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Rataj A, Alcusky M, Baek J, Ott B, Lapane KL. Geographic Variation of Antidementia and Antipsychotic Medication Use Among US Nursing Home Residents With Dementia. Med Care 2024; 62:511-520. [PMID: 38833712 DOI: 10.1097/mlr.0000000000002016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms. OBJECTIVE The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use. SETTING US nursing homes (n=9735), hospital referral regions (HRR; n=289). SUBJECTS Long-stay residents with dementia (n=273,004). METHODS Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV). RESULTS Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCV STATE : 27.80%; PCV HRR : 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCV STATE : 37.44%; ChEI PCV STATE : 39.02%). CONCLUSION Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.
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Affiliation(s)
- Alison Rataj
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, Division of Biostatistics and Health Services Research, University of Massachusetts Chan Medical School, Worcester, MA
| | - Brian Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, Division of Epidemiology, University of Massachusetts Chan Medical School, Worcester, MA
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Wang J, Shen JY, Conwell Y, Yu F, Nathan K, Heffner KL, Li Y, Caprio TV. Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes. J Am Geriatr Soc 2023; 71:3768-3779. [PMID: 37671461 PMCID: PMC10841208 DOI: 10.1111/jgs.18555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/07/2023] [Accepted: 07/26/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD. METHODS In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses. RESULTS The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (β = -0.70, p < 0.001). CONCLUSIONS HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York, USA
| | - Kathi L Heffner
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester, School of Nursing, Rochester, New York, USA
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Home Care, Rochester, New York, USA
- Finger Lakes Geriatric Education Center, Rochester, New York, USA
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Anderson TS, Ayanian JZ, Curto VE, Politzer E, Souza J, Zaslavsky AM, Landon BE. Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis. JAMA Intern Med 2023; 183:1098-1108. [PMID: 37603340 PMCID: PMC10442785 DOI: 10.1001/jamainternmed.2023.3575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/09/2023] [Indexed: 08/22/2023]
Abstract
Importance Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management. Objective To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults. Design, Setting, and Participants In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023. Exposure Incident dementia diagnosis. Main Outcomes and Measures The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date. Results The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase). Conclusions and Relevance In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, University of Michigan, Ann Arbor
| | - Vilsa E. Curto
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Eran Politzer
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Haider I, Kosari S, Naunton M, Niyonsenga T, Koerner J, Peterson G, Davey R. Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study). Sci Rep 2023; 13:15962. [PMID: 37749102 PMCID: PMC10519995 DOI: 10.1038/s41598-023-42894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.
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Affiliation(s)
- Ibrahim Haider
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia.
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia.
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
| | - Mark Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
| | - Theo Niyonsenga
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
| | - Jane Koerner
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
| | - Gregory Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, 7005, Australia
| | - Rachel Davey
- Health Research Institute, Faculty of Health, University of Canberra, Bruce, ACT, 2617, Australia
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Gerlach LB, Zhang L, Strominger J, Kim HM, Teno J, Bynum JPW, Maust DT. Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing. J Am Geriatr Soc 2023; 71:2571-2578. [PMID: 36971013 PMCID: PMC10522794 DOI: 10.1111/jgs.18344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing. METHODS Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics. RESULTS In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions. CONCLUSIONS Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.
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Affiliation(s)
- Lauren B. Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Lan Zhang
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Joan Teno
- Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P. W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Kaskie B, Xu L, Smith L, Bounds D, Carder P, Thomas KS. Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States. J Am Med Dir Assoc 2023; 24:821-826. [PMID: 36870364 PMCID: PMC10238629 DOI: 10.1016/j.jamda.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 01/23/2023] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities. DESIGN We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations. SETTING AND PARTICIPANTS AL regulations and licensed AL communities across all 50 states in 2018. METHODS We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission. RESULTS The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment. CONCLUSIONS AND IMPLICATIONS The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.
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Affiliation(s)
- Brian Kaskie
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA.
| | - Lili Xu
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Lindsey Smith
- School of Public Health and Center for Gerontology and Healthcare Research, Brown University, Providence, RI, USA
| | - Delaney Bounds
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Paula Carder
- School of Public Health, Oregon Health Sciences University-Portland State University, Portland, OR, USA
| | - Kali S Thomas
- School of Public Health and Center for Gerontology and Healthcare Research, Brown University, Providence, RI, USA; U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA
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Winter JD, Kerns JW, Winter KM, Richards A, Sabo RT. Community, Social, and Facility Factors and Long-stay Antipsychotic Use. Clin Gerontol 2022; 45:1180-1188. [PMID: 35443876 PMCID: PMC9806733 DOI: 10.1080/07317115.2022.2063777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Compare Virginia nursing homes in the top- and bottom-quintiles of antipsychotic use for variation in community, social, and facility factors. METHODS 2018 CMS data ascertained Virginia nursing homes in the top and bottom quintiles for antipsychotic use. The Virginia Health Department provided social determinant of health (SDOH) statistics for each facility's county/city while claims identified facility demographics. Chi square and independent two-sample t-tests compared quintiles for regional, social, and demographic differences. RESULTS Quintiles averaged 3000 residents and 56 facilities. Facilities with the lowest rates of antipsychotic use were more likely to be privately owned and had fewer African-American and minority residents and more white residents. All 18 SDOH statistics were superior for the communities of facilities with the lowest antipsychotic rates. Nine of these differences were statistically significant, including the aggregated "Health Opportunity Index." CONCLUSIONS The antipsychotic prevalence rate for facilities in the top-quintile of antipsychotic use is fivefold the bottom-quintile's rate. Antipsychotic prescribing in nursing homes is associated with regional, demographic, and social factors not addressed by existing antipsychotic reduction measures, with vulnerable populations at greatest risk. CLINICAL IMPLICATIONS The efficacy of measures aimed at curbing long-stay antipsychotic prescribing could be improved by addressing SDOH including economic opportunities.
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Affiliation(s)
- Jonathan D Winter
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - J William Kerns
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Katherine M Winter
- Shenandoah Family Practice Residency, Deparment of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
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Lim D, Liu D, Burston B. Impacts of 2012 update to the AGS beers criteria on potentially inappropriate antipsychotic medication use among older adults. AGING AND HEALTH RESEARCH 2021. [DOI: 10.1016/j.ahr.2021.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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9
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Impact of interdisciplinary approaches to deprescribing psychotropics on clinical outcomes in older residents of long-term care facilities. Int Psychogeriatr 2021; 33:543-546. [PMID: 34078496 DOI: 10.1017/s1041610220001453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Thomas KS, Wretman CJ, Sloane PD, Carder P, Schwartz L, Beeber AS, Zimmerman S. To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living? J Am Med Dir Assoc 2021; 22:1813-1818.e3. [PMID: 33382990 DOI: 10.1016/j.jamda.2020.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs. DESIGN Observational, cross-sectional AL data linked to publicly reported NH measures. SETTING AND PARTICIPANTS Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states. METHODS We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects. RESULTS The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = -0.03; 95% confidence interval (CI) -0.50 to -0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16-0.70; P = .002). CONCLUSIONS AND IMPLICATIONS This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.
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Affiliation(s)
- Kali S Thomas
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA.
