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Randle JM, Heckman G, Oremus M, Ho J. Intermittent antipsychotic medication and mortality in institutionalized older adults: A scoping review. Int J Geriatr Psychiatry 2019; 34:906-920. [PMID: 30907448 DOI: 10.1002/gps.5106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 03/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE/BACKGROUND Antipsychotic use appears to increase mortality risk among older adults with dementia. Whether this risk is similar for regular or intermittent use is unknown. This scoping review aims to explore the temporal association between antipsychotic use and mortality risk for older institutionalized adults. METHOD We conducted a scoping review using Medline (PubMed), EMBASE, CINAHL, and the Cochrane libraries between October 2018 and January 2019. RESULTS Twenty-eight articles met review criteria. We found that different antipsychotic medications present different safety profiles. The risk of mortality was highest with conventional antipsychotic use and within 40 days of antipsychotic initiation. CONCLUSIONS Conventional antipsychotic use increases mortality for older institutionalized adults. The evidence for atypical antipsychotics is less clear. Mortality risk appears highest within 30 to 40 days of initiating antipsychotic treatment. This temporal association suggests increased mortality may actually be the result of some previously unrecognized illness, comorbidity, change in health status, or increased frailty, rather than an idiosyncrasy of the antipsychotic itself.
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Affiliation(s)
- Jason M Randle
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Schlegel Research Institute for Aging, Waterloo, Ontario, Canada
| | - Mark Oremus
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanne Ho
- Schlegel Research Institute for Aging, Waterloo, Ontario, Canada.,Department of Medicine, McMaster University, Kitchener, Ontario, Canada
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Haw C, Yorston G, Stubbs J. Guidelines on antipsychotics for dementia: are we losing our minds? PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.107.017947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodThe National Institute for Health and Clinical Excellence (NICE) and the Royal College of Psychiatrists have each issued guidance on the use of antipsychotics for behavioural and psychiatric symptoms of dementia (BPSD). We sent all old age psychiatrists an anonymous questionnaire asking for their opinions on these documents and for details of their use of antipsychotics for BPSD.ResultsThe response rate was 202 out of 648 (31.2%). the two documents, though similar in content provoked very different responses, with the College guidance being much more favourably received. All respondents prescribed antipsychotics for BPSD, most commonly quetiapine.Clinical ImplicationsWhen prescribing antipsychotics for behavioural and psychiatric symptoms of dementia, psychiatrists should take both NICE and College guidelines into account and use their clinical judgement.
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Saleh N, Penning M, Cloutier D, Mallidou A, Nuernberger K, Taylor D. Social Engagement and Antipsychotic Use in Addressing the Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities. Can J Nurs Res 2017; 49:144-152. [DOI: 10.1177/0844562117726253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nasrin Saleh
- School of Nursing, University of Victoria, British Columbia, Canada
| | - Margaret Penning
- Department of Sociology and Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada
| | - Denise Cloutier
- Department of Geography and Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada
| | | | - Kim Nuernberger
- British Columbia Trajectories in Care Project, University of Victoria, British Columbia, Canada
| | - Deanne Taylor
- Research and Knowledge Translation, Interior Health Authority, Research Affiliate, Fraser Health Authority, British Columbia, Canada
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Helvik AS, Šaltytė Benth J, Wu B, Engedal K, Selbæk G. Persistent use of psychotropic drugs in nursing home residents in Norway. BMC Geriatr 2017; 17:52. [PMID: 28193181 PMCID: PMC5307887 DOI: 10.1186/s12877-017-0440-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/02/2017] [Indexed: 08/23/2023] Open
Abstract
Background The prevalence of psychotropic drug (PTD) use in NH residents is high, but few have explored prevalence and persistency in PTD in NH residents and factors associated with persistency. This at the same time as we know that risk of side events may be higher with long- term use in older adults. Thus, the aim of this study was to describe the prevalence and persistence in use of PTD and to explore factors associated with persistence in use of PTD at two consecutive time points in nursing home (NH) residents. Methods We included 1163 NH residents in a 72-month longitudinal study with five assessments. Use of PTD, neuropsychiatric symptoms (NPS), severity of dementia and physical health were assessed each time. Results The prevalence over time and persistent use of antipsychotic drugs, antidepressants, anxiolytics and sedatives at two consecutive time points were high in residents with and without dementia. There was an association between greater NPS at the first time point, and persistent use of these drugs, but changes in NPS between time points, did not explain such use. A longer NH stay increased the odds for persistent use of antipsychotics. Conclusion Psychotropic drugs are frequently used as a long-term treatment among NH residents and are associated with severity of neuropsychiatric symptoms, but not with severity of dementia. Closer attention should be paid to follow-up of psychotropic drug treatment, and especially for long –term use of antipsychotics, since the duration of such treatment should be as short as possible.
