Mansfield et al., 1999) or more haphazard withdrawal or substitution (Zullich et al., 1993).

Underutilization of Medications

A few studies have considered underutilization of medications in long-term care, that is, failure to prescribe or administer medications for which there is an evidence base for reduction of morbidity and mortality and a best-practice designation (see Table C-9). Economic restrictions on medication acquisition could be a factor in the underutilization rates quoted below.

A retrospective study of 2,014 residents over age 65 from a stratified random sample of 193 assisted-living facilities in four U.S. states demonstrated that underutilization of medications was common (Sloane et al., 2004). Of 328 residents with congestive heart failure, 62 percent were not receiving an ACE inhibitor; of 172 subjects with a history of myocardial infarction, 60.5 percent were not receiving aspirin, and 76 percent were not receiving beta-blockers; of 435 residents with a history of stroke, 37.5 percent were not receiving an anticoagulant or antiplatelet product; and of 315 residents with osteoporosis, 61 percent were not receiving calcium supplementation, and 51 percent were not receiving any treatment.

In another retrospective review of the records of 2,587 nursing home residents, only 53 percent of ideal candidates with atrial fibrillation were receiving warfarin. The therapeutic international normalized ratio (INR) range was maintained only 51 percent of the time (McCormick et al., 2001).

In a Dutch study (van Dijk et al., 2003), the most common prescribing problem was omission of a gastroprotective drug, which occurred in 85 percent of residents taking nonsteroidal anti-inflammatory drugs (NSAIDs). Using judgments of an expert review panel, Ruths and colleagues identified underuse of beneficial therapy in 13 percent of residents in 23 nursing homes in Norway (Ruths et al., 2003).

Studies using the SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) database that linked information from the Minimum Data Set (MDS) and nursing home drug utilization data showed that only 25 percent of 86,094 nursing home residents with congestive heart failure were prescribed an ACE inhibitor (Gambassi et al., 2000). Another study using SAGE data showed that only 55 percent of residents identified as depressed based on the MDS received antidepressants, and 35 percent of those received less than the manufacturer’s recommended dose (Brown et al., 2002), although underdosing may be appropriate for more frail elderly adults.

Inadequate pain management is a well-documented example of under-utilization of medication, with 45–80 percent of nursing home residents

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