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Paula Carder
- OHSU-PSU School of Public Health, Portland State University, Portland, OR, USA
| | - Lindsay Schwartz
- Center for Health Policy Evaluation in Long-Term Care; American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Anna S Beeber
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
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Gerlach LB, Kales HC, Kim HM, Bynum JPW, Chiang C, Strominger J, Maust DT. Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014. J Am Med Dir Assoc 2020; 21:1629-1635.e8. [PMID: 32693995 DOI: 10.1016/j.jamda.2020.05.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes focuses on but is not limited to long-term care (LTC) residents with dementia; the potential impact on residents with other diagnoses is unclear. We sought to determine whether resident subpopulations experienced changes in antipsychotic and mood stabilizer prescribing. DESIGN Repeated cross-sectional analysis of a 20% Medicare sample, 2011-2014. SETTING AND PARTICIPANT Fee-for-service Medicare beneficiaries with Part D coverage in LTC (n = 562,485) and a secondary analysis limited to persons with depression or bipolar disorder (n = 139,071). METHODS Main outcome was quarterly predicted probability of treatment with an antipsychotic or mood stabilizer. RESULTS From 2011 to 2014, the adjusted predicted probability (APP) of antipsychotic treatment fell from 0.120 [95% confidence interval (CI) 0.119-0.121] to 0.100 (95% CI 0.099-0.101; P < .001). Use decreased for all age, sex, and racial/ethnic groups; the decline was larger for persons with dementia (P < .001). The APP of mood stabilizer use grew from 0.140 (95% CI 0.139-0.141) to 0.185 (95% CI 0.184-0.186), growth slightly larger among persons without dementia (P < .001). Among persons with depression or bipolar disorder, the APP of antipsychotic treatment increased from 0.081 (95% CI 0.079-0.082) to 0.087 (95% CI 0.085-0.088; P < .001); APP of mood stabilizer treatment grew more, from 0.193 (95% CI 0.190-0.196) to 0.251 (0.248-0.253; P < .001). Quetiapine was the most commonly prescribed antipsychotic. The most widely prescribed mood stabilizer was gabapentin, prescribed to 70.5% of those who received a mood stabilizer by the end of 2014. CONCLUSIONS AND IMPLICATIONS The likelihood of antipsychotic and mood stabilizer treatment did not decline for residents with depression or bipolar disorder, for whom such prescribing may be appropriate but who were not excluded from the Partnership's antipsychotic quality measure. Growth in mood stabilizer use was widespread, and largely driven by growth in gabapentin prescribing.
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Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Helen C Kales
- Department of Psychiatry, University of California, Davis, CA, USA
| | - Hyungjin Myra Kim
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of California, Davis, CA, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of California, Davis, CA, USA.
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12
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Wang S, Temkin-Greener H, Conwell Y, Cai S. Policy to Reduce Antipsychotic Use and Hospitalization of Nursing Home Residents With Dementia. J Am Med Dir Assoc 2020; 21:1617-1622.e3. [PMID: 32527648 DOI: 10.1016/j.jamda.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer's disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN Observational cross-sectional study. SETTING/PARTICIPANTS NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership). RESULTS We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use. CONCLUSIONS AND IMPLICATIONS Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.
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Affiliation(s)
- Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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13
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Aerts L, Cations M, Harrison F, Jessop T, Shell A, Chenoweth L, Brodaty H. Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: Insights from the HALT study. Int J Geriatr Psychiatry 2019; 34:1572-1581. [PMID: 31276255 DOI: 10.1002/gps.5167] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 06/29/2019] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes. MATERIALS AND METHODS Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context. RESULTS Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education. DISCUSSION Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.
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Affiliation(s)
- Liesbeth Aerts
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Monica Cations
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Fleur Harrison
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia.,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Tiffany Jessop
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Allan Shell
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Lynn Chenoweth
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia.,Centre for Healthy Brain Ageing, School of Psychiatry, UNSW Sydney, Sydney, NSW, Australia
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14
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McCreedy E, Ogarek JA, Thomas KS, Mor V. The Minimum Data Set Agitated and Reactive Behavior Scale: Measuring Behaviors in Nursing Home Residents With Dementia. J Am Med Dir Assoc 2019; 20:1548-1552. [PMID: 31678075 DOI: 10.1016/j.jamda.2019.08.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/24/2019] [Accepted: 08/30/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Interventions aimed at managing agitated and aggressive behaviors in dementia without the use of antipsychotics are currently being tested in nursing homes (NHs). Researchers and clinicians require a measure that can capture the severity of residents' behaviors. We test the internal consistency and construct validity of the Agitated and Reactive Behavior Scale (ARBS), a measure created using data from mandatory NH assessments. DESIGN Cross-sectional. SETTING AND PARTICIPANTS The 2016 national sample of 15,326 Centers for Medicare and Medicaid Services-certified NHs. The analytic sample included 489,854 new admissions and 765,367 long-stay residents (at least 90 days in NH). All participants have a dementia diagnosis. METHODS Minimum Data Set (MDS), version 3.0. The ARBS is a composite measure of (1) physical behavioral symptoms directed at other people; (2) verbal behavioral symptoms directed at other people; (3) other behavioral symptoms not directed at other people; and (4) rejection of care. Variables used to establish construct validity included degree of cognitive impairment, use of medications for managing agitation and aggression, and co-occurring conditions associated with agitated and aggressive behaviors (eg, schizophrenia, depression, or delirium). RESULTS This report has 3 important findings: (1) the ARBS score has borderline-adequate internal consistency (α = .64-.71) in the national population NH residents with dementia; (2) only 18% of new admissions and 21% of long-stay residents with dementia evidence any agitated or aggressive behaviors in the last week, as rated in the MDS assessment; and (3) the ARBS demonstrates good construct validity; it increases with cognitive impairment, treatment with relevant medications, and co-occurring psychiatric conditions and symptoms. DISCUSSION Nationally available MDS data may significantly underestimate the prevalence of agitated and aggressive behaviors among NH residents with dementia. CONCLUSIONS AND IMPLICATIONS Researchers conducting pragmatic trials of non-pharmaceutical interventions to manage behaviors in NH residents with dementia should consider the likely underdetection of these behaviors in the available MDS data.
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Affiliation(s)
- Ellen McCreedy
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI; Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI.
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI; Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI; VA Medical Center, Providence, RI
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, School of Public Health, Brown University, Providence, RI; Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI; VA Medical Center, Providence, RI
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15
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Assessing the Relative Contribution of Resident Versus Facility Characteristics Associated With Antipsychotic Medication Receipt Among Nursing Facility Residents. Med Care 2019; 57:822-829. [PMID: 31415339 DOI: 10.1097/mlr.0000000000001183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE In 2012 Centers for Medicare and Medicaid Services (CMS) launched a multifaceted initiative aimed at reducing the unnecessary use of antipsychotic medications in nursing facilities due to evidence these medications are associated with little or uncertain benefit and substantial risk. Yet, little is known about whether efforts to reduce antipsychotic medication should be focused on residents with targeted characteristics, or on nursing facility regulation (eg, staffing levels). Our objective was to identify the relative contribution of resident and facility characteristics to potentially inappropriate antipsychotic use. METHODS We examined 1,156,875 long stay residents in 14,699 US nursing facilities in 2014 and predicted resident antipsychotic use controlling sequentially for resident and facility characteristics and calculated the incremental variation explained. RESULTS We found significant variability in unadjusted rates of potentially inappropriate antipsychotic use among nursing facilities (mean=18.0%; interquartile range: 11.3%-23.7%; SD: 11.1). Regression results indicated that 93% of the explained variation in antipsychotic use was attributed to resident characteristics and 7% was attributed to facility-level factors. At the facility level, worker hours per resident day was not significantly associated with antipsychotic use. Simulations indicated that applying the effect sizes achieved by the best performing facilities to the existing case mix across all nursing facilities would result in no more than a 1 percentage point change in population-level antipsychotic use. CONCLUSIONS Efforts to reduce antipsychotic use may have greater impact by developing new clinical strategies to address specific diagnoses rather than regulations related to facility-level attributes.