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Affiliation(s)
- Anne-Sofie Helvik
- Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Postboks 8905, NO-7491, Trondheim, Norway. .,St Olavs University Hospital, Trondheim, Norway. .,Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,HØKH, Research Centre, Akershus University Hospital, Lørenskog, Norway.,Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Bei Wu
- Rory Meyers College of Nursing, New York University, New York, NC, USA
| | - Knut Engedal
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway
| | - Geir Selbæk
- Norwegian National Advisory Unit on Ageing and Health, Vestfold Health Trust, Tønsberg, Norway.,Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway.,Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Kuronen M, Kautiainen H, Karppi P, Hartikainen S, Koponen H. Antipsychotic drug use and associations with neuropsychiatric symptoms in persons with impaired cognition: a cross-sectional study. Nord J Psychiatry 2016; 70:621-5. [PMID: 27300080 DOI: 10.1080/08039488.2016.1191537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) in cognitive disorders impair quality of life, increase caregiver stress, and may lead to earlier institutionalization and death. The objective of this study was to investigate the use of antipsychotics among persons with cognitive impairment in home care and residential care, and its associations with NPS and personal characteristics. METHODS Data were collected in the South Savo Hospital District area with 105 000 inhabitants, where 66 of 68 institutions providing long-term residential care and 20 of 21 municipal home care producers joined the study. Nurses recorded the current use of drugs, the activities of daily living (ADL), prevalence of diagnosed dementia, and assessed the cognitive status and the prevalence of recent NPS based on the item list of the Neuropsychiatric Inventory (NPI). RESULTS The study population was 1909 persons with cognitive impairment, and 1188 of them lived in residential care. Antipsychotics were used by 563 (29.5%) persons in the whole study population. In residential care 448 (37.7%) used antipsychotics and the corresponding figure in home care was 115 (15.9%). In the multivariate analysis, the antipsychotic use was associated with living in residential care, benzodiazepine use, and with NPS symptoms agitation/aggression (OR =1.70, 95% CI =1.16-2.48), disinhibition (OR =2.33, 95% CI =1.31-4.15), hallucinations (OR =2.77, 95% CI =1.69-4.55), and delusions (OR =1.71, 95% CI =1.01-2.91). CONCLUSIONS Antipsychotic use was common among persons with cognitive impairment. The results suggest that antipsychotics are commonly used to treat hyperactivity and psychotic symptoms, especially in residential care.
