N. Boussier1, M-E. Rougé-Bugat1,3, J. Dupouy1, A. Stillmunkès1, S. Bismuth1, Y. Rolland3, B. Vellas3, S. Oustric1
1. Universitary Department of General Practice, Paul Sabatier University; 133 route de Narbonne, 31062 Toulouse, France; 2. INSERM-Paul Sabatier University Unit 1027 ; 37 allées Jules Guesde ; 31000 Toulouse; 3. Gerontopôle, Toulouse, France. Corresponding author: Nathalie Boussier, General Practionner, Department of General Practice, 133 route de Narbonne, 31062 Toulouse, France, firstname.lastname@example.org
Background: Behavioural disorders or swallowing difficulties result in delivery of medication in crushed form for more than 30% of older people living in the community and 23% in the nursing home (NH). This practice can results in poor efficacy of the treatment. Based on the recommendations from the French National Authority for Health, general practitioners (GP) should be informed when their patient’s pills are crushed by the nurses. Our aim was to assess knowledge of general practitioner on medication delivered in crushed form to their patients in NH settings. Materials and method: A survey of practice was send in January and February 2013 to 63 coordinating physicians (CPs) working in 63 NH in the south of France. Self-administered questionnaire were sent. The subject of the questionnaire was information given to general practitioners (GPs) and medicine-crushing practices in NH. Results: Sixteen CPs (25.4%) agree to participate. Nine of them (56.3%) reported that they did not tell GPs about medicine crushing. Only one CP reported that his NH had a written protocol of information for GPs. However, no CP reported having a written protocol on medicine crushing. Only one CP reported that the reason for crushing medicine was systematically reported by the nurses of the NH in the charts. Conclusion: Despite national guidance, CPs reported that they did not frequently inform attending GPs when medicines were crushed.
Key words: Crushing pills, elderly patients, nursing home, general practitioner.
The estimate number of disabled patient will probably be around 1,200,000 in 2015 in France (1). In 2008, 515,000 were living in nursing home (NH) and this number is going to grow very fast in the coming years (2). The nursing home residents are often dependant, demented with a mean number of medications of eight. The general practitioners (GPs) must be sensitive to the risk of polypharmacy and inappropriate medication with these patients and must detect the frailty to adapt their prescriptions (3). In 2009, in this disabled population, 30 to 40% of the patient received their pills in a crushed form (4). Other authors have raised the poor quality of the administration of medicines and the inappropriately altered medication in nursing homes (5). Swallowing difficulties and behavioural disorders are reported to be the two main reasons for medicine crushing (4). Unfortunately 42% of crushed medicines are uncrushable-medication. Inappropriate-technique and food-drug interactions have also been reported (6).
Medicine crushing can be dangerous (7). It is an important risk factor for medication administration errors and increases the risk of side-effects such as falls (8, 9). Drug-nutrient interactions can occur, especially in the elderly (10). Crushing different medicines together can result in drug-drug interactions which would not occur if those medicines were administered simultaneously but without being crushed. These drug-drug interactions have been described among 138 residents living in two NH by Tamai and al. They identified 24 suspected cases of drug-drug interaction, of which 11 altered the metabolism or action of at least one medicine (11). When a single crusher/grinder is used for the residents, a significant risk of interaction between multiple patients’ drugs exist (11).
To improve medication administration in NH residents, the French Health Authority has edited in 2010 national recommendations on medicine crushing (12) (Table 1). The recommendations advocate that medicines should be crushed separately from one another, that crushed medicines should be administered in a neutral vehicle (iced water) rather than mixed into nutrients, and that only one piece of crushing/grinding equipment per patient should be used (12). GPs should be aware of the risks associated with this practice and informed by the CPs of the NHs to adapt their prescriptions. Since these recommendations, no study has investigated whether the information related to medicine crushing in NH are communicated to the GPs.
The aim of our study was to describe the information given to the GPs by CPs when medicines are crushed and to describe NH’ medicine-crushing practices.