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16
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Miller SC, Cai S, Daiello LA, Shireman TI, Wilson IB. Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use. J Am Geriatr Soc 2019; 67:1353-1360. [PMID: 31063676 DOI: 10.1111/jgs.15949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status. DESIGN A cross-sectional comparative study. SETTING NHs in the 14 states accounting for 75% of persons living with HIV. PARTICIPANTS A total of 9 245 009 long-stay NH residents. MEASUREMENTS Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression. RESULTS Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9). CONCLUSION The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.
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Affiliation(s)
- Susan C Miller
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Shubing Cai
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Lori A Daiello
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island.,Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Alzheimer's Disease and Memory Disorders Center, Rhode Island Hospital, Providence, Rhode Island
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
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STOPPFrail (Screening Tool of Older Persons’ Prescriptions in Frail adults with a limited life expectancy) criteria: application to a representative population awaiting long-term nursing care. Eur J Clin Pharmacol 2019; 75:723-731. [DOI: 10.1007/s00228-019-02630-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/10/2019] [Indexed: 11/28/2022]
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18
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Carnahan RM, Daly JM, Minion S, Gryzlak B, Weckmann MT, Levy BT, Bay CP. A Needs Assessment of Family Physicians to Inform Development of Educational Resources on Antipsychotic Use in Dementia. J Prim Care Community Health 2019; 10:2150132719840113. [PMID: 31006318 PMCID: PMC6477762 DOI: 10.1177/2150132719840113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Objectives of this study were to (1) assess the needs and preferred resources of Iowa physicians to inform the development of educational resources for best practice dementia care and (2) compare the responses of nursing home medical directors with nonmedical directors. METHODS Of 498 physicians, 101 (20%) completed and returned the survey. Family physicians were obtained from a list of family physicians from the Iowa Board of Medical Examiners. Respondent answers were summarized and presented as total numbers and percentages in tables. Significant differences between medical directors and nonmedical directors were evaluated using chi-square tests, Fisher exact tests, and Wilcoxon rank-sum tests. RESULTS Medical directors and nonmedical directors had similar preferences for resources used and information needs. Online resources, pocket guides, a handbook, consulting pharmacists, and facility in-services were the most commonly preferred sources of new information. Medical directors were significantly more aware of the Food and Drug Administration warning on antipsychotic use in dementia and treated more nursing home patients. No differences were observed between groups related to confidence in and use of nondrug strategies instead of antipsychotics to manage behavioral symptoms of dementia. CONCLUSION The results of this survey illustrate physician preferences for information and resources on the management of behavioral and psychological symptoms in dementia. Information was used to inform the development of resources to aid physicians and other health care providers in making decisions about managing these symptoms.
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19
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Trenaman SC, Hill-Taylor BJ, Matheson KJ, Gardner DM, Sketris IS. Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases. Curr Ther Res Clin Exp 2018; 89:27-36. [PMID: 30294400 PMCID: PMC6170214 DOI: 10.1016/j.curtheres.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization. Methods A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated. Findings We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis. Implications In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.
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Affiliation(s)
- Shanna C Trenaman
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.,Geriatric Medicine Research Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Kara J Matheson
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - David M Gardner
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ingrid S Sketris
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada
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20
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Kim DH, Mahesri M, Bateman BT, Huybrechts KF, Inouye SK, Marcantonio ER, Herzig SJ, Ely EW, Pisani MA, Levin R, Avorn J. Longitudinal Trends and Variation in Antipsychotic Use in Older Adults After Cardiac Surgery. J Am Geriatr Soc 2018; 66:1491-1498. [PMID: 30125337 PMCID: PMC6217828 DOI: 10.1111/jgs.15418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 03/22/2018] [Accepted: 03/27/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To evaluate temporal trends and between-hospital variation in off-label antipsychotic medication (APM) use in older adults undergoing cardiac surgery. DESIGN Retrospective cohort study. SETTING National administrative database including 465 U.S. hospitals. PARTICIPANTS Individuals aged 65 and older without known indications for APMs who underwent cardiac surgery from 2004 to 2014 (N=293,212). MEASUREMENTS Postoperative exposure to any APMs and potentially excessive dosing were examined. Hospital-level APM prescribing intensity was defined as the proportion of individuals newly treated with APMs in the postoperative period. RESULTS The rate of APM use declined from 8.8% in 2004 to 6.2% in 2014 (p<.001). Use of haloperidol (parenteral 7.0% to 4.5%, p<.001; oral: 1.9% to 0.5%, p<.001), and risperidone (1.1% to 0.3%, p<.001) declined, whereas quetiapine use tripled (0.6% to 1.9%, p=.03). Hospital APM prescribing intensity varied widely, from 0.3% to 35.6%, across 465 hospitals. Treated individuals at higher-prescribing hospitals were more likely to receive APMs on the day of discharge (highest vs lowest quintile: 15.1% vs 9.6%; p<.001) and for a longer duration (4.8 vs 3.7 days; p<.001) than those at lower-prescribing hospitals. Delirium was the strongest risk factor for APM exposure (odds ratio=9.73, 95% confidence interval=9.02-10.5), whereas none of the hospital characteristics were significantly associated. The rate of potentially excessive dosing declined (60.7% to 44.9%, p<.001), and risk factors for potentially excessive dosing were similar to those for any APM exposure. CONCLUSIONS Our findings suggest highly variable prescribing cultures and raise concerns about inappropriate use, highlighting the need for better evidence to guide APM prescribing in hospitalized older adults after cardiac surgery.
