Background/Aims: Old age and institutionalization in care homes are associated with increased use of risk medications affecting the central nervous system (CNS). This study evaluated medication utilization and appropriateness; and assessed frailty among residents of Malaysian aged care homes. Methods: The subjects of this study included 202 elderly (≥65 years) residents of 17 aged care homes in suburban peninsular Malaysia. Frailty was measured using the Groningen Frailty Indicator (GFI) score and independence in daily living was measured as KATZ activity of daily living score. Medication appropriateness was assessed using the Medication Appropriateness Index (MAI) and 2015 Beers' criteria for Potentially Inappropriate Medication (PIM). Results: CNS medications constituted about 16% of the total, with an average of 0.8 ± 1.1 medications per resident, which reduced to 0.5 ± 0.8 medications after 3 months. Frailty (154/202) and polypharmacy (90/202) were highly prevalent in study subjects. Subjects on CNS medications had significantly higher GFI score (7.1 vs. 5.9; p = 0.031), polypharmacy (57.8 vs. 35.3%; p = 0.002), number of PIMs (0.9 vs. 0.2; p = 0.001), and mean summed MAI score (3.6 vs. 2.6; p = 0.015) than subjects not on CNS medications. Medication number was also significantly correlated with GFI (r = 0.194; p = 0.006) and KATZ (r = 0.141; p = 0.046) scores. Conclusion: Frailty and polypharmacy were highly prevalent among aged care home subjects taking CNS medications. These findings support the notion that periodic regular medication review should improve the overall use of medications in elderly patients.

Scobie J: Global Age Watch Index 2015. London, Help Age International, 2015.
Gellis ZD, McGinty J, Horowitz A, Bruce ML, Misener E: Problem-solving therapy for late-life depression in home care: a randomized field trial. Am J Geriatr Psychiatry 2007;15:968-978.
Hogan DB, Freiheit EA, Strain LA, Patten SB, Schmaltz HN, Rolfson D, et al: Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living. BMC Geriatr 2012;12:56.
DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD: Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. Am J Psychiatry 1999;156:1007-1013.
Morley J, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al: Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392-397.
Cole MG, Bellavance F, Mansour A: Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis. Am J Psychiatry 1999;156:1182-1189.
Mulsant BH, Ganguli M: Epidemiology and diagnosis of depression in late life. J Clin Psychiatry 1999;60:9-15.
Bryant C, Jackson H, Ames D: The prevalence of anxiety in older adults: methodological issues and a review of the literature. J Affect Disord 2008;109:233-250.
Wolitzky-Taylor KB, Castriotta N, Lenze EJ, Stanley MA, Craske MG: Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 2010;27:190-211.
Lenze EJ, Wetherell JL: A lifespan view of anxiety disorders. Dialogues Clin Neurosci 2011;13:381-99.
Seitz D, Purandare N, Conn D: Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. Int Psychogeriatr 2010;22:1025-1039.
Lustenberger I, Schüpbach B, von Gunten A, Mosimann U: Psychotropic medication use in Swiss nursing homes. Swiss Med Wkly 2011;141:w13254.
Neikrug AB, Ancoli-Israel S: Sleep disturbances in nursing homes. J Nutr Health Aging 2010;14:207-211.
Cardwell K, Hughes CM, Ryan C: The association between anticholinergic medication burden and health related outcomes in the “oldest old”: a systematic review of the literature. Drugs Aging 2015;32:835-848.
Sumukadas D, McMurdo ME, Mangoni AA, Guthrie B: Temporal trends in anticholinergic medication prescription in older people: repeated cross-sectional analysis of population prescribing data. Age Ageing 2014;43:515-521.
Steinman MA, Landefeld CS, Rosenthal GE, Berthenthal D, Sen S, Kaboli PJ: Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 2006;54:1516-1523.
Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al: A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992;45:1045-1051.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel: American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015;63:2227-2246.
O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P: STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 2015;44:213-218.
Lau DT, Kasper JD, Potter DE, Lyles A: Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics. Health Serv Res 2004;39:1257-1276.
Fougère B, Kelaiditi E, Hoogendijk EO, Demougeot L, Dudouné M, Vellas B, et al: Frailty index and quality of life in nursing home residents: results from INCUR study. J Gerontol A Biol Sci Med Sci 2016;71:420-424.
