Women’s Health and Aging Study reports that use of 5 or more medications was associated with a reduced ability to perform IADLs (Rosso et al. 2013). A prospective cohort of almost 300 older adults found that patients taking 10 or more medications had diminished functional capacity and trouble performing daily tasks. As part of the Women’s Health Initiative Observational study, polypharmacy was associated with incident disability in older women (Rosso et al. 2013). In patients who have reported falling in the past year, higher medication use was found to be associated with functional decline (Stel et al. 2004). Prescribers should be aware of the risk of functional decline in patients taking multiple medications (Stel et al. 2004)
1.5.6 Cognitive Impairment:
Cognitive impairment is seen with both delirium and dementia and also its associated with polypharmacy. The study reported in hospitalized elderly people reported that the number of medications was a risk factor for delirium. In a prospective cohort study of 294 elders, 22% of the patients were taking 5 or less medications were found to have impaired cognition, whereas 33% of the patients were taking 6-9 medications and 54% of the patients were taking 10 or more medications (Jyrkka et al. 2010)
Falls are associated with increased morbidity and mortality in older adults and may be precipitated by certain medications. A study comparing patients who have not fallen compared to those who have fallen once and those multiple times, reported that the number of medications was associated with an increased risk of falls. A study in elderly adult outpatients as the number of medications increased, the falls risk index score increased and the duration of the one-leg standing test duration decreased (Kojima et al. 2011). In a prospective contingent study, the use of 4 or more medications was associated with increased risk of falling and the risk of recurrent falls (Tromp et al. 2001). A study in elderly patients with dementia reported that those patients who reported a fall had an increased prevalence of polypharmacy (Lee et al 2011). In a study of institutionalized older adults, the risk of experiencing a fall within the previous 30 days was by 7% for each additional medication (Damian 2013). Given the serious consequences of falls in older adults, caution should be used in prescribing new medications to those who are at risk of falling.
1.5.8 Urinary Incontinence:
Urinary indulgence is yet another problem that is associated with the use of multiple medications. In a population-based study of women aged 70 years and more, polypharmacy was associated with an increased risk of lower urinary tract symptoms (Nuotio et al. 2005). Many medications are known to worsen urinary indulgence; hence a medication review should be performed to evaluate both the number of medications as well as the specific type of medications a patient should be taking.
Polypharmacy has also been reported to affect a patient’s nutritional status. A prospective comparative study found that 50% of those taking 10 or more medications were found to be malnourished or at risk of malnourishment (Jyrkka et al. 2010). A survey of community-dwelling elderly people found that polypharmacy was associated with a reduced intake of fiber, fat soluble and B vitamins, and minerals as well as an increased intake of cholesterol, glucose, and sodium (Heuberger & Caudell 2011)
- Nurses Knowledge:
The nurse must be alert in assessing not only the effectiveness of a drug but also symptoms of toxicity from drug-drug interactions that are subtle in the elderly patients. Hence the knowledge of the clinical pharmacology of drugs, drug interactions, adverse side effects, and rational use of medications is very important for the nurses. Nurses are the primary ones in assisting patients to understand the risk associated with polypharmacy. Numerous incidents have been documented the key role of nurses in controlling polypharmacy especially among the elderly age group (Woodruff 2010). John et al. (2012) did a qualitative study on Nurse’s Knowledge and Clinical experience of Polypharmacy in Ajman. The study reveals that more than half of the nurses participated were not aware of the meaning of polypharmacy and the more experienced nurses answered with the alternative definition.
Due to the necessity to treat the different disease conditions polypharmacy will be prevailing. As a result of increase in such multiple medication usage, there will also be an increase in risk for health problems such as higher healthcare costs, ADEs, drug-interactions, medication nonadherence, decreased functional status and geriatric syndromes. Nurses as a key member of the multidisciplinary team in the health care system can play a vital role in preventing such problems related to polypharmacy. It is imperative to do a study on nurses’ knowledge on polypharmacy and prevalence in elderly care. This study will be aiming at meeting this need.
Chapter 2: Methodological Issues in Research
This chapter will focus on the methodological issues relevant to the research question. Research methods pertinent to assess the nurse’s knowledge in relation to polypharmacy and its prevalence in elderly care. This chapter also deals with the population, sample, selection criteria of sampling and study setting. In addition, this section provides details on establishing trustworthiness and ethical approval for this study.
The aim of this study is to assess nurse’s knowledge in relation on polypharmacy and its prevalence in elderly care.
- To describe the prevalence of polypharmacy effects in Irish nursing homes
- To elicit the knowledge of nurses regarding ill effects of polypharmacy among nursing residents
- To understand the perception of nurses regarding ill effects of polypharmacy among nursing residents
- To evaluate the effectiveness of selected nursing among nurses in the selected clinical setting
2.4 Research Question
- What are the ill effects of polypharmacy among geriatric nursing residents in Irish nursing homes?
- What is the knowledge perception of nurses regarding polypharmacy?
- How effective is the selected nursing in preventing the ill effects of polypharmacy among geriatric nursing residents in Irish nursing homes?
