Introduction
Method
Results
Discussion
Conclusion
References

Introduction

The quality of care provided in nursing homes comes under regular scrutiny. At the present time, the majority of care for residents in care facilities is delivered by GPs.1 Improving access to general practice through redesigning services and investing in general practice are key-stones of the NHS five-year forward view recommendations2, but recent British Medical Association work has noted that there are significant variations to the implementation of this programme in particular when considering care provision to vulnerable adults including those in care and residential homes.3

Patients usually remain with their own GP when then move into a care home when the home remains in the GP practice area. A common expectation is that GPs are readily available to deliver primary care led services (including acute and chronic disease care, anticipatory care planning) within the nursing home environment. This commonly involves ad-hoc nursing home visits, which can provide a suboptimal use of clinical time. Such approaches to care provision have limitations. Indeed, the NHS five-year forward view2 reports that both the Care Quality Commission and British Geriatrics Society have shown that many people with dementia living in care homes are not getting their health needs regularly assessed and met, with one unfortunate consequence being avoidable admissions to hospital.

There are a range of innovative models of medical care which are emerging across the UK, which have the potential to improve the standard of care provided in homes, reduced secondary care admissions but only are delivered in a minority of areas.4 

This study aimed to establish the characteristics of the current nursing home resident population and review the reasons for nursing homes requesting GP visits over a 4-month period within a Scottish GP practice. The aim of such work was to use this to develop and enhance future care.

Methods

GP service characteristics & current model of nursing home provision

The Lomond Practice is one of the five practices providing primary care services to the population of Glenrothes, and also includes a branch practice in Cardenden. The practice serves approximately 10,400 patients in a densely populated town with marked deprivation, based upon the Scottish Index of Multiple Deprivation Quintile.5 The SIMD is based upon information from major population surveys in Scotland and allows comparison between the most deprived and the rest of the population in Scotland in numerous domains.

The current model of care for nursing home patients is that nursing homes request home visits as they feel indicated. These calls are triaged by a duty nurse and the visit is added to the on the day home visits with a reason for review noted. There may be further triage by the doctor requested to visit the patient. All home visits were performed by a GP or GP trainee during the period of study. Each resident has a named GP, and will have chronic disease care provided as part of the normal systems for primary care follow-up. The local pharmacy team perform medication reviews as part of locally enhanced service policies. Other anticipatory care planning arises is performed on an ad-hoc basis.

There are four nursing homes within the boundary of the practice where general medical services are provided, three within Glenrothes and one within Cardenden. These provide similar level of care and support for patients with frailty, multi-morbidity and requirement for 24-hour care. Lomond Practice also provides coverage for temporary patients admitted to any of these four homes for respite care, and those residing within nursing homes for short periods after a hospital admission during ‘re-ablement’ programmes.

Data collection

Clinical information was obtained from the EMIS GP practice system. This system is the basis for all routinely collected clinical data in the practice, and is accessed through protected security processes.

Data for nursing patients on the Lomond Practice patient list in April 2019 was gathered, including baseline patient characteristics (age, gender) resuscitation status, patient diagnoses, and prescribing data. Any face-to-face or over-the-phone contact regarding patient health was noted if within the previous 3-months. Patients were not separated into different groups based upon nursing home due to the small numbers of patients residing in some of the homes.

Patient diagnoses were recorded, and collated into broader categories. For example, diagnoses of ischaemic heart disease and hypertension were collated into a cardiovascular category. Appendix 1 summarises the diagnoses within each category. Patients were assessed to see whether they met the criteria for being multi-morbid (>= 2 chronic medical conditions). This definition of multi-morbidity is well validated and provides the baseline for the new NICE guideline on multi-morbidity.6

Full list of diagnoses within collated diagnosis groups

 

Cardiovascular Disease

Ischemic heart disease, Peripheral vascular disease, Angina pectoris, Hypertension

Respiratory Disease

Chronic obstructive pulmonary disease, Chronic obstructive airways disease, Asthma