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Affiliation(s)
- Marja Kuronen
- a South Savo Hospital District, Mikkeli Central Hospital , Mikkeli , Finland
| | - Hannu Kautiainen
- b Primary Care, University of Helsinki and Helsinki University Hospital , Helsinki , Finland ;,c Unit of Primary Health Care, Kuopio University Hospital , Kuopio , Finland
| | - Pertti Karppi
- a South Savo Hospital District, Mikkeli Central Hospital , Mikkeli , Finland
| | - Sirpa Hartikainen
- d School of Pharmacy, University of Eastern Finland , Joensuu , Finland ;,e Kuopio Research Center of Geriatric Care , Kuopio , Finland ;,f Department of Psychiatry , Kuopio University Hospital , Kuopio , Finland
| | - Hannu Koponen
- g Department of Psychiatry , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Szczepura A, Wild D, Khan AJ, Owen DW, Palmer T, Muhammad T, Clark MD, Bowman C. Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period. BMJ Open 2016; 6:e009882. [PMID: 27650756 PMCID: PMC5051335 DOI: 10.1136/bmjopen-2015-009882] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To assess associations between the launch of the National Dementia Strategy (NDS) and antipsychotic prescribing in long-term residential care (LTC) in England. SETTING AND PARTICIPANTS Retrospective analysis of prescribing patterns in 616 LTC institutions (31 619 residents) following launch of the NDS, using information from electronic medicines management system. PRIMARY AND SECONDARY OUTCOME MEASURES Antipsychotic prescribing point prevalence (PP) for all residents in a cross section of LTC settings over a 4-year period following NDS launch. Secondary outcomes included dosages, length of treatment and use of recommended second-generation antipsychotics (SGAs) versus first-generation antipsychotics (FGAs). Associations between facility-level PP values and institutional characteristics, resident demographics were explored. Variations across geographical areas examined. Prescription net ingredient costs calculated. RESULTS No statistically significant difference was observed in overall prescribing rates over the 4-year period (Kolmogorov-Smirnov (KS) test p=0.60), and there was no significant shift towards newer SGAs (KS test p=0.32). Dosages were above the maximum indicated in only 1.3% of cases, but duration of prescribing was excessive in 69.7% of cases. Care homes in the highest prescribing quintile were more likely to be located in a deprived area (rate ratio (Q5/Q1) RR=5.89, 95% CI 4.35 to 7.99), registered for dementia (RR=3.38, 95% CI 3.06 to 3.73) and those in the lowest quintile were more likely to be served by a single general practitioner (GP) practice (RR=0.48; 95% CI 0.37 to 0.63); p<0.001 all. A sixfold variation in PP levels was observed between geographical areas. The average annual expenditure on antipsychotics was £65.6 per person resident (2012 prices). CONCLUSIONS The NDS in England was not associated with reduced PP levels or the types of antipsychotic prescribing in care homes. Further research is needed to explore why. Clear standards specifying recommended agents, dosages and length of treatment, together with routine monitoring and greater accountability for antipsychotic prescribing, may be required.
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Affiliation(s)
- Ala Szczepura
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Deidre Wild
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - Amir J Khan
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - David W Owen
- Institute for Employment Research, University of Warwick, Coventry, UK
| | - Thomas Palmer
- Department Mathematics & Statistics, Lancaster University, Lancaster, UK
| | | | | | - Clive Bowman
- School of Health Sciences, City University London, London, UK
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Alanen HM, Pitkänen A, Suontaka-Jamalainen K, Kampman O, Leinonen E. Acute Psychogeriatric Inpatient Treatment Improves Neuropsychiatric Symptoms but Impairs the Level of Functioning in Patients with Dementia. Dement Geriatr Cogn Disord 2016; 40:290-6. [PMID: 26334962 DOI: 10.1159/000431087] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2015] [Indexed: 11/19/2022] Open
Abstract
AIMS To explore the impact of hospitalization on neuropsychiatric symptoms (NPS) and the level of functioning in patients with dementia. Our aim was also to study the influence of psychotropic medications. METHODS Behavioral disturbances, cognition and functional status of 89 patients were assessed using the Neuropsychiatric Inventory (NPI), Mini-Mental State Examination, Barthel Index, and Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCSADL). RESULTS The total NPI score decreased from 34.6 to 19.5 (p < 0.001), and ADL decreased from 32.2 to 21.7 (p < 0.001) during the hospital stay (mean of 44 days). For a change in ADL, only the effect of anxiolytics was significant (p = 0.045). For a change in NPI with antipsychotic and anxiolytic doses and Mini-Mental State Examination as covariates, no significant relationship was found. CONCLUSION NPS improved significantly during hospitalization, but neither antipsychotic nor anxiolytic medication use explained this improvement. In patients using anxiolytics, the functional decline was substantial. These results do not support anxiolytic use in demented patients with NPS.