Buckinx F, Reginster J, Petermans J, Croisier JL, Beaudart C, Brunois T, et al: Relationship between frailty, physical performance and quality of life among nursing home residents: the SENIOR cohort. Aging Clin Exp Res 2016;28:1149-1157.
Handajani YS, Widjaja NT, Turana Y: Frailty decreases physical health domain of quality of life in nursing home elderly. Univ Med 2015;34:213-219.
Kanwar A, Singh M, Lennon R, Ghanta K, McNallan SM, Roger VL: Frailty and health-related quality of life among residents of long-term care facilities. J Aging Health 2013;25:792-802.
Tse MM, Lai C, Lui JY, Kwong E, Yeung SY: Frailty, pain and psychological variables among older adults living in Hong Kong nursing homes: can we do better to address multimorbidities? J Psychiatr Ment Health Nurs 2016;23:303-311.
Lwanga SK, Lemeshow S: Sample Size Determination in Health Studies: A Practical Manual. Geneva, World Health Organization, 1991.
Draugalis JR, Plaza CM: Best practices for survey research reports revisited: Implications of target population, probability sampling, and response rate. Am J Pharm Educ 2009;73:142.
Steverink N, Slaets JPJ, Schuurmans H, van Lis M: Measuring frailty: development and testing of the Groningen Frailty Indicator (GFI). Gerontologist 2001;41:236-237.
Bielderman A, van der Schans CP, van Lieshout MR, de Greef MH, Boersma F, Krijnen WP, et al: Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people. BMC Geriatr 2013;13:86.
Daniels R, van Rossum E, Beurskens A, van den Heuvel W, de Witte L: The predictive validity of three self-report screening instruments for identifying frail older people in the community. BMC Public Health 2012;12:69.
Hoogendijk EO, van der Horst HE, Deeg DJ, Frijters DH, Prins BA, Jansen AP, et al: The identification of frail older adults in primary care: comparing the accuracy of five simple instruments. Age Ageing 2013;42:262-265.
Metzelthin SF, Daniëls R, van Rossum E, de Witte L, van den Heuvel WJ, Kempen GI: The psychometric properties of three self-report screening instruments for identifying frail older people in the community. BMC Public Health 2010;10:176.
Peters LL, Boter H, Buskens E, Slaets JP: Measurement properties of the Groningen frailty indicator in home-dwelling and institutionalized elderly people. J Am Med Dir Assoc 2012;13:546-551.
Schuurmans H, Steverink N, Lindenberg S, Frieswijk N, Slaets JP: Old or frail: what tells us more? J Gerontol A Biol Sci Med Sci 2004;59:M962-M965.
Smets IH, Kempen GI, Janssen-Heijnen ML, Deckx L, Buntinx FJ, van den Akker M: Four screening instruments for frailty in older patients with and without cancer: a diagnostic study. BMC Geriatr 2014;14:26.
Tegels JJ, de Maat MF, Hulsewe KW, Hoofwijk AG, Stoot JH: Value of geriatric frailty and nutritional status assessment in predicting postoperative mortality in gastric cancer surgery. J Gastrointest Surg 2014;18:439-445.
Peters LL, Boter H, Burgerhof JG, Slaets JP, Buskens E: Construct validity of the Groningen Frailty Indicator established in a large sample of home-dwelling elderly persons: evidence of stability across age and gender. Exp Gerontol 2015;69:129-141.
Bowling A, Stenner P: Which measure of quality of life performs best in older age? A comparison of the OPQOL, CASP-19 and WHOQOL-OLD. J Epidemiol Community Health 2011;65:273-280.
Kassam R, Martin LG, Farris KB: Reliability of a modified medication appropriateness index in community pharmacies. Ann Pharmacother 2003;37:40-46.
Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, et al: A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 1994;47:891-896.
Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-370.
Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM: A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997;27:363-370.
Rustøen T, Wahl AK, Hanestad BR, Lerdal A, Paul S, Miaskowski C: Age and the experience of chronic pain: differences in health and quality of life among younger, middle-aged, and older adults. Clin J Pain 2005;21:513-523.
Friedman MM: Gender differences in the health related quality of life of older adults with heart failure. Heart Lung 2003;32:320-327.