Material and methods
A survey was carried out among CPs working in the South West of France (Toulouse area) to a sample of 63 CPs. CPs are in France in charge of coordinating the geriatrics domains of the NH (comprehensive geriatric assessment, geriatric training of the team, prevention, coordination with the GPs). They have a geriatric training. CPs are not in charge of the prescription but have to improve medication of the resident on coordination with the GPs. Communication and training of the GP is an important aspect of their mission.
A panel of 63 CP members of an independent medical association dedicated to the medical training in geriatrics and NH care was investigated. A self-administered questionnaire was sent by email in January 2013 in Toulouse area. The questionnaire had to be completed and returned before the 7th March 2013. Data were then extracted and analyzed using Excel 2010.
The CP fulfilled a self-administrated questionnaire of 16 questions. The CPs were asked about the information given to the GPs about medicine-crushing practices according to the national recommendations such as ‘Is the patient’s GP informed when a medication is crushed/ground?’ (always – often – seldom – never). Various dichotomic questions (yes/no) were also asked about the practice of crushing pills. CPs were also asked to reported the age of the residents in their NH, their level of disability, the percentage of residents with crushed medication, the number of crushed medication among the all prescription of each residents and whether they known the type of equipment used to crush medicines (examples of various crushing/grinding devices were proposed in photo Figure 1). Number of GPs working in NH was also reported.
a- Source: Silent Knight mechanical tablet crusher. armen-sante.com; b- Source: SEVERO electric medicine grinder. severo.biz; c- Source: Manual tablet crusher. msmedical.net; d- Source: Pestle. la-carpe.com
Sixteen responses were received and analyzed, giving a response rate of 25.4%. Ten CPs out of a total of 16 respondents were men.
Practices of crushing medicine
Information concerning 1187 nursing home residents were collected. Based on CPs answers, middle age of the residents was 83.5 (SD=9) and more than half were severely disabled based on the French GIR scale (Groupe Iso-Ressouces, the French scale used for funding of the nursing home).The mean number of GP per NH was 18 (SD = 12). The CPs reported that 23% (SD=3; min=3%; max=51%) of the residents had their medicines crushed. The mean number of medication crushed per resident was 4 (SD=3; min=1 max=12).
Details about the information about medicine crushing are presented in Table 2.
Information given to GPs
Nine out of 16 CPs (56%) reported that they seldom or never informed attending physicians when medicines had to be crushed. Seven CPs (44%) reported that they often informed attending GPs. None of the CP reported that attending physicians were systematically informed. Only one CP reported that they had a written protocol to inform the GPs; in that NH, the CP did not report that attending GPs were systematically informed of this.
Our study suggested that crushing medicine practice is often performed for NH residents and poorly reported to the prescribers.
Previous study has reported a high rate of crushing medicine practice in institution of care. In the United Kingdom, Stubbs et al. reported in unit of geriatric psychiatry that 26% of the medicines were crushed and that 44% of these crushed medicines were crushed without the prescriber’s approval (13). The same findings are reported in our study. About one to four resident had their medicines crushed.
A recent Norwegian study reported that in a sample of 2108 NH patients across 65 NH, 23% had at least one crushed drug. These drugs are mainly mixed into food or drink and 10% of the residents had at least one non-crushable drug crushed (5). Our study did not investigated the details of the delivery approach but the rate of crushed medicine is similar.
The lack of information to the GP about medicine crushing in the NH and the poor impact of the current national recommendations on medicine crushing rise several comments: First, both drug-drug interactions may results in adverse health events and eventually in legal concerns for medical staff. Indeed, in theory, the recommendations support that health workers (e.g. doctors and nurses) are legally obliged to justify why medicines are crushed (14). Second, regular contact with medicines has been reported to lead to contact allergies in nursing home staff (15). Drug-drug interaction among the residents and contact allergies among the NH staff, related to the crushed medicine may be underestimated. Cutaneous allergies to tetrazepam after administering this medicine in crushed form have been recently reported from nurses (16).