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Affiliation(s)
- Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Sharon K. Inouye
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shoshana J. Herzig
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - E. Wesley Ely
- Division of Allergy, Pulmonology, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Veterans Affairs Tennessee Valley Geriatric Research Education Clinical Center, Nashville, TN
| | - Margaret A. Pisani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Raisa Levin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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21
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Brodaty H, Aerts L, Harrison F, Jessop T, Cations M, Chenoweth L, Shell A, Popovic GC, Heffernan M, Hilmer S, Sachdev PS, Draper B. Antipsychotic Deprescription for Older Adults in Long-term Care: The HALT Study. J Am Med Dir Assoc 2018; 19:592-600.e7. [DOI: 10.1016/j.jamda.2018.05.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 04/08/2018] [Accepted: 05/01/2018] [Indexed: 11/28/2022]
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22
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Lucas JA, Bowblis JR. CMS Strategies To Reduce Antipsychotic Drug Use In Nursing Home Patients With Dementia Show Some Progress. Health Aff (Millwood) 2018; 36:1299-1308. [PMID: 28679818 DOI: 10.1377/hlthaff.2016.1439] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Centers for Medicare and Medicaid Services initiated three strategies (in March and July 2012 and in May 2013) to reduce the use of unnecessary antipsychotic medications in nursing homes, especially their widespread use to control behavioral symptoms of dementia. We examined 86,163 state recertification surveys conducted at 15,055 facilities in the period January 1, 2009-March 31, 2015. We found that these strategies were associated with increases in citations for only one of two targeted deficiencies (unnecessary drug use) and only after the third strategy (revisions to the federal guidelines for the citations) was implemented. Each strategy was associated with a modest but significant reduction in antipsychotic prevalence in the general nursing home population. Initial reductions were greater in the ten states with the highest prevalence of antipsychotic use in nursing homes, compared to the ten states with the lowest prevalence. Use of other psychoactive medications, some of which are potential substitutes for antipsychotics, varied with each strategy and by state. Continuous monitoring and consistent enforcement are needed to ensure the continued decline in unnecessary use of antipsychotics and psychoactive medications in nursing homes.
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Affiliation(s)
- Judith A Lucas
- Judith A. Lucas is an associate professor in the College of Nursing at Seton Hall University, in South Orange, New Jersey
| | - John R Bowblis
- John R. Bowblis is an associate professor and Endres Fellow in the Department of Economics and Research Fellow with the Scripps Gerontology Center at Miami University, in Oxford, Ohio
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Maust DT, Kim HM, Chiang C, Kales HC. Association of the Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014. JAMA Intern Med 2018; 178:640-647. [PMID: 29550856 PMCID: PMC5885206 DOI: 10.1001/jamainternmed.2018.0379] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE The Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing. OBJECTIVE To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care. DESIGN, SETTING, AND PARTICIPANTS This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637 426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018. MAIN OUTCOMES AND MEASURES Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics). RESULTS Among the 637 426 individuals in the study (446 538 women and 190 888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31 056 of 145 841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of -0.53% (95% CI, -0.63% to -0.44%; P < .001) until the start of the partnership. At that point, the quarterly rate of decline decreased to -0.29% (95% CI, -0.39% to -0.20%; P < .001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P = .003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; P < .001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P < .001), reaching 71 492 of 355 716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75 841 of 145 841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; P < .001). Findings were similar when limited to patients with dementia. CONCLUSIONS AND RELEVANCE Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, the use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia. Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.
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Affiliation(s)
- Donovan T Maust
- Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - H Myra Kim
- Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Claire Chiang
- Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor
| | - Helen C Kales
- Program for Positive Aging, Department of Psychiatry, University of Michigan, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor
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IAGG/IAGG GARN International Survey of End-of-Life Care in Nursing Homes. J Am Med Dir Assoc 2018; 18:465-469. [PMID: 28549702 DOI: 10.1016/j.jamda.2017.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 02/05/2023]
Abstract
This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and "end of life," and a series of questions related to the following areas-attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home.
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Olivieri-Mui BL, Devlin JW, Ochoa A, Schenck D, Briesacher B. Perceptions vs. evidence: therapeutic substitutes for antipsychotics in patients with dementia in long-term care. Aging Ment Health 2018; 22:544-549. [PMID: 28080146 PMCID: PMC5547007 DOI: 10.1080/13607863.2016.1277974] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare differences between clinician perceptions of therapeutic substitutes for antipsychotics prescribed to patients with dementia in long term care (LTC) and published evidence. METHODS A mixed-methods approach that included a drug information search, online survey of 55 LTC clinicians and a comprehensive literature review was used. For 41 pharmacologic antipsychotic substitute candidates identified, LTC clinicians rated the likelihood they would substitute each for patients with dementia and identified non-pharmacologic antipsychotic substitutes. The quality of evidence supporting the most likely antipsychotic substitutes was assessed using a modified GRADE approach. RESULTS Among 36 (65%) of LTC clinicians responding, the pharmacologic candidates deemed likely or somewhat likely to be substituted for an antipsychotic were: valproic acid, serotonin modulator antidepressants, short-acting benzodiazepines, serotonin reuptake inhibitor antidepressants, alpha-adrenoceptor antagonist, buspirone, acetaminophen, serotonin-norepinephrine reuptake inhibitor antidepressants, memantine, and a cholinesterase inhibitor. High quality evidence supporting these substitutions existed for only memantine and cholinesterase inhibitors, while high quality evidence cautioning against this substitution existed for valproic acid. Activities and music therapy were the most commonly cited non-pharmacologic substitutes but the supporting evidence for each is sparse. CONCLUSION Perceptions of LTC clinicians regarding substitutes for antipsychotics in LTC patients with dementia vary widely and are often discordant with published evidence.
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Affiliation(s)
- Brianne L. Olivieri-Mui
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Aileen Ochoa
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Danielle Schenck
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Becky Briesacher
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
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Zhang Y, Letuchy EM, Carnahan RM. Where Are Antipsychotics Prescribed in Nursing Homes Initiated? J Am Geriatr Soc 2018; 66:1082-1088. [PMID: 29355891 PMCID: PMC6935510 DOI: 10.1111/jgs.15223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To describe the settings of care in which antipsychotics that nursing home (NH) residents received were likely to have been initiated. DESIGN Cross-sectional. SETTING Iowa NHs. PARTICIPANTS Fee-for-service Medicare beneficiaries who had NH stays between January 1, 2011, and December 31, 2014, and had new use of antipsychotics during their NH stays, defined as no antipsychotic use in NHs in the last 6 months. MEASUREMENTS A linked dataset of Chronic Condition Data Warehouse Medicare claims and Long-Term Care Minimum Data Set (MDS) 3.0 was used to determine care settings of antipsychotic initiations. RESULTS Of 7,496 residents with new antipsychotic use in NHs, 4,794 (64.0%, 95% confidence interval (CI) = 62.9-65.0%) initiated them in NHs, 1,392 (18.6%, 95% CI 17.7-19.5%) appeared to have had them initiated in hospitals, and 1,310 (17.5%, 95% CI = 16.6-18.3%) had antipsychotics first dispensed as outpatients. Antipsychotics were commonly prescribed during the early NH stays, and 3,026 (40.4%, 95% CI = 39.3-41.5%) of the entire sample received antipsychotic therapy within the first 7 days after NH admissions. Fifty-eight percent (n = 4,348) of the study residents initiating antipsychotics had potentially appropriate antipsychotic indications according toMDS records. CONCLUSION Most residents initiated antipsychotic therapy in NHs, confirming that NH providers are appropriate primary target of interventions to reduce antipsychotic initiation in their residents. However, many antipsychotics were continued from other settings, indicating a need to evaluate the necessity of continued antipsychotic treatment after such transitions of care. J Am Geriatr Soc 66:1082-1088: 2018.