2.5 Research Methodology
According to Polit & Beck (2008), research methods are techniques that researchers are using to organise their study and to collect and analyse information significant to the research question. The data collection will be carried out through interviews with the staff nurses working with geriatric residents. The writer will use a focus group semi-structured interview agenda focusing on their experiences with poly pharmacy among geriatric residents.
According to Burns & Grove (1999) the goal of qualitative research is to explore the depth, richness, and complexity inherent in phenomena. A qualitative descriptive approach will be employed which includes data from experiences and situations taking account of the nurse’s knowledge in relation on poly pharmacy and its prevalence in elderly care (Gerrish & Lacey 2010). Qualitative descriptive method will allow participants to express their feelings, beliefs and behaviours completely and the data collected during qualitative study will be narrative (Polit & Beck 2013). For this study, the researcher will use qualitative method. In qualitative method, there will be a good relationship between researcher and participants (Polit & Beck 2013). The weakness of the methodology depends on the accuracy of the interpretation of the writer. Accuracy of the interpretation and reproduction of subjects’ views mainly depend upon the writer’s knowledge about the subject and the social background of the settings (Cormack 2000).
2.6 Population, Sample and Sampling:
Population can be defined as the total number of units with same features from which the data can be collected and a sample is the subset of the population (Parahoo 2014). The nurses working in the proposed nursing home is the target population. Sampling is the process of selecting a portion from the entire population for collecting data. Burns & Grove (1999) state that sampling is the key element of research methodology. The writer is proposing to conduct the study in four wards of a geriatric unit in one of the Dublin Academic Teaching Hospitals. The study will be conducted in 4 weeks time, a sample size of 12 registered nurses will be taken for the research purpose. Planned duration for the collection of data would be from end of January, February and March 2017.
2.6.1 Inclusion Criteria:
- Nurses working in the selected setting.
- Nurses who will be available for pre-test and post-test.
- Nurses who works both full and part time.
- Nurses who are able to fluently communicate, read and write English.
2.6.2 Exclusion Criteria:
- Nurses who are on Annual Leave/ Maternity/ Sick leave during the study period.
- Agency nurses who do not attend the facilities on a regular basis.
2.7 Study setting
The study will be conducted in the geriatric unit in one of the Dublin Academic Teaching Hospitals. Nurses working with the geriatric patients will be interviewed for the study. The time frame will be according to the nurse’s convenience and availability. Before commencement of this study, approval will be sought from the research ethics committee (Appendix 1). The permission from the Director of Nursing of the research site will be sought to conduct this study (Appendix 2). In addition to this, permission will be obtained from clinical nurse manager to conduct the study and for the use the education room as the interview room (Appendix 3). A demographic sheet of participant’s details such as age, identification number, gender, qualifications, number of years of experience will be prepared. After the proposed participants are listed out, the letter of invitation, which contains the information about the study, and a consent form will be posted to the participants, requesting them to return the signed consent form within two weeks (Appendix 4 & 5).
2.8 Data collection
Data will be collected using a semi-structured one-to-one interview which includes a combination of predetermined topics and open-ended questions, which will allow the participants to provide detailed and in-depth information of the events (Ellis 2010, Gerrish & Lacey 2010). Flexibility will be maintained in the interview to follow concerns and issues raised by participants that had not been expected. Control and direction of this type of interview is with researcher but will respond to the interviewee’s opinions. Semi-structured interviews are commonly used in qualitative studies (Gerrish & Lacey 2010, Karlsson et al. 2013). The interviews will be conducted in a comfortable environment in the nursing home where the participants work. During the interview a “do not disturb” sign will be placed on the door to avoid any disturbance. The interview will be recorded on audiotape with their permission and after finishing the interview, the recorded interview will be played back to each of the participant to ensure rigour. The researcher will ask for any clarifications of answers, so that important data will not be missed. Finally, all data collected will be stored in a locked cabinet in the researcher’s unit and data that is stored in the computer will be password protected. Researcher will maintain confidentiality strictly adhering to the Data Protection Act (Government of Ireland 2003).
2.9 Data Analysis
To analyse data from interview, the researcher will tape record the interaction and will transcribe the tape (Gerrish & Lacey 2010). The qualitative data analysis begins during data collection and the finding of all data collected relates to aspects of the phenomenon under study (Parahoo 2014). From the start of data collection, the emerging results will be noted down in the field notes after each interview. This will help for prompts in further questioning and as a back-up.
2.10 Pilot study:
There is a pilot study planned on the research. The pilot study is a preliminary study, which will help to find out whether the questions are appropriate and length of the interview takes (Polit & Beck 2013). The researcher intends to select two participants to conduct a pilot interview in the education room of the nursing home. The semi structured questionnaire will be given to two nurses to assess the existing knowledge (pre-test). Data collected in the pilot interview will not be included in the main study (Gerrish & Lacey 2010).
A set of nursing interventions will be provided which include:
- Booklet (different aspects of polypharmacy)
This will be conducted for four weeks with the same structured questions.