Hasche LK, Morrow-Howell N, Proctor EK: Quality of life outcomes for depressed and nondepressed older adults in community long-term care. Am J Geriatr Psychiatry 2010;18:544-553.
Awad AG, Voruganti LN: Impact of atypical antipsychotics on quality of life in patients with schizophrenia. CNS Drugs 2004;18:877-893.
Martinez-Martin P, Rodriguez-Blazquez C, Forjaz MJ, Kurtis MM: Impact of pharmacotherapy on quality of life in patients with Parkinson's disease. CNS Drugs 2015;29:397-413.
Kojima G: Prevalence of frailty in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc 2015;16:940-945.
Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M: Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997;31:529-533.
Lund BC, Carnahan RM, Egge JA, Chrischilles EA, Kaboli PJ: Inappropriate prescribing predicts adverse drug events in older adults. Ann Pharmacother 2010;44:957-963.
Hanlon JT, Sloane RJ, Pieper CF, Schmader KE: Association of adverse drug reactions with drug-drug and drug-disease interactions in frail older outpatients. Age Ageing 2011;40:274-277.
Chen LL, Tangiisuran B, Shafie AA, Hassali MA: Evaluation of potentially inappropriate medications among older residents of Malaysian nursing homes. Int J Clin Pharm 2012;34:596-603.
Hanlon JT, Schmader KE: The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging 2013;30:893-900.
Steinman MA, Rosenthal GE, Landefeld CS, Bertenthal D, Sen S, Kaboli PJ: Conflicts and concordance between measures of medication prescribing quality. Med Care 2007;45:95-99.
Hartikainen S, Mantyselka P, Louhivuori-Laako K, Enlund H, Sulkava R: Concomitant use of analgesics and psychotropics in home-dwelling elderly People-Kuopio 75 + study. Br J Clin Pharmacol 2005;60:306-310.
Hajjar E, Hanlon JT: Polypharmacy in the elderly; in; Calhoun K, Eibling DE (eds): Geriatric Otolaryngology . London, UK, Informa Healthcare, 2006, pp 667-673.
Simoni-Wastila L, Wei YJ, Luong M, Franey C, Huang TY, Rattinger GB, et al: Quality of psychopharmacological medication use in nursing home residents. Res Social Adm Pharm 2014;10:494-507.
Leow JB, Pont L, Low LF: Effect of humour therapy on psychotropic medication use in nursing homes. Australas J Ageing 2016;35:E7-E12.
Nolan L, O'Malley K: The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Ageing 1989;18:52-56.
Azermai M, Elseviers M, Petrovic M, Van Bortel L, Vander Stichele R: Geriatric drug utilisation of psychotropics in Belgian nursing homes. Hum Psychopharmacol 2011;26:12-20.
Bell JS, Taipale HT, Soini H, Pitkälä KH: Prognostic value of the quality indicator “concurrent use of three or more psychotropic drugs” among residents of long-term-care facilities. Eur J Clin Pharmacol 2009;65:1163-1164.
Schmidt I, Claesson CB, Westerholm B, Nilsson LG, Svarstad BL: The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc 1998;46:77-82.
Gulla C, Selbaek G, Flo E, Kjome R, Kirkevold Ø, Husebo BS: Multi-psychotropic drug prescription and the association to neuropsychiatric symptoms in three Norwegian nursing home cohorts between 2004 and 2011. BMC Geriatrics 2016;16:115.
Olazarán J, Valle D, Serra JA, Cano P, Muñiz R: Psychotropic medications and falls in nursing homes: a cross-sectional study. J Am Med Dir Assoc 2013;14:213-217.
Cool C, Cestac P, Laborde C, Lebaudy C, Rouch L, Lepage B, et al: Potentially inappropriate drug prescribing and associated factors in nursing homes. J Am Med Dir Assoc 2014;15:850.e1-e9.
Ruths S, Sorensen PH, Kirkevold O, Husebo BS, Kruger K, Halvorsen KH, et al: Trends in psychotropic drug prescribing in Norwegian nursing homes from 1997 to 2009: a comparison of six cohorts. Int J Geriatr Psychiatry 2013;28:868-876.
Wright RM, Roumani YF, Boudreau R, Newman AB, Ruby CM, Studenski SA, et al: Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: findings from the Health, Aging and Body Composition Study. J Am Geriatr Soc 2009;57:243-250.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.