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Affiliation(s)
- Yan Zhang
- From the Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Elena M Letuchy
- From the Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Ryan M Carnahan
- From the Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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Arnold I, Straube K, Himmel W, Heinemann S, Weiss V, Heyden L, Hummers-Pradier E, Nau R. High prevalence of prescription of psychotropic drugs for older patients in a general hospital. BMC Pharmacol Toxicol 2017; 18:76. [PMID: 29202811 PMCID: PMC5715648 DOI: 10.1186/s40360-017-0183-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 11/23/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many elderly patients receive psychotropic drugs. Treatment with psychotropic agents is associated with serious side effects including an increased risk of falls and fractures. Several psychotropic drugs are considered potentially inappropriate for treatment of the elderly. METHODS A retrospective chart review was conducted covering all patients aged ≥ 65 years who were admitted to Evangelisches Krankenhaus Göttingen-Weende between 01/01/2013 and 03/31/2013. Psychotropic drugs reviewed for included benzodiazepines, Z-drugs, antidepressants and neuroleptics, but not drugs for sedation during artificial ventilation or pre-medication before surgery. Potentially inappropriate drugs were identified according to the PRISCUS list. To assess which factors were associated with the administration of psychotropic drugs, univariate and multivariable logistic regression analyses were performed. RESULTS The charts of 2130 patients (1231 women) were analyzed. 53.9% of all patients received at least one psychotropic medication (29.5% benzodiazepines, 12.6% Z-drugs, 22.2% antidepressants, 11.9% neuroleptics). The mean number of psychotropic drugs prescribed per patient with at least one prescription was 1.6. Patients treated in the geriatric department most often received antidepressants (45.0%), neuroleptics (20.6%) and Z-drugs (27.5%). Benzodiazepines and Z-drugs were prescribed mostly as medication on demand (77.7% of benzodiazepines, 73.9% of Z-drugs). Surgical patients most frequently received benzodiazepines (37.1%). Nearly one-third of all patients ≥ 65 years was treated with at least one potentially inappropriate psychotropic medication. The mean number of potentially inappropriate psychotropic medications per patient with at least one psychotropic prescription was 0.69. The percentage of patients with potentially inappropriate psychotropic medication was highest in the surgical departments (74.1%). Female gender (adjusted OR 1.36; 95% CI 1.14 to 1.63), stay in the Department of Geriatrics (2.69; 2.01 to 3.60) or the interdisciplinary intensive care unit (1.87; 1.33 to 2.64) and age ≥ 85 years (1.33; 1.10 to 1.60) were associated with psychotropic drug treatment. CONCLUSIONS A high percentage of patients aged ≥ 65 years received psychotropic drugs. The chance that a potentially inappropriate psychotropic drug would be administered was highest in the surgical departments. Antidepressants, neuroleptics and Z-drugs were used surprisingly often in geriatric medicine. Educational strategies could reduce the use of psychotropic drugs and the prescription of potentially inappropriate medications.
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Affiliation(s)
- Inken Arnold
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany.,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany
| | - Kati Straube
- Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.,Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany.,Department of Internal Medicine, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany
| | - Wolfgang Himmel
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Stephanie Heinemann
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Vivien Weiss
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Laura Heyden
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany.,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.,Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Eva Hummers-Pradier
- Department of General Practice, University Medical Center Göttingen, Humboldtallee 38, 37073, Göttingen, Germany
| | - Roland Nau
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37075, Göttingen, Germany. .,Institute of Neuropathology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Germany.
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Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia. Int Psychogeriatr 2017; 29:1391-1403. [PMID: 28266282 DOI: 10.1017/s1041610217000084] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management. METHODS LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations. CONCLUSION While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.
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Kirkham J, Sherman C, Velkers C, Maxwell C, Gill S, Rochon P, Seitz D. Antipsychotic Use in Dementia. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2017; 62:170-181. [PMID: 28212496 PMCID: PMC5317021 DOI: 10.1177/0706743716673321] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.
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Affiliation(s)
- Julia Kirkham
- Department of Psychiatry, Queen’s University, Kingston, Ontario
| | - Chelsea Sherman
- Department of Psychiatry, Queen’s University, Kingston, Ontario
| | - Clive Velkers
- Department of Psychiatry, Queen’s University, Kingston, Ontario
| | - Colleen Maxwell
- Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario
| | - Sudeep Gill
- Division of Geriatric Medicine, Department of Medicine, Queen’s University, Kingston, Ontario
| | - Paula Rochon
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario
| | - Dallas Seitz
- Department of Psychiatry, Queen’s University, Kingston, Ontario
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Cioltan H, Alshehri S, Howe C, Lee J, Fain M, Eng H, Schachter K, Mohler J. Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review. BMC Geriatr 2017; 17:32. [PMID: 28122506 PMCID: PMC5267409 DOI: 10.1186/s12877-017-0428-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. METHODS We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic. RESULTS Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality. CONCLUSIONS Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement.
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Affiliation(s)
- Hannah Cioltan
- College of Public Health, University of Arizona, Tucson, Arizona, USA.
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA.
| | - Samah Alshehri
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Carol Howe
- University of Arizona Health Sciences Library, Tucson, USA
| | - Jeannie Lee
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Mindy Fain
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Howard Eng
- College of Public Health, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Kenneth Schachter
- College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Jane Mohler
- College of Public Health, University of Arizona, Tucson, Arizona, USA
- Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA
- College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
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Tjia J, Lemay CA, Bonner A, Compher C, Paice K, Field T, Mazor K, Hunnicutt JN, Lapane KL, Gurwitz J. Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes. J Am Geriatr Soc 2017; 65:59-65. [PMID: 27550398 PMCID: PMC5258777 DOI: 10.1111/jgs.14299] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented. DESIGN Mixed-methods study based on semistructured interviews. SETTING U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX). PARTICIPANTS Family members of nursing home residents (N = 41). MEASUREMENTS Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent. RESULTS Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started. CONCLUSION Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | - Kelli Paice
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Terry Field
- University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Primary Care Institute, Worcester, MA, USA
| | - Kathleen Mazor
- University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Primary Care Institute, Worcester, MA, USA
| | | | - Kate L. Lapane
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry Gurwitz
- University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Primary Care Institute, Worcester, MA, USA
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Kuo CL, Chien IC, Lin CH. Trends, correlates, and disease patterns of antipsychotic use among elderly persons in Taiwan. Asia Pac Psychiatry 2016; 8:278-286. [PMID: 26667822 DOI: 10.1111/appy.12230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 11/09/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION We used the population-based database to investigate the trends, correlates, and disease patterns of antipsychotic use among elderly people in Taiwan. METHODS The National Health Research Institutes provided a database of 1,000,000 random subjects for health service studies. We analyzed a sample of subjects over the age of 65 years from 1997 to 2005. The trends in and factors associated with antipsychotic use were detected. We also examined the proportions of antipsychotics used for psychiatric and medical disorders. RESULTS The 1-year prevalence of antipsychotic use in elderly persons increased from 9.8% in 1997 to 12.8% in 2005. The prevalence of first-generation antipsychotic (FGA) use increased from 9.8% to 11.6%, and the prevalence of second-generation antipsychotic (SGA) use increased greatly from 0.01% to 2.02%. Higher prevalence of both FGAs and SGAs were associated with age and higher Charlson Comorbidity Index scores. Psychiatric disorders were commonly found in SGA users (80.8%), whereas only 19.3% of the FGA users had psychiatric disorders. Among the major psychiatric disorders, greater proportions of antipsychotic use were for senile and presenile organic psychotic conditions, other organic psychotic conditions, and affective psychoses. FGAs were much more commonly prescribed for nonpsychiatric disorders, including diseases of symptoms, signs, and ill-defined conditions, the digestive system, and the respiratory system. DISCUSSION The prevalence of antipsychotic use, particularly the use of SGAs, increased greatly from 1997 to 2005 among elderly persons in Taiwan. SGAs were most used by subjects with psychiatric disorders, and FGAs were most used by those with nonpsychiatric disorders.