        Musculoskeletal & Rheumatological (%)

Osteoarthritis, Rheumatoid arthritis, Polymyalgia rheumatic, Gout

Stroke & Neurological Conditions (%)

Cerebrovascular disease (cerebrovascular accident / Transient ischemic attack), Parkinsons disease,  Myasthenia gravis

Diagnosis of Malignancy

All forms of malignant cancer diagnoses

Diagnosed Frailty

Refers to an EMIS coding of frailty (subjective assessment by primary care physician)

Chronic Kidney Disease 3, 4 or 5

Chronic Kidney Disease 3a, 3b, 4 or 5

Psychiatric Disorders and Dementia

Multi-infarct dementia, Vascular dementia, Alzheimers disease, Lewy Body Dementia, Depression, Anxiety and Neurosis, Bipolar affective disorder

 Gastrointestinal Diagnoses

Diverticular disease and associated states, Chronic constipation, Irritable bowel syndrome, Inflammatory bowel disease

Diabetes Mellitus 1 and 2

Diabetes mellitus 1 and Diabetes mellitus 2

 

Patient prescribing data was reviewed and the total number of medications recorded, alongside medication groups of interest. These medication groups included antipsychotics, anxiolytics/hypnotics, antidepressants, statins, anticoagulants, anti-platelets and drugs prescribed in dementia. These groups of medications were recorded in line with British National Formulary (BNF) medication classification.7

Information from nursing home visits between January 2019 to April 2019 was collected. This information is readily available in the practice home visit list. The listed reason for requesting a home visit from the home was recorded, and medical notes were reviewed to establish whether the visit was urgent and required same day assessment. The reason for clinician visit were recorded, and collected into broader categories. For example, ‘chesty’ and ‘productive cough’ were collated into chest infection. Information regarding resuscitation status was collected from the patient summary sheet.

This study was deemed not to require ethical approval as it entailed analysis of routinely collected clinical data and has been performed as part of quality improvement within the practice.

Results

The total practice list size was 10,441 as of the January 1st 2019. There are four care/nursing homes where clinical services are delivered by the practice.

There were 62 permanent patients residing within these four homes, 12 males and 50 females, which is 0.6% of the practice list. These patients had an average age of 83.62 years, and were all multi-morbid. 49 patients (79%) had required face to face or over the phone consultation with a GP or nursing member of staff within the preceding 3 months. Full characteristics of patient cohort is summarised in Table 1.

The most common medical conditions within the cohort were cardiovascular disease (67.7%), psychiatric disorders and dementia (64.5%) and musculoskeletal and rheumatological conditions (58.1%). Patients were prescribed medications from a preventative perspective, with 19 patients (30.6%) prescribed statins, and 22 patients (35.5%) of patients prescribed a anti-platelet agent. Prescription of psychotropic medications included 7 patients prescribed antipsychotics (11.3%), 39 patients prescribed antidepressants (63%), and 6 patients prescribed anxiolytic / hypnotic medications (9.7%).

  

Table 1 – Characteristics of the overall nursing home cohort

Characteristics

Cohort as a Whole

n= 62

Mean Age (years) (SD)

 

83.62 (7.7)

Male Sex (%)

 

 12 (22.6)

                     Multi-morbidity Criteria (%)

62 (100)

        Contact with Practice within 3 months (%)

49 (79)

Do Not Attempt Resuscitation Form Completion (%)

18 (29)

Median Number of Prescribed Medications [IQR]

8 [5-11]

Prescribed Antipsychotic (%)

7 (11.3)

Prescribed Anxiolytic / Hypnotic (%)

6 (9.7)

Prescribed Antidepressant (%)

39 (63)

Prescribed Statin (%)

19 (30.6)

 Prescribed Anticoagulation (%)

4 (6.5)

Prescribed Antiplatelet (%)

22 (35.5)

Prescribed acetylcholinesterase inhibitors or  glutamate receptor antagonist (%)