In qualitative research, the criteria for developing trustworthiness are credibility, transferability, dependability and conformability (Lincoln & Guba 1985).
Credibility means confidence in the truth or believability of the findings (Lincoln & Guba 1985). This will be established by allowing the participants to listen back to the recorded interview in order to increase their trust.
Transferability refers to the generalizability of the data, ie., the findings from the data can be transferred to other settings (Polit & Hungler 1999). The descriptive findings about the result of this study shall be made accessible to all readers. The findings of this context can be transferred to other relevant context by other researchers.
Dependability means the stability or reliability of the data (Polit & Hungler 1999). This study will be conducted in a consistent manner and accurate manner in all times. The researcher will transcribe all interviews and listen to the recorded tape repeatedly to reach a conclusion during the process of data analysis.
Conformability refers to the objectivity, ie., the interpretations of the data are accurate (Holloway & Wheeler 2010). The findings will reflect only the participants’ views and responses, not researcher’s assumptions or pre-conceptions. The readers can trace data to its original source. The openness and thoroughness in collecting the data and consideration of each and every data from each participant will ensure rigour (Burns & Grove 2010). At all times these criteria are aimed to be met.
2.12 Ethical considerations
Before starting the research, the ethics need to be considered because ethics can be challenging and sometimes conflict with the outcomes (Polit & Beck 2013). The researcher will request the ethical approval for the proposed study in writing from the Research ethical committee and from Director of Nursing. Those people are the gatekeepers, who control access to either participants or data (Gerrish & Lacey 2010).
The main ethical principles for protecting participants considered in conducting this research are beneficence, non-maleficence, respect for autonomy and justice.
The principle of beneficence imposes a duty to minimise harm and maximise benefits (Polit & Beck 2013). The principle of non-maleficence implies that the participants will be ensured with the right to freedom from discomfort in physical, psychological or emotional form. In the principle of respect for autonomy, participants will be allowed to make independent choice to sign the consent form. This consent form contains information about the research purpose, right to withdraw, confidentiality, right to ask questions and to refuse to disclose any kind of information.
The participants will have the right to be protected from exploitation, in a way that their identification and the information provided by the participants will not be disclosed to anyone without the participants’ consent. This also ensures trust and confidence between the researcher and participants. The findings in the final report will be the actual facts stated in the interview. The principle of justice includes the participant’s right to fair treatment and their right to privacy (Polit & Hungler 1999). The participant’s right to privacy will be adhered through anonymity by allocating an identification number. After the study is completed, it is planned to communicate with the participants by sending a thank you letter for their participation, along with final research report.
2.13 Limitations of the Study
The researcher understands that in this qualitative research, the sample size is limited. The nature of the study will make the findings difficult to generalise a large population. It will be time consuming to collect and analyse data in this qualitative study compared to quantitative study. But this qualitative study will provide a deep understanding and detailed description of the participant’s experience and perceptions.
This chapter discusses about the research design and methodology for use in the proposed study. A qualitative research method will be used to investigate the research objectives and question. A semi-structured interview shall be used to explore the nurse’s knowledge on poly pharmacy and prevalence in elderly patients.
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Appendix I – Letter to Research Committee
My name is ______________, currently taking Post Graduate Diploma in Gerontology. In part fulfilment of this course, I have to undertake a research study. My proposal is regarding the experiences of student nurses in geriatric nursing. I am writing to you to seek approval to conduct my study it in four geriatric ward of ___________ Long term care unit.
With this, I would like to do a focus interview on student nurses following their 4-week placement on the four wards from end week of January, February and March 2015. Interview session would take about 30-45 minutes. Participation is completely voluntary and anonymity is guaranteed throughout.
It is hoped that the result of the study will highlight the experiences of the student nurses. It is hoped that through this study we can also find ways in promoting geriatric area as a career to our future nurses.
Please don’t hesitate to contact me if you have any queries. I have attached the copy of my proposal for you and I welcome the opportunity to discuss this further with you.
Appendix II – Consent Letter
My name is ______________, currently taking Post Graduate Diploma in Gerontology. In part fulfillment of this course, I have to undertake a research study. My proposal is regarding the experiences of student nurses in geriatric nursing. I would like to ask for your co-operation in participating a focus group interview following your placement in __________ Long-term care unit. The date of the interview will be given to you by your preceptor. You can choose whether or not to participate in the focus group interview and stop at any time. Your responses will remain anonymous and no names will be mentioned in the report. There are no right or wrong answers to the focus group questions. I would like to hear many different viewpoints and would like to hear from everyone. Hope you can be honest even when your responses may not be in agreement with the rest of the group. In respect for each other, I would ask that only one individual speak at a time in the group. Interview session would last for about 30-45 minutes. All responses made by all participants be kept confidential. Pleases sign below if you understand this information and agree to participate fully under the conditions stated above. Thank you!
Signed: ____________________________________________ Date: __________________
Appendix III – Timescale
|Develop Research Questions and methodology|
|Collection of Research Materials|