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Affiliation(s)
- Hanna-Mari Alanen
- Neuropsychiatry and Geriatric Psychiatry, Tampere University Hospital, Tampere, Finland
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Stroka MA. Drug overprescription in nursing homes: an empirical evaluation of administrative data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:257-267. [PMID: 25749894 DOI: 10.1007/s10198-015-0676-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 02/23/2015] [Indexed: 06/04/2023]
Abstract
A widely discussed shortcoming of long-term care in nursing homes for the elderly is the inappropriate or suboptimal drug utilization, particularly of psychotropic drugs. Using administrative data from the largest sickness fund in Germany, this study was designed to estimate the effect of institutionalization on the drug intake of the frail elderly. Difference-in-differences propensity score matching techniques were used to compare drug prescriptions for the frail elderly who entered a nursing home with those who remained in the outpatient care system; findings suggest that nursing home residents receive more doses of antipsychotics, antidepressants, and analgesics. The potential overprescription correlates with estimated drug costs of about €87 million per year.
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Affiliation(s)
- Magdalena A Stroka
- RWI Essen, Essen, Germany.
- Department of Economics, Ruhr-Universität Bochum, Universitätsstr. 150, 44801, Bochum, Germany.
- WINEG-Scientific Institute of TK for Benefit and Efficiency in Health Care, Hamburg, Germany.
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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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Talaslahti T, Alanen HM, Hakko H, Isohanni M, Häkkinen U, Leinonen E. Change in antipsychotic usage pattern and risk of relapse in older patients with schizophrenia. Int J Geriatr Psychiatry 2013; 28:1305-11. [PMID: 23558986 DOI: 10.1002/gps.3962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 02/06/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to explore the use of first (FGAs) and second generation antipsychotics (SGAs) in older outpatients with schizophrenia and schizoaffective disorder. Factors associated with schizophrenic relapses were also studied. METHODS The study sample consisting of 8792 patients aged 64 years or more was collected from Finnish nationwide registers. The register data on the use of FGAs and SGAs were followed up between 1998 and 2003. Factors associated with psychiatric hospitalization in 1999 indicating relapse were studied using logistic regression analysis. RESULTS The use of SGAs increased from 2.8% to 12.4%, and the use of FGAs decreased from 57.5% to 39.4%. The use of a combination of SGAs and FGAs increased from 4.0% to 8.5%. The proportion of those who did not buy any antipsychotics varied between 35.8% and 39.7%. The number of patients hospitalized on psychiatric wards within a year (1999; relapsed) was 8.8%. Factors independently associated with relapse were use of combined FGAs and SGAs [odds ratio (OR) 1.70, p = 0.001] and use of antidepressants (OR 1.27, p = 0.019). Diagnosis of cardiovascular disease was negatively associated with risk of schizophrenic relapse (OR 0.84, p = 0.040). CONCLUSION The use of SGAs increased while the use of FGAs decreased in older outpatients with schizophrenia. Almost 40% of the study sample did not use any antipsychotic medication. The 1-year relapse rate was 8.8%. Several factors, such as combined use of FGAs and SGAs, or antidepressants, were associated with schizophrenic relapse, whereas cardiovascular disease showed a negative association with the relapse.