19 (30.6)

Median Number of Chronic Health Conditions [IQR]

4 [3.75 – 6]

Diagnosed Frailty (%)

50 (80.6)

Cardiovascular Disease (%)

 42 (67.7)

Psychiatric Disorders and Dementia (%)

 40 (64.5)

        Musculoskeletal & Rheumatological (%)

36 (58.1)

Chronic Kidney Disease 3, 4 or 5 (%)

24 (38.7)

 Gastrointestinal Diagnoses (%)

19 (30.6)

Stroke & Neurological Conditions (%)

19 (30.6)

     Respiratory Disease (%)

14 (22.6)

Diagnosis of Malignancy (%)

12 (19.4)

Diabetes Mellitus 1 and 2 (%)

11 (17.7)

IQR – inter-quartile range

 

Table 2 summarises the number visits to nursing homes provided by clinicians, broken down by month. Over the first four months of 2019, a total of 90 home visits were performed. Over the four month period there was some variation in the number of visits provided, with average number of visits per working day ranging from 0.7 in April to 1.43 in March. Clinicians performed at least one nursing home visit on 69% of all working days in the first four months of 2019.

 

Table 2 – Summary of home visits provided to nursing homes

Month

Number of Working Days in the Month

Number of Home Visits Provided

Number of Days where Nursing Home Visit Performed

Visits per Day (total visits / number of working days)

January

22 days

25 visits

17 days

1.14

February

20 days

21 visits

14 days

1.05

March

21 days

30 visits

17 days

1.43

April

20 days

14 visits

9 days

0.7

Total (4 month period)

83 days

90 visits

57 days

1.08

 

Table 3 summarises the reasons provided by nursing homes to request a GP home visit. Chest infections (14.4%), mobility issues / falls (14.4%) and musculoskeletal complaints (11.1%) were the most common reasons for requesting a home visit. 5.6% of visits related to GPs providing routine and proactive care, such as discussions surrounding resuscitation, incapacity or anticipatory care planning. When the reason for the nursing home visit request was assessed, 34 visits of 90 visits (38%) did not require to be performed on the same day as an urgent assessment and could have been performed as routine care. 

 

Table 3 – Reasons for nursing home visit requests 

Category of Request

Number of Visits

n=90

Chest infection (%)

13 (14.4)

Mobility Issues / Falls (%)

13 (14.4)

Musculoskeletal Complaints (%)

10 (11.1)

Medication Review or Adverse Drug Reactions (%)

10 (11.1)

Behavioural and Psychological Symptoms of Dementia (%)

9 (10)

Cardiac Presentations (%)

7 (7.8)

Urinary Tract Complaints (%)

6 (6.7)

Skin Complaints (%)

6 (6.7)

Palliative Care (%)

5 (5.6)

Routine Care (resuscitation discussions, anticipatory care planning) (%)

5 (5.6)

Neurological Presentations (%)

5 (5.6)

Gastrointestinal Presentations (%)

1 (1)

Discussion

Key findings

This study extends previous research that patients residing in nursing homes are a population with complex care needs,8 and required considerable input from primary care despite being only forming 0.6% of the practice population.

Prescribing for older people is a complex process and can elevate the risk of inappropriate prescribing, with potentially severe consequences. Firstly, this study reports that nursing home patients within the practice are prescribed psychoactive medication at rates higher than the national average.9 Secondly, almost a third of the nursing home population were prescribed anti-platelets and statins raising questions about the perceived versus achievable benefits of preventative prescribing. Thirdly, do not attempt resuscitation (DNaCPR) forms were completed for 18 (29%) of patients. Finally, many of the requested home visits did not require a GP to provide patient care and highlighted the opportunity to utilise other clinicians times to enable GPs to prioritise other aspects of nursing home care provision. These areas will be the focus of broader discussion.