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Affiliation(s)
- Chia-Lun Kuo
- Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan.,Central Taiwan University of Science and Technology, Taichung, Taiwan
| | - I-Chia Chien
- Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan. , .,Department of Public Health & Institute of Public Health, National Yang-Ming University, Taipei, Taiwan. ,
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Murphy AL, Gardner DM, Kisely S, Cooke CA, Kutcher SP, Hughes J. System struggles and substitutes: A qualitative study of general practitioner and psychiatrist experiences of prescribing antipsychotics to children and adolescents. Clin Child Psychol Psychiatry 2016; 21:634-648. [PMID: 26614572 PMCID: PMC5094295 DOI: 10.1177/1359104515617518] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians' experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers' experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.
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Affiliation(s)
- Andrea L Murphy
- College of Pharmacy, Dalhousie University, Canada .,Department of Psychiatry, Dalhousie University, Canada
| | - David M Gardner
- College of Pharmacy, Dalhousie University, Canada.,Department of Psychiatry, Dalhousie University, Canada
| | - Steve Kisely
- School of Population Health, University of Queensland, Australia
| | | | - Stanley P Kutcher
- Department of Psychiatry, Dalhousie University, Canada.,Sun Life Financial Chair in Adolescent Mental Health, Dalhousie University and IWK Health Centre, Canada
| | - Jean Hughes
- School of Nursing, Dalhousie University, Canada
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Abstract
The aim of this study was to investigate the characteristics and treatment patterns of older antipsychotic (AP) users in Germany. We carried out a cohort study in the German Pharmacoepidemiological Research Database and identified new AP users aged at least 65 years between 2005 and 2011. Possible indications, comedication, and information on persistence and adherence, concurrent multiple use, and switch of APs were assessed. Overall, 298,847 individuals were included in the cohort. Almost 70% entered the cohort with a typical antipsychotic (TAP). Melperone (23.4%) was used most frequently, followed by promethazine (18.3%), sulpiride (11.0%), and risperidone (10.3%). AP users had a low prevalence of schizophrenia and bipolar disorders in contrast to dementia. Initiators of atypical antipsychotics had more treatment episodes compared with TAPs (median 3 vs. 2), but lower median persistence (14 vs. 22 days). Persistence was also lower in patients with, rather than without, dementia. The overall percentage of concurrent multiple use and switch to other APs was low with 5.6%, but higher in patients with, rather than without, dementia. In conclusion, APs were used for a broad range of indications, mostly other than schizophrenia and bipolar disorders. Low persistence and a high number of treatment episodes suggest frequent 'as-needed' treatment, especially in dementia patients.
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Selbæk G, Aarsland D, Ballard C, Engedal K, Langballe EM, Benth JŠ, Bergh S. Antipsychotic Drug Use Is Not Associated With Long-Term Mortality Risk in Norwegian Nursing Home Patients. J Am Med Dir Assoc 2016; 17:464.e1-7. [PMID: 26935533 DOI: 10.1016/j.jamda.2016.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the long-term mortality risk associated with antipsychotic drug (AP) use in nursing homes. DESIGN A longitudinal study with 5 assessments over a 75-month follow-up period. SETTING A representative sample of nursing home patients in 4 Norwegian counties. PARTICIPANTS At baseline, 1163 patients were included. At the last follow-up, 98 patients were still alive. MEASUREMENTS Prevalent drug use at each assessment was registered. Level of dementia, neuropsychiatric symptoms, level of functioning, medical health, and use of restraints were recorded at each assessment. A Cox regression model with time-dependent psychotropic drug use as the main predictor was estimated and adjusted for confounders. RESULTS In unadjusted Cox regression, a lower mortality risk was associated with the use of other psychotropic drugs, but not APs, compared with nonusers. In the adjusted analysis, neither use of APs nor other psychiatric drugs was associated with increased mortality risk. Higher age, male gender, not being married, medical disease burden, lower level of functioning, more severe degree of dementia, and a higher number of drugs were all associated with increased mortality risk. CONCLUSION In this long-term study of nursing home patients, AP drug use was not associated with increased risk of mortality. This is in line with results from earlier studies of clinical samples, but contrasts with results from randomized controlled trials and registry-based studies. The findings should be interpreted with caution. Taking into account the modest benefit and high risk of adverse effects of AP drug use, nonpharmacological treatment remains the first-line treatment approach.
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Affiliation(s)
- Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway.
| | - Dag Aarsland
- Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway; Department NVS, Karolinska Institutet, Center for Alzheimer Research, Stockholm, Sweden
| | - Clive Ballard
- Wolfson Centre for Age-Related Diseases, King's College, London, UK
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway; Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Ellen Melbye Langballe
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway; Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway; Wolfson Centre for Age-Related Diseases, King's College, London, UK; Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lorenskog, Norway
| | - Sverre Bergh
- Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
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Tjia J, Reidenberg MM, Hunnicutt JN, Paice K, Donovan JL, Kanaan A, Briesacher BA, Lapane KL. Approaches to Gradual Dose Reduction of Chronic Off-Label Antipsychotics Used for Behavioral and Psychological Symptoms of Dementia. THE CONSULTANT PHARMACIST : THE JOURNAL OF THE AMERICAN SOCIETY OF CONSULTANT PHARMACISTS 2015; 30:599-611. [PMID: 26450142 PMCID: PMC8092101 DOI: 10.4140/tcp.n.2015.599] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Little is known about how to best taper antipsychotics used in patients with dementia. To address this gap, we reviewed published antipsychotic discontinuation trials to summarize what is known about tapering strategies for antipsychotics used with older adults with dementia. We further developed pharmacokinetic-based gradual dose reduction (GDR) protocols based on antipsychotic half-lives. DATA SOURCES MEDLINE, EMBASE, and International Pharmaceutical Abstracts were searched up to October 2014 to identify intervention studies reporting the behavioral and psychological symptoms of dementia outcomes resulting from discontinued off-label use of antipsychotics in nursing facility populations. Recently published pharmacokinetic reviews and standard pharmacology texts were used to determine antipsychotic drug half-lives for the pharmacokinetic-based GDR protocols. STUDY SELECTION For the review, studies with an intervention resulting in antipsychotic medication discontinuation or tapering were eligible, including randomized controlled trials and pre- and post-intervention studies. DATA EXTRACTION When available, we extracted the protocols used for antipsychotic GDR from each study included in the review. DATA SYNTHESIS We found that clinical trials used different approaches to antipsychotic discontinuation, including abrupt discontinuation, slow tapers (more than two weeks), and mixed strategies based on drug dosage. None of the published trials described an approach based on pharmacokinetic principles. We developed a two-stage GDR protocol for tapering antipsychotic medications based on the log dose-response relationship; each stage was designed to result in a 50% dose reduction prior to discontinuation. This pharmacologically based strategy for patients chronically prescribed antipsychotics resulted in recommendations for slow tapers. CONCLUSION Our theoretically derived GDR recommendations suggest a different approach than previously published in clinical trials. Further study is needed to evaluate the effect of this approach on patients.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Mattingly TJ. A Review Exploring the Relationship Between Nursing Home Staffing and Antipsychotic Medication Use. Neurol Ther 2015; 4:169-75. [PMID: 26662363 PMCID: PMC4685870 DOI: 10.1007/s40120-015-0032-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Indexed: 12/02/2022] Open
Abstract
Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.