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Affiliation(s)
- Tiina Talaslahti
- Department of Psychiatry, Helsinki University Central Hospital, Finland
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Parsons C, Lapane K, Kerse N, Hughes C. Prescribing for older people in nursing homes: a review of the key issues. Int J Older People Nurs 2011; 6:45-54. [DOI: 10.1111/j.1748-3743.2010.00264.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Cornegé-Blokland E, Kleijer BC, Hertogh CMPM, van Marum RJ. Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers. J Am Med Dir Assoc 2010; 13:80.e1-6. [PMID: 21450216 DOI: 10.1016/j.jamda.2010.10.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Despite serious safety concerns, prescription rates of antipsychotics for the treatment of the behavioral and psychological symptoms of dementia remain high, especially in nursing homes. This high prevalence of antipsychotic use cannot be explained by the modest success rate reported in the literature. In this study, we aim at clarifying the reasons for prescribing an antipsychotic drug in behavioral and psychological symptoms of dementia and look at the role of nurses and family caregivers in the decision-making process that precedes the prescription of an antipsychotic drug. DESIGN Questionnaire used in a one-on-one interview with elderly care physicians, nurses, and family caregivers. SETTING We conducted a survey in 23 nursing homes in the Netherlands. METHOD On each dementia ward, the physician selected 1 or 2 patients who started antipsychotics most recently. An interviewer then held a structured questionnaire with the physician, the nurse, and the first relative of the patient. The first part of the interview consisted of questions about the general ideas of the physicians and the second part consisted of case-related questions to physicians, nurses, and family caregivers. RESULTS Physicians, nurses, and family caregivers generally consider the possible benefits of antipsychotics to outweigh the risk of side effects. The main reasons to start therapy are agitation and aggression. Physicians felt pressured by nurses to prescribe in 17% of cases. Physicians felt supported by the guideline of the Dutch Association of Elderly Care Physicians. The estimated average success rate in the discussed cases (the patient is expected to improve on the target behavior) among physicians was 50%, nurses reported 53%, and relatives 55%. The most frequently expected adverse reactions were increased fall risk, sedation, and parkinsonism. Nurses expected cognitive decline. The family felt insufficiently informed about the side effects in 44% of the cases. CONCLUSION The interviewed nursing home physicians and nurses expect almost half of their patients with dementia and behavioral disturbances to benefit from antipsychotic therapy. Serious side effects were expected to occur only sporadically. These expectations may contribute to the high rate of antipsychotic use among these patients.
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Bell JS, Taipale HT, Soini H, Pitkälä KH. Sedative load among long-term care facility residents with and without dementia: a cross-sectional study. Clin Drug Investig 2010; 30:63-70. [PMID: 19995099 DOI: 10.2165/11531460-000000000-00000] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE People with cognitive impairment are particularly susceptible to adverse drug events linked to sedative and psychotropic drugs. A model to calculate sedative load has been developed to quantify the cumulative effect of taking multiple drugs with sedative properties. The objective of this study was to describe the sedative load and use of sedative and psychotropic drugs among long-term care facility residents with and without dementia. METHODS Cross-sectional data were collected from all 53 long-term care wards in Helsinki, Finland, in September 2003. Of the 1444 eligible residents, consent to participate was obtained for 1087 (75%) residents. Medication and diagnostic data were available for 1052 residents. All drugs were classified using the Anatomical Therapeutic Chemical (ATC) classification system. Sedative load was calculated for each resident using a previously published four-group model. RESULTS Of the 1052 residents, 781 (74.2%) were determined to have dementia. Residents with and without dementia had a similar sedative load (mean 3.0 vs 2.7, p = 0.267), but residents with dementia were taking fewer drugs than residents without dementia (mean 6.7 vs 7.4, p = 0.011). Residents with dementia were more frequent users of antipsychotics (42.8% vs 32.8%, p = 0.004), but less frequent users of antidepressants (35.6% vs 46.1%, p = 0.002) and sedative-hypnotics (22.8% vs 27.7%, p = 0.003) than residents without dementia. The most frequently used primary sedatives among people with dementia were temazepam (n = 122, 15.6%), oxazepam (n = 98, 12.5%) and lorazepam (n = 95, 12.2%). The most frequently used drugs with sedation as a prominent adverse effect or preparations with a sedating component among people with dementia were citalopram (n = 183, 23.4%), risperidone (n = 155, 19.8%) and olanzapine (n = 73, 9.3%). CONCLUSIONS Residents with dementia were less frequent users of sedative-hypnotic drugs than residents without dementia. However, residents with and without dementia had a similar sedative load. Clinicians should be aware of the extent to which all individual drugs, not only those prescribed for intentional sedation, contribute to a resident's sedative load. The very high rates of sedative and psychotropic use observed in long-term care facility residents highlight the need for new strategies to optimize drug use.