Psychoactive prescribing

Older people are often prescribed medications with psychoactive properties.10 These medications have a considerable side‐effect profile in older patients9 but equally may be clinical effective when used cautiously.11 Assessments of psychoactive drug prescribing in older patients showed that patients over 65 years are not uncommonly prescribed antidepressants (10.8%), hypnotic/anxiolytics (7.5%), and antipsychotic medications (1%).9 Furthermore, it is common for patients to be prescribed more than one agent with psychoactive properties.9,12 In our local practice, albeit with a small patient number, our prescription rates were higher than this and in particular for antidepressant medications. Our prescription rates of antidepressants in particular are more in line with our American13 and European counterparts.14

The prescription of psychoactive drugs to patients over 65 years old is an area of intense medical and political interest.15 Clearly, prescribing psychoactive medications to this patient group is often clinically appropriate and safe, but the risks that these drugs may pose to older people are increasingly recognised. For example, despite increasing evidence of adverse outcomes, the proportion of older people prescribed anticholinergic medications; the proportion with a high anticholinergic exposure increased between 1995 and 2010.16 Other numerous studies have linked psychoactive medications to adverse outcomes including adverse drug reactions and reduced cognition and mobility17-19 and this has led to changes in the type of psychoactive medications prescribed to manage behavioural and psychological symptoms of dementia (eg - neuroleptics to anti-depressants).

Initiatives to optimize prescribing for older people through service developments within primary care20 are particularly important as it has been reported that physicians can feel that solutions to inappropriate prescribing, in particular, psychoactive prescribing, are beyond the scope of the individual physician.21 Previous successful approaches to optimize prescribing for older people have usually been either educational or administrative, and a combined approach is recommended.22

Prescription of preventative medications

Long-term residential aged care or nursing home residents are among the frailest of all older populations. This complexity together with age-related pharmacokinetics puts them at high risk of adverse outcomes related to medication23 (Taxis et al, 2016). Of all nursing home residents, 91% die in the nursing home after an average stay of 38.6 months for women and 25.3 months for men, indicating that the majority of residents have limited life expectancy following nursing home admission.24

This study noted that a significant number of our nursing home residents were receiving medications for primary or secondary prevention. Indeed, a recent systematic review found that use of preventative medications with limited life expectancy was common.25 Furthermore, an Australian study recently reported that at death, preventive medication such as antithrombotic agents, antihypertensive medications, and osteoporosis medications were still prescribed to one third of all residents.26

The awareness of de-prescribing inappropriate medication at the end of life is growing throughout the literature. Although a recent systematic review reported that there was no one interventional strategy that has proved to be effective, clinician education programs and multi-disciplinary meetings seemed to show most promise when compared to pharmacist medication reviews and computerised clinical decision support systems.27

Medication reviews require individual decisions to be patient focused, and decisions about medication cessation may often prove more difficult than starting new medications. Further work locally at promoting medication review priority and ability to frame risk and benefit for individual patients or their decision makers will be the focus of further work.

Cardiopulmonary resuscitation (CPR)

For patients where there is an identifiable risk of cardiorespiratory arrest, it is important to make decisions about CPR in advance so that a decision is not needed at a point of crisis.28 Given the nature of comorbid disease in nursing home residents, this is an area that has particular relevance and rates of completed do not attempt resuscitation forms range from 30% to 46.8%.29-31

Such decisions should be made in the patients best interests with active engagement of patients, proxy decision makes (Power of Attorney) and family. In addition, to reducing futile and often traumatic medical interventions making these decisions may influence broader decision-making. For example, recent research reported that patients with dementia who remain for resuscitation were significantly more likely to die in hospital.32

However, there are numerous barriers to this in practice. Firstly, commonly clinicians are providing reactive care after being requested to review a patient for an urgent problem. Discussions around resuscitation often are commonly opportunistic, but clinicians may feel that reviewing a patient after a fall for example may not be the best time to discuss resuscitation. Furthermore, within the nursing home setting it is more common than not to have patients who lack the capacity to consent to aspects of their care. It can be time consuming to actively seek out family member or proxy-decision makers to discuss this decision especially when the need is not felt to be a priority.