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Affiliation(s)
- T Joseph Mattingly
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.
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Urick BY, Kaskie BP, Carnahan RM. Improving antipsychotic prescribing practices in nursing facilities: The role of surveyor methods and surveying agencies in upholding the Nursing Home Reform Act. Res Social Adm Pharm 2015; 12:91-103. [PMID: 25990258 DOI: 10.1016/j.sapharm.2015.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/18/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Inappropriate prescribing of antipsychotics is a longstanding challenge to providing high quality care in nursing facilities. The 1987 Nursing Home Reform Act (NHRA) had an initial impact in reducing inappropriate prescribing, but rates returned to pre-NHRA levels. While the recent Partnership to Improve Dementia Care in Nursing Homes (Partnership) initiative has been successful in reducing the prescribing of antipsychotics in skilled nursing facilities/nursing facilities (NF), it is not known how this guidance initiative impacted prescribing practices and other care processes concerning NF residents with dementia. OBJECTIVES The objectives of this study were to explore surveyor observations of NF care practices subsequent to participation the Partnership guidance program and to use a social ecological framework to estimate how these observations were influenced by individual, organizational, and contextual factors. METHODS A total of 320 NF surveyors responded to a 49-item questionnaire designed in collaboration with CMS officials and state surveying agency personnel, and distributed by state agency directors. Three outcome variables: measuring improvements in clinical care, deficiencies in clinical care, and falsification of records in response to the Partnership initiative, were created from survey responses. A four-level social ecological framework describing the NF surveyor's environment was used to identify potential influences on surveyors' care observations. Logistic regression was used to evaluate the relationship between environment and outcome variables. RESULTS Surveyors observed both improvements in clinical care, including 80.6% reporting nursing facility providers responding to consultant pharmacists' recommendations, and deficits in clinical care in response to the Partnership initiative. Furthermore, 39.7% of surveyors observed a new, but false, diagnosis of psychosis (as defined by the surveyor). Surveyor characteristics and methods and surveying agency and culture were found to substantially impact the success of the Partnership initiative. The most distal level of the framework evaluated in this study, state contextual effects, was found not to impact care observations. CONCLUSIONS There is substantial variation in surveyor observations of changes to clinical care in response to the Partnership guidance initiative. Further investigation is needed into the type and severity of falsification of records observed by nursing facility surveyors. When constructing interventions to care for residents in NFs, policymakers must consider the environment in which surveyors operate.
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Caring for people with dementia and challenging behaviors in nursing homes: A needs assessment geriatric nursing. Geriatr Nurs 2015; 36:182-91. [DOI: 10.1016/j.gerinurse.2015.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/29/2014] [Accepted: 01/05/2015] [Indexed: 01/13/2023]
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Pimentel CB, Donovan JL, Field TS, Gurwitz JH, Harrold LR, Kanaan AO, Lemay CA, Mazor KM, Tjia J, Briesacher BA. Use of atypical antipsychotics in nursing homes and pharmaceutical marketing. J Am Geriatr Soc 2015; 63:297-301. [PMID: 25688605 DOI: 10.1111/jgs.13180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs. DESIGN Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial. SETTING Forty-one NHs in Connecticut. PARTICIPANTS NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%). MEASUREMENTS Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing. RESULTS Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader. CONCLUSION NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.
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Affiliation(s)
- Camilla B Pimentel
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Kaskie BP, Nattinger M, Potter A. Policies to protect persons with dementia in assisted living: déjà vu all over again? THE GERONTOLOGIST 2015; 55:199-209. [PMID: 26035596 PMCID: PMC4542835 DOI: 10.1093/geront/gnu179] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/04/2014] [Indexed: 11/12/2022] Open
Abstract
Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.
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Affiliation(s)
- Brian P Kaskie
- Department of Health Management & Policy, The University of Iowa.
| | | | - Andrew Potter
- Department of Health Management & Policy, The University of Iowa
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Tjia J, Briesacher BA, Peterson D, Liu Q, Andrade SE, Mitchell SL. Use of medications of questionable benefit in advanced dementia. JAMA Intern Med 2014; 174:1763-71. [PMID: 25201279 PMCID: PMC4689196 DOI: 10.1001/jamainternmed.2014.4103] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized. OBJECTIVES To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010. MAIN OUTCOMES AND MEASURES Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes. RESULTS Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications. CONCLUSIONS AND RELEVANCE Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.
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Affiliation(s)
- Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Becky A Briesacher
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester
| | | | - Qin Liu
- Wistar Institute, University of Pennsylvania, Philadelphia
| | | | - Susan L Mitchell
- Hebrew Senior Life, Institute for Aging Research, Boston, Massachusetts
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Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry 2014; 71:1006-14. [PMID: 25006837 PMCID: PMC4703317 DOI: 10.1001/jamapsychiatry.2014.436] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE In 2011, an estimated 26.8 million US adults used prescription medications for mental illness. OBJECTIVE To estimate the numbers and rates of adverse drug event (ADE) emergency department (ED) visits involving psychiatric medications among US adults between January 1, 2009, and December 31, 2011. DESIGN AND SETTING Descriptive analyses of active, nationally representative surveillance of ADE ED visits using the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance system and of drug prescribing during outpatient visits using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. PARTICIPANTS Medical records from national probability samples of ED and outpatient visits by adults 19 years or older were reviewed and analyzed. EXPOSURES Antidepressants, antipsychotics, lithium salts, sedatives and anxiolytics, and stimulants. MAIN OUTCOMES AND MEASURES National estimates of ADE ED visits resulting from therapeutic psychiatric medication use and of psychiatric medication ADE ED visits per 10,000 outpatient visits at which psychiatric medications were prescribed. RESULTS From 2009 through 2011, there were an estimated 89,094 (95% CI, 68,641-109,548) psychiatric medication ADE ED visits annually, with 19.3% (95% CI, 16.3%-22.2%) resulting in hospitalization and 49.4% (95% CI, 46.5%-52.4%) involving patients aged 19 to 44 years. Sedatives and anxiolytics, antidepressants, antipsychotics, lithium salts, and stimulants were implicated in an estimated 30,707 (95% CI, 23,406-38,008), 25,377 (95% CI, 19,051-31,704), 21,578 (95% CI, 16,599-26,557), 3620 (95% CI, 2311-4928), and 2779 (95% CI, 1764-3794) respective ADE ED visits annually. Antipsychotics and lithium salts were implicated in 11.7 (95% CI, 10.1-13.2) and 16.4 (95% CI, 13.0-19.9) ADE ED visits per 10,000 outpatient prescription visits, respectively, compared with 3.6 (95% CI, 3.2-4.1) for sedatives and anxiolytics, 2.9 (95% CI, 2.3-3.5) for stimulants, and 2.4 (95% CI, 2.1-2.7) for antidepressants. The commonly used sedative zolpidem tartrate was implicated in 11.5% (95% CI, 9.5%-13.4%) of all adult psychiatric medication ADE ED visits and in 21.0% (95% CI, 16.3%-25.7%) of visits involving adults 65 years or older, in both cases significantly more than any other psychiatric medication. CONCLUSIONS AND RELEVANCE Psychiatric medications are implicated in many ADEs treated in US EDs. Efforts to reduce ADEs should include adults of all ages but might prioritize medications causing high numbers and rates of ED visits.