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Affiliation(s)
- J Simon Bell
- Kuopio Research Centre of Geriatric Care, University of Kuopio, Box 1627 Kuopio 70211, Finland.
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Taipale HT, Bell JS, Soini H, Pitkälä KH. Sedative load and mortality among residents of long-term care facilities: a prospective cohort study. Drugs Aging 2010; 26:871-81. [PMID: 19761280 DOI: 10.2165/11317080-000000000-00000] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Older people are often prescribed multiple drugs with sedative properties. Most research has focused on specific classes of sedative and psychotropic drugs. The cumulative effect of taking multiple drugs with sedative properties has been termed 'sedative load'. Few previous studies have investigated the sedative load among residents of long-term care facilities. No previous studies have assessed the possible association between sedative load and mortality. OBJECTIVE The objective of this study was to describe the sedative load among residents of long-term care facilities, and to investigate a possible association between sedative load and mortality. METHODS This was a prospective cohort study. The study population comprised all 1444 residents of 53 long-term care wards in seven hospitals in Helsinki during September 2003. Of the eligible residents, 1087 residents or their proxies provided written informed consent to participate. Medical, medication and follow-up mortality data were available for 1004 residents. The main outcome measures were sedative load and all-cause mortality. RESULTS The mean age of the residents was 81.3 (SD 10.9) years, and the mean number of regularly used drugs per resident was 7.1 (SD 3.4). Fifteen percent of residents were categorized as non-users of sedative drugs, 32% as users of some drugs with sedative properties and 53% as residents with a high sedative load. There was a bivariate association between having a higher sedative load and younger age (p < 0.001), male sex (p = 0.006), not being widowed (p = 0.001), diagnosis of depression (p < 0.001), diagnosis of psychiatric illness other than depression (p < 0.001), not being diagnosed with dementia (p = 0.009) and a shorter duration of institutional care (p = 0.02). Unadjusted analysis revealed that having a higher sedative load was associated with increased survival (p = 0.04, log rank test). However, in the adjusted Cox proportional hazard model, only poor nutritional status (hazard ratio [HR] 1.55; 95% CI 1.32, 1.82), male sex (HR 1.37; 95% CI 1.12, 1.69), increasing age (HR 1.04; 95% CI 1.03, 1.05) and co-morbidity (HR 1.07; 95% CI 1.02, 1.13) were significantly associated with risk of death. CONCLUSIONS There is a very high rate of sedative and psychotropic drug use among residents of long-term care facilities in Helsinki. However, having a high sedative load was not associated with an increased risk of death. Further research is needed to investigate the possible association between sedative load and mortality using alternative models and methods, and in different resident populations.