The law is now very clear about the need for communication regarding do not attempt resuscitation forms. Indeed, if a doctor believes that CPR will not be successful, there is still a presumption in favour of explaining the need and basis for the decision to the patient, or for patients who lack capacity, those close to them.28

Future work to develop and deliver structured advanced care planning in the community within clinician job plans may assist in making it easier and feasible for clinicians to have these discussions. Broader interventions including using end-of-life care pathways for dementia patients and staff training/education have also been shown aid patient preference towards less invasive levels of care at life’s end and increased compliance with participants’ wishes and deaths at home (including DNACPR).33

New models of care

The practice currently provides a reactive model of care to nursing homes that relies upon nursing homes to request visits as they see appropriate, alongside normal chronic disease monitoring. This has led to regular ad-hoc visits at all of the four homes, and often the reason for the request for the visit does not require an urgent response or may actually be better suited to another member of the healthcare team such as an Advanced Nurse Practitioner (ANP) or Advanced Physiotherapist.

One model of care that has been of particular interest for our own practice has been attached primary care services. As part of the model, GPs provide locally enhanced services to nursing homes within their catchment areas which may include provision of weekly visits to the home (planned ‘ward round’), anticipatory care planning (resuscitation status / incapacity status) and regular medication reviews of residents.4 The benefits of such an approach is that care homes find this more responsive to their needs, and may provide more proactive rather than reactive care.34-35 There is data suggesting that this approach may reduce hospital admissions1, improve satisfaction of care provided by GPs and patients,4 and may lead to emerging relationships between primary and secondary care geriatricians for complex cases.35 Furthermore, our practice is working to utilise ANP time to perform nursing home visits in order to enable clinicians to perform some of the other more nuanced aspect of nursing home resident care.

Limitations

This research paper has several limitations. Firstly, this was a single centre study of a general practice in an urban-deprived area delivering a certain model of care to nursing home residents. These results are not necessarily generaliasble to other areas of the United Kingdom or further afield, and form the basis for further local development. However, such work does provide a useful platform for discussing general themes and aspects of care for nursing home residents.

Secondly, by focusing upon home visits to nursing homes only, this is likely to under-represent GP work within anticipatory care planning and broader aspects of proactive care. Third, due to the small sample size, we were unable to perform any statistical analyses or analyse different nursing homes in sub-group analyses. Fourthly, information regarding only three preventative medications were obtained and as such conclusions about other commonly prescribed preventative medications (anti-hypertensive / osteoporotic medications) cannot be drawn.

Conclusion

Our results confirm and extend previous work that patients residing in nursing homes are commonly multi-morbid, frail and are prescribed significant numbers of medications. Furthermore, psychoactive prescribing remains high in this patient group. With GP work-force challenges, the fact that a significant minority of nursing home resident home visits did not necessitate a GP review and could have been safely and appropriately reviewed by a different clinician, links into broader GP contract discussions to promote the GP as ‘expert generalist’.

Extending this further, considering reviewing the model of care to nursing homes to a more proactive model may reduce the overall requirement for unscheduled visits. Work is needed to develop intervention packages that address the needs of nursing home residents and mitigate risks common to a range of diseases and syndromes of ageing, with a focus both on optimising physiology, but also supporting and empowering patients and nursing home staff.


Lloyd David Hughes.

GP Registrar, Lomond Practice & Medical Practitioner, Care of the Elderly, NHS Fife

e-mail contact: l.hughes5@nhs.net


 

Acknowledgements

Many thanks to Andy Thompson (Practice Manager) for providing the information which has provided the basis for this work.

Key findings

What is already known

Nursing home residents are commonly multi-morbid, frail and likely to be prescribed several medications.

There is work looking at how to best provide primary care services to this group of patients in UK primary care, but many GP practices provide reactive home visits for nursing home residents alongside broader government mediated primary healthcare delivery (such as the Quality Outcomes Framework).