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Affiliation(s)
- Lee M. Hampton
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew Daubresse
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Hsien-Yen Chang
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, The Johns Hopkins University, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland5Department of Medicine, The Johns Hopkins University School of Med
| | - Daniel S. Budnitz
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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de Mauleon A, Sourdet S, Renom-Guiteras A, Gillette-Guyonnet S, Leino-Kilpi H, Karlsson S, Bleijlevens M, Zabategui A, Saks K, Vellas B, Jolley D, Soto M. Associated factors with antipsychotic use in long-term institutional care in eight European countries: Results from the RightTimePlaceCare study. J Am Med Dir Assoc 2014; 15:812-8. [PMID: 25129474 DOI: 10.1016/j.jamda.2014.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 06/15/2014] [Accepted: 06/19/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine factors associated with the antipsychotic (AP) prescription for people with dementia (PwD) recently admitted to institutional long-term care facilities (LTCFs) and to ascertain differences in the use of this medication in 8 European countries. DESIGN An exploratory cross-sectional study. SETTING LTCFs from 8 European countries (Estonia, Finland, France, Germany, The Netherlands, Spain, Sweden, and England). PARTICIPANTS A total of 791 PwD recently admitted to an LTCF and their caregivers. MEASUREMENTS Baseline data from RightTimePlaceCare survey was used. Patients' medical conditions, neuropsychiatric symptoms, physical and cognitive status, and medications were recorded. Multiple logistic regression models were used to assess associations with the AP use. RESULTS A group of 296 patients (37.4%) of 791 patients recently admitted received AP medication. The prevalence of the use of 1 or more APs varied between study countries, ranging from 12% in Sweden to 54% in Spain. Factors independently associated with the AP use were living in Sweden [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.05-0.30], Finland (OR 0.26, 95% CI 0.14-0.48), Germany (OR 2.75, 95% CI 1.55-4.86) and Estonia (OR 6.79, 95% CI 3.84-12.0). The odds of AP use decreased with the presence of a dementia specific unit in the LTCF (OR 0.60, 95% CI 0.39-0.92), but was higher among residents with a hyperactivity behavior (OR 2.12, 95% CI 1.41-3.18). CONCLUSION The current study shows that more than one-third of the residents recently admitted received APs and that prescription frequency across countries varied significantly. This study raises the possibility that the presence of a dementia-specific unit might play a role in the AP use. Further studies should investigate this association and seek better understanding of what will achieve optimal quality of AP use among newly admitted residents in LTCF.
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Affiliation(s)
- Adelaide de Mauleon
- Department of Geriatric Medicine, Gerontopole, Toulouse University Hospital, INSERM 1027, Toulouse, France
| | - Sandrine Sourdet
- Department of Geriatric Medicine, Gerontopole, Toulouse University Hospital, INSERM 1027, Toulouse, France
| | - Anna Renom-Guiteras
- Institut fuer Allgemeinmedizin und Familienmedizin, Universitaet Witten/Herdecke, Witten, Germany
| | - Sophie Gillette-Guyonnet
- Department of Geriatric Medicine, Gerontopole, Toulouse University Hospital, INSERM 1027, Toulouse, France
| | | | | | - Michel Bleijlevens
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Kai Saks
- Department of Internal Medicine, University of Tartu, Tartu, Estonia
| | - Bruno Vellas
- Department of Geriatric Medicine, Gerontopole, Toulouse University Hospital, INSERM 1027, Toulouse, France
| | - David Jolley
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Maria Soto
- Department of Geriatric Medicine, Gerontopole, Toulouse University Hospital, INSERM 1027, Toulouse, France.
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Konetzka RT, Brauner DJ, Shega J, Werner RM. The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment. J Am Geriatr Soc 2014; 62:454-61. [PMID: 24617991 DOI: 10.1111/jgs.12711] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment. DESIGN Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs. SETTING Medicare- and Medicaid-certified NHs in the United States. PARTICIPANTS Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states. INTERVENTION Public reporting of physical restraint use rates. MEASUREMENTS Use of physical restraints and antipsychotic medications. RESULTS Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints. CONCLUSION This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.
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Affiliation(s)
- R Tamara Konetzka
- Department of Health Studies, University of Chicago, Chicago, Illinois
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Rojas-Fernandez C, Mikhail M, Brown SG. Psychotropic and Cognitive-Enhancing Medication Use and Its Documentation in Contemporary Long-term Care Practice. Ann Pharmacother 2014; 48:438-46. [DOI: 10.1177/1060028013520196] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: In long-term care (LTC) settings, use of psychotropic medications to manage behavioral and psychological symptoms of dementia and use of cognitive enhancers are commonplace. It is important that these medications are properly used to ensure resident well-being, and thus, it is paramount to understand use of these medications in contemporary practice to develop appropriate quality improvement initiatives. Objective: To characterize psychotropic and cognition-enhancing medication use LTC residents and current trends in documentation. Methods: Cross-sectional chart review of residents aged >65 years with dementia receiving psychotropic medications and/or cognitive enhancers. Results: From 180 residents, 84 (82% female) met inclusion criteria (average age 86 years). The prevalence of psychotropic medication use was as follows: cognitive enhancers, 71%; antidepressants, 98%; antipsychotics, 61%; sedative hypnotics, 23%. Quetiapine was the most commonly used antipsychotic (48%), followed by risperidone (28%) and olanzapine (15%), all of which were dosed within accepted guidelines. The duration of therapy ranged from 2 to 5 years for antipsychotic medications and 1¼ to 3 years for antidepressants. Documentation documentation rates were hightest for psychotropics versus cognitive enhancers. There was no documentation of attempts to lower doses or discontinue psychotropic medications or cognitive enhancers. Conclusions: Many, but not all psychotropics used were acceptable choices. The duration of therapy appears to be excessive for antipsychotic medications. Documentation of ongoing need for medications varied and could be improved on to better assess residents’ medication regimens. Further research will inform efforts to enhance the care of these residents.
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Affiliation(s)
- Carlos Rojas-Fernandez
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada
- Schlegel-University of Waterloo Research Institute for Ageing, Kitchener, ON, Canada
| | | | - Susan G. Brown
- Schlegel-University of Waterloo Research Institute for Ageing, Kitchener, ON, Canada
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