Our result supports that this frequent and sometime unavoidable practice should be perform with caution and improved in its procedure. Reducing this practice when inappropriate should be the first step. An interventional study conducted in the Netherlands showed that implementing a protocol in NH on medicine crushing for residents with swallowing difficulties reduced the number of errors involving the crushing of non-crushable medicines by 63% (6). In 2000, an Australian study concluded that recommendations on medicine crushing were required in retirement homes (17). Another study showed that an educational intervention on drug use in NH reduced the risk of delirium, falls and reduced the use of health care resources (18). Our study suggests that recommendations are not sufficient. Written protocol and communication between prescribers and nurses are also required. In 2005, a Dutch study showed that regular meetings between GPs and coordinating physicians made it easier for patient information to be exchanged (19). More implication of the pharmacies is probably a relevant option. The adoption of such measures would allow drug prescriptions to be better tailored to patient needs.
Conflict of interest: The authors have no conflict of interests to declare.
1. Lécroart A. Projections du nombre de bénéficiaires de l’APA en France à l’horizon 2040-2060 – Sources, méthode et résultats. DREES, No. 23, September 2011
2. Chazal J, Perrin-Haynes J. L’hébergement offert en établissements pour personnes âgées. Dossier Solidarité et Santé, DREES, No. 29, June 2012.
3. Fialová D1, Topinková E, Gambassi G et al. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 2005 Mar 16;293(11):1348-58.
4. Caussin M, Mourier W, Philippe S et al. Crushing drugs in geriatric units: an «handicraft» practice with frequent errors which imposed recommendations. Rev Med Interne. 2012 Oct; 33(10):546-51.
5. Kirkevold O, Engedal K. What is the matter with crushing pills and opening capsules ? Int J Nurs Pract 2010; 16:81-5.
6. Stuijt CC, Klopotowska JE, van Driel CK, Le N et al. Improving medication administration in nursing home residents with swallowing difficulties: sustainability of the effect of a multifaceted medication safety programme. Pharmacoepidemiology and drug safety 2013; 22: 423-429.
7. Gill D, Spain M, Edlund BJ. Crushing or splitting medications: unrecognized hazards. J Gerontol Nurs. 2012 Jan;38(1):8-12.
8. Morley JE, Abbatecola AM, Argiles JM, Baracos V et al. Sarcopenia with limited mobility: an international consensus. J Am Med Dir Assoc. 2011 Jul;12(6):403-9.
9. Fielding RA, Vellas B, Evans WJ, Bhasin S et al. Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56.
10. Roe DA. Therapeutic effects of drug-nutrient interactions in the elderly. J Am Diet Assoc.1985;85:174-8, 181.
11. Tamai IY, Strome LS, Marshall CE, Mooradian AD. Analysis of drug-drug interactions among nursing home residents. Am J Hosp Pharm 1989; 46: 1567-9.
12. website : www.has-sante.fr. Accessed December 15, 2010. Recommandations sur l’écrasement des médicaments en Gériatrie.
13. Stubbs J, Haw C, Dickens G. Dose form modification – a common but potentially hazardous practice. A literature review and study of medication administration to older psychiatric inpatients. Int Psychogeriatr 2008;20:616-27.
14. Griffith R, Davies R. Tablet crushing and the law: the implications for nursing. Prof Nurse 2003;19:41-2.
15. Gielen K, Goossens A. Occupational allergic contact dermatitis from drugs in healthcare workers. Contact Dermatitis 2001;45:273-9.
16. Vander Hulst K, Kerre S, Goossens A. Occupational allergic contact dermatitis from tetrazepam in nurses. Contact Dermatitis 2010; 62: 303-8.
17. Barnes L, Cheek J, Nation RL, Gilbert A et al. Making sure the residents get their tablets: medication administration in care homes for older people. J Adv Nurs 2006; 56:190-9.
18. García-Gollarte F, Baleriola-Júlvez J, Ferrero-López I, Cuenllas-Díaz A et al. An Educational Intervention on Drug Use in Nursing Homes Improves Health Outcomes Resource Utilization and Reduces Inappropriate Drug Prescription. J Am Med Dir Assoc. 2014 May 31.
19. Schols JM, de Veer AJ. Information exchange between general practitioner and nursing home physician in The Netherlands. J Am Med Dir Assoc. 2005 May-Jun;6(3):219-25.