What this research adds

The traditional model of reactive home visits for nursing home residents is limited and often is disease focused rather than patient focused. Indeed, clinical domains representing proactive care such as resuscitation decisions and polypharmacy reviews seem not to be prioritised. 

Other models of nursing home care provision led by GP practices require investment, but have the potential to deliver patient-centred care.

What gap this fills

A common expectation is that GPs are readily available to deliver primary care led services (including acute and chronic disease care, anticipatory care planning) within the nursing home environment.

The most common causes for nursing home to request a visit from the practice were for falls/mobility issues (14.4%) and chest infections (14.4%), and around a third of requested visits were not urgent. This raises the question about other models of care that may utilize the different professional competencies and promote the GP as ‘expert medical generalist’ in line with the NHS 5-year forward view.

 

References

  1. Roche E. 2014. Time for change care home resident management – reflections on a GP-led service. British Journal of General Practice. 64(628):591-592
  2. NHS England. Five-Year Forward View. 2014. NHS England. London.
  3. British Medical Association (2018). The general practice forward view: two years on. London.
  4. Donald IP, Gladman J, Conroy S, Vernon M, Kendrick E & Burns E. 2008. Care home medicine in the UK – in from the cold. Age and Ageing. 37:618-620
  5. Scottish Index of Multiple Deprivation. SIMD Results 2012. Available from: http://simd.scotland.gov.uk/publications-2012/simd-2012-results/outcomes-of -people-living=in-the-most-deprived-areas/ Last Accessed 19th March 2019.
  6. National Institute for Health and Clinical Excellence. Multimorbidity: clinical assessment and management. London: National Institute for Health and Clinical Excellence, 2016.
  7. BNF. British National Formulary 63. 2012. London: BMJ Publishing Group Ltd., RPS Publishing.
  8. Burton JK, Lynch E, Love S, Rintoul J, Starr JM, Shenkin SD. 2019. Who lives in Scotland’s care homes? Descriptive analysis using routinely collected social care data 2012–16. J R Coll Physicians Edin. 49: 12–22
  9. Guthrie, B, Clark, SA, McCowan, C. 2010. The burden of psychotropic drug prescribing in people with dementia: a population database study. Age Ageing 39(5): 637– 642.
  10. Thronson, LR, Pagalilauan, GL. 2014. Psychopharmacology. Med Clin North Am 98( 5): 927– 958.
  11. Hughes LD, Murphy F & Findlay DJ. 2019. Assessment and treatment of depression associated with dementia. British Journal Hospital Medicine. 80(3):151–156
  12. Hughes, LD, Hanslip, J, Witham, MD. 2012. Centrally active prescribing for nursing home residents—how are we doing? Eur Geriatr Med 3( 5): 304– 307.
  13. Shah S, Schoenbachler B, Streim J & Meeks S 2012. Antidepressant Prescribing Patterns in the Nursing Home: Second-Generation Issues Revisited. J Am Med Dir Assoc. 13(4): 406.e13–406.e18.
  14. Bourgeois J, Elseviers MM, Van Bortel L, Petrovic M, Vander Stichele RH. 2012. The use of antidepressants in Belgian nursing homes: focus on indications and dosages in the PHEBE study. Drugs Aging. 29(9):759-69.
  15. Banerjee, S. 2009. The use of antipsychotic medication for people with dementia: time for action. A report for the Minister of State for Care Services London: Department of Health.
  16. Sumakadas, D, McMurdo, MET, Mangoni, AA, Guthrie, B. 2013. Temporal trends in anticholinergic medication prescription in older people: repeated cross‐sectional analysis of population prescribing data. Age and Ageing 43( 4): 515– 21.
