Assessment and treatment of nursing home residents with depression or behavioral symptoms associated with dementia: a review of the literature

Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial

BACKGROUND

Poorly executed transfers of older patients from hospitals to long-term care facilities carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission.

OBJECTIVE

This study was conducted to assess the impact of adding a pharmacist transition coordinator on evidence-based medication management and health outcomes in older adults undergoing first-time transfer from a hospital to a long-term care facility.

METHODS

This randomized, single-blind, controlled trial enrolled hospitalized older adults awaiting transfer to a long-term residential care facility for the first time. Patients were randomized either to receive the services of the pharmacist transition coordinator (intervention group) or to undergo the usual hospital discharge process (control group). The intervention included medication-management transfer summaries from hospitals, timely coordinated medication reviews by accredited community pharmacists, and case conferences with physicians and pharmacists. The primary outcome was the quality of prescribing, measured using the Medication Appropriateness Index (MAI). Secondary outcomes were emergency department visits, hospital readmissions, adverse drug events, falls, worsening mobility, worsening behaviors, increased confusion, and worsening pain.

RESULTS

One hundred ten older adults (67 women, 43 men; mean [SD] age, 82.7 [6.4] years) were recruited from 3 metropolitan hospitals and assigned to 85 metropolitan long-term care facilities. Fifty-six patients were randomized to the intervention group and 54 to the control group; 44 patients in each group were evaluable at 8-week follow-up. There were no significant differences in baseline characteristics between treatment groups, with the exception of the number of medications discontinued during hospitalization: a mean of 1.1 more drugs was discontinued in the control group compared with the intervention group (P = 0.011). The majority of patients (35 [62.5%] in the intervention group, 41 [76.0%] in the control group) changed physicians as part of the transition to a long-term care facility. At 8-week follow-up, there was no change in MAI from baseline in the intervention group, whereas it had worsened in the control group (mean [95% CI], 2.5 [1.4-3.7] vs 6.5 [3.9-9.1], respectively; P = 0.007). Patients who received the intervention and were alive at follow-up exhibited a significant protective effect of the intervention against worsening pain (relative risk ratio [95% CI], 0.55 [0.32-0.94]; P = 0.023) and hospital usage (i.e., the combination of emergency department visits and hospital readmissions) (0.38 [0.15-0.99]; P = 0.035), but did not differ from control patients in terms of adverse drug events (1.05 [0.66-1.68]), falls (1.19 [0.71-1.99]), worsening mobility (0.39 [0.13-1.15]), worsening behaviors (0.52 [0.25-1.10]), or increased confusion (0.59 [0.28-1.22]). When data for patients who had died were included, the intervention had no effect on hospital usage in all patients (0.58 [0.28-1.21]).

CONCLUSIONS

Older people transferring from hospital to a long-term care facility are vulnerable to fragmentation of care and adverse events. In this study, use of a pharmacist transition coordinator improved aspects of inappropriate use of medicines across health sectors.

Geropsychology training in a VA nursing home setting

There is a growing need for professional psychology training in nursing home settings, and nursing homes provide a rich environment for teaching geropsychology competencies. We describe the nursing home training component of our Department of Veterans Affairs (VA) Predoctoral Internship and Geropsychology Postdoctoral Fellowship programs. Our training objectives for Interns and Fellows include: increased exposure and interest in nursing home practice; increased competencies in assessment, intervention, and consultation in this setting; and increased confidence in the role of the psychologist in medically oriented, geriatric care settings. We describe the local VA nursing home training setting and our training model, including expected competencies, training activities, special issues in supervision, and evaluation of competencies. We have found group supervision and peer support to be an important component of our nursing home training program. The VA healthcare system allows great flexibility for psychologists to both provide psychological services and training in the nursing home setting.

Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The Treatment Outcome Package

In 1994, the American Psychological Association and the Society for Psychotherapy Research convened a Core Battery Conference to develop a set of criteria for the selection of a universal core battery that could be used as a common outcome tool across all outcome studies. The Treatment Outcome Package (TOP) is a behavioral health assessment and outcome battery with modules for assessing a wide array of behavioral health symptoms and functioning, demographics, case-mix, and treatment satisfaction. It was developed to follow the design specifications set forth by the Core Battery Conference, but also to ensure the battery's applicability to naturalistic treatment settings in which randomization may be impossible. In this article we discuss a number of studies that evaluate the initial psychometrics of the items that comprise the mental health symptom and functional modules of the TOP. We conclude that the TOP has an excellent factor structure, good test-retest reliability, promising initial convergent and discriminant validity, measures the full range of pathology on each scale, and has some ability to distinguish between behavioral health clients and members of the general population.

The Pharmacological Approach of Behavioral Disturbances in Dementia

Behavioral and psychological symptoms in dementia (BPSD) are often overlooked due to the main focus of treating or preventing cognitive decline symptoms. Almost two-thirds of patients with dementia will develop some type of noncognitive symptoms that include symptoms such as wandering, agitation, sexually inappropriate behaviors, physical and verbal aggression, uncooperativeness, and “sun-downing.” Psychological symptoms include depression, anxiety, delusions, hallucinations, and suspiciousness/paranoia. Worsening of these symptoms can lead to caregiver burden and is one of the major reasons for patients with dementia to be institutionalized. A major drawback of treating these symptoms pharmacologically is that the response rate is low with the current available therapies such as antipsychotics, anxiolytics, and antidepressants. In addition, all of these therapeutic classes have drawbacks due to side effect profiles. This article provides an overview of the current recommendations for pharmacological approaches for the treatment of behavioral and psychological symptoms of dementia.