Aging of the population or steady increases in life expectancy bring with them an increase in medical conditions characteristic of older persons, such as cardiovascular disease, degenerative diseases and cancer. In addition, the epidemiological profile of the population is changing, and diseases that were previously lethal are now associated with high survival rates.1 Moreover, changes in lifestyle in our society--changes are making it increasingly hard to care for older persons at home. As a result the number of persons living in nursing homes is growing. Primary care is increasingly concerned with the care of older people, as seen at the most recent congress of the Spanish Society of Family and Community Medicine.2
The article by Sicras Mainar and colleagues3 reports on the challenging approach--a quasi-experimental multicenter study--these authors used to examine improvements in appropriate drug prescribing practices. Although the authors themselves note the potential methodological limitations of their study to lie in the composition of the intervention and control groups, nonrandom assignment, and differences in the type (public or private) of nursing home, their study is undoubtedly an excellent addition to the scant number of publications on the topic in Spain.
The intervention carried out by the Pharmacy Unit of the Barcelonés Norte and Maresme health region comprised a combination of feedback with printed materials, periodic reminders and methods based on personalized interviews. At the present time, combined strategies such as that used by Sicras Mainer and colleagues are the types of intervention that have yielded evidence of the best results.4
The need to optimize pharmacotherapy for older persons is urgent. Excessive medication can affect quality of life in a direct manner, through redundant or unnecessary medication, and indirectly through iatrogenic effects. Other sources of problems are drug interactions, side effects, noncompliance with treatment and self-medication. These problems related with use of medications have been shown to be worse in older patients living in retirement or nursing homes.
To measure the results of their intervention, Sicras Mainar and colleagues used indicators that are common in primary care to measure general features of prescribing, such as the proportion of generic pharmaceutical specialties and the use of drugs with high intrinsic pharmacological value, along with specific indicators for groups of drugs used to treat respiratory illness, analgesics and antibacterials, and to measure choice of drug or relative drug use. The authors also included quantitative indicators for the use of drugs to treat peptic ulcer, antidepressants and antihypertensives. Another recent study of indicators of prescribing practices in retirement homes looked at these groups of drugs but also tracked prescriptions for benzodiazepines and hypnotics, which are widely used for older patients. This study also investigated compliance of prescribing practices with the recommendations in the health service formulary.5
In this case the authors based the choice of indicators on the Guía Farmacoterapéutica Marco (Pharmacotherapeutic Guideline Framework) for residential nursing homes, an indispensable document for any type of intervention, and of fundamental importance, moreover, for clinical decision-making by clinicians who care for older persons. These guidelines were prepared by several autonomous communities, i.e., Valencia, the Basque Country, and Madrid. In the United Kingdom, the National Health Service has developed a National Service Framework for Older People which includes a specific document that aims to improve the use of medications in this population.6
In addition to the importance of medications, the authors drew attention to the importance of other medical care products in this population, in which more than one-third of the costs are for urinary incontinence products. Simple management interventions have the potential here for important repercussions on efficiency.
One element that comes to the fore in the discussion section of this article is the potential limitation imposed by the fact that prescriptions were reviewed, but the reasons that motivated the prescriptions in the first place were not examined. Undoubtedly, aside from the issues noted above, additional work is needed in efforts to improve care for older patients. Such efforts may include automatization of prescription ordering and fulfillment, the integration of care for medical conditions common in older patients into the services provided by primary care centers, and a system to make medical records available at primary care centers (whether or not nursing and primary care centers are to be amalgamated). Moreover, additional support is needed for therapeutic services provided through programs for integrated pharmacotherapeutic care at residential facilities for older persons. In this area the experience of primary care pharmacists offers the potential to optimize and enhance prescribing practices, as shown in the article by Sicras Mainar and colleagues. This is clearly an important issue that is bound to have important consequences for the care of older persons and their quality of life.