  17. Boudreau, RM, Hanlon, JT, Roumani, YF, et al. 2009. Central nervous system medication use and incident mobility limitation in community elders: the health, aging, and body composition study. Pharmacoepidemiol Drug Saf 18( 10): 916– 22.
  18. Guthrie, B, McCowan, C, Davey, P, et al. 2011. High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice. BMJ 342: d3514.
  19. Lowry, E, Woodman, RJ, Soiza, RL, Mangoni, AA. 2011. Associations between the anticholinergic risk scale score and physical function: potential implications for adverse outcomes in older hospitalized patients. J Am Med Dir Assoc 12( 8): 565– 72.
  20. The Model of Care Polypharmacy Working Group. 2012. Polypharmacy Quick Reference Guidance for Clinicians. Scottish Government Health and Social Care Directorates: Edinburgh.
  21. Damestoy, N, Collin, J, Lalande, R. 1999. Prescribing psychotropic medication for elderly patients: some physicians' perspectives. CMAJ 161( 2): 143– 5.
  22. Mort, JR, Aparasu, RR. Prescribing of psychotropics in the elderly: why is it so often inappropriate? 2002. CNS Drugs 16( 2): 99– 109.
  23. Taxis, K., O’Sullivan, D., Cullinan, S., and Byrne, S. 2016. Drug utilization in older people, in Drug Utilization Research: Methods and Applications, eds M. Elseviers, B. Wettermark, A. Almarsdóttir, M. Andersen, R. Benko, M. Bennie, et al. (New Jersey, NJ: Wiley-Blackwell), 259–269.
  24. Australian Institute of Health and Welfare (2017). Residential Aged Care in Australia 2010-11: A Statistical Overview. Available at: http://www.aihw.gov.au/publication-detail/?id=10737422821 Last Accessed: 30th April 2019
  25. Poudel, A., Yates, P., Rowett, D., and Nissen, L. M. 2017. Use of preventive medication in patients with limited life expectancy: a systematic review. J. Pain Symptom Manage. 53, 1097–1110.
  26. van der Meer HG, Taxis K, Pont LG. 2018. Changes in Prescribing Symptomatic and Preventive Medications in the Last Year of Life in Older Nursing Home Residents. Front Pharmacol. 2018 23;8:990
  27. Loganathan M, Singh S, Franklin BD, Bottle A, Majeed A, 2011. Interventions to optimise prescribing in care homes: systematic review, Age and Ageing. 40(2),150–162
  28. Campbell R. 2017. Do not attempt cardiopulmonary resuscitation decisions: joint guidance. J R Coll Physicians Edinb. 47:47–5
  29. Becker LJ, Yeargin K, Rea TD, Owens M, Eisenberg MS. 2003. Resuscitation of residents with do not resuscitate orders in long-term care facilities. Prehosp Emerg Care. 7(3):303-6.
  30. Fritz Z, Slowther AM & Perkins GD. 2017. Resuscitation policy should focus on the patient, not the decision. BMJ;356:j813
  31. Rahman AN, Bressette M, Gassoumis ZD & Enguidanos S. 2016. Nursing Home Residents’ Preferences on Physician Orders for Life Sustaining Treatment. The Gerontologist. 56 (4): 714–722
  32. Wiggins N, Droney J, Mohammed K, Riley J & Sleeman KE. 2019. Understanding the factors associated with patients with dementia achieving their preferred place of death: a retrospective cohort study. Age and Ageing. 48:433-439.
  33. Schmitten J, Lex K, Mellert C, Rotharmel S, Wegscheider K, Marckmann G. 2014. Implementing an advance care planning program in German nursing homes: results of an inter-regionally controlled intervention trial. Deutsch Arztebl Int 2014;111:50–7.
  34. Burns E & Nair S. 2014. New horizons in care home medicine. Age Ageing. 43(1):2-7.
  35. Royal College of Physicians, Royal College of Nursing & British Geriatrics Society. 2000. The health and care of older people in care homes. A comprehensive interdisciplinary approach. Report of a Working Party. London:RCP.
  36. Baylis A & Perks-Baker S. 2017. Enhanced health in care homes. Learning from experience. Kings Fund. London.