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Affiliation(s)
- Heidi T Taipale
- Division of Social Pharmacy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
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Feng Z, Hirdes JP, Smith TF, Finne-Soveri H, Chi I, Pasquier JND, Gilgen R, Ikegami N, Mor V. Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study. Int J Geriatr Psychiatry 2009; 24:1110-8. [PMID: 19280680 PMCID: PMC3764453 DOI: 10.1002/gps.2232] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES This study compares inter- and intra-country differences in the prevalence of physical restraints and antipsychotic medications in nursing homes, and examines aggregated resident conditions and organizational characteristics correlated with these treatments. METHODS Population-based, cross-sectional data were collected using a standardized Resident Assessment Instrument (RAI) from 14,504 long-term care facilities providing nursing home level services in five countries participating in the interRAI consortium, including Canada, Finland, Hong Kong (Special Administrative Region, China), Switzerland, and the United States. Facility-level prevalence rates of physical restraints and antipsychotic use were examined both between and within the study countries. RESULTS The prevalence of physical restraint use varied more than five-fold across the study countries, from an average 6% in Switzerland, 9% in the US, 20% in Hong Kong, 28% in Finland, and over 31% in Canada. The prevalence of antipsychotic use ranged from 11% in Hong Kong, between 26-27% in Canada and the US, 34% in Switzerland, and nearly 38% in Finland. Within each country, substantial variations existed across facilities in both physical restraint and antipsychotic use rates. In all countries, neither facility case mix nor organizational characteristics were particularly predictive of the prevalence of either treatment. CONCLUSIONS There exists large, unexplained variability in the prevalence of physical restraint and antipsychotic use in nursing home facilities both between and within countries. Since restraints and antipsychotics are associated with adverse outcomes, it is important to understand the idiosyncratic factors specific to each country that contribute to variation in use rates.
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Affiliation(s)
- Zhanlian Feng
- Center for Gerontology & Health Care Research, The Warren Alpert Medical School, Brown University, Providence, RI 02903, USA.
| | - John P. Hirdes
- Department of Health Studies and Gerontology, University of Waterloo, Waterloo ON, Canada,Homewood Research Institute, Guelph ON, Canada
| | - Trevor F. Smith
- Department of Sociology, Nipissing University, North Bay, Ontario, Canada
| | | | - Iris Chi
- Golden Age Association Frances Wu Chair for Chinese Elderly, School of Social Work, University of Southern California, Los Angeles, CA, USA
| | | | - Ruedi Gilgen
- Klinik für Akutgeriatrie, Waidspital, Zürich, Switzerland
| | - Naoki Ikegami
- Department of Health Policy & Management, School of Medicine, Keio University, Shinjuku-ku, Tokyo,Japan
| | - Vincent Mor
- Department of Community Health, The Warren Alpert Medical School, Brown University, Providence RI, USA
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The course of behavioral problems in elderly nursing home patients with dementia when treated with antipsychotics. Int Psychogeriatr 2009; 21:931-40. [PMID: 19538831 DOI: 10.1017/s1041610209990524] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although antipsychotic treatment of behavioral problems in dementia is common, studies investigating the course of these symptoms in nursing homes are scarce. Our primary objective is therefore to describe the course of behavioral problems during antipsychotic treatment in a large sample of elderly nursing home patients with dementia. METHODS The course of behavioral problems during antipsychotic treatment was studied by comparing the characteristics of patients before, during and after antipsychotic treatment. The study was conducted using the VURAIDB, a database with over 40,000 assessments of over 10,000 nursing home residents in the Netherlands. We used the Challenging Behavior Profile (CBP) to measure an overall behavior score. RESULTS In total, 556 patients starting with antipsychotics were studied. Of these, 101 (18.2%) improved and 260 (46.8%) deteriorated at three months on the behavior score, compared with their scores before therapy (z = -7.955; P<0.0001). Patients with severe challenging behavior showed improvement more often than patients with mild disturbances. The course of behavioral symptoms after withdrawal was evaluated in 520 patients. Of these patients, 352 (68%) remained stable or improved at 3 months compared with their scores before withdrawal (z = -0.697; p = 0.486), this figure was 58% at 6 months after withdrawal (z = -2.77; p = 0.006). CONCLUSIONS During treatment of nursing home residents with dementia with antipsychotics the severity of most behavioral problems continues to increase in most patients, with only one out of six patients showing improvement. After withdrawal of antipsychotics, behavioral problems remained stable or improved in 58% of patients.
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Pouwels S, van Staa TP, Egberts ACG, Leufkens HGM, Cooper C, de Vries F. Antipsychotic use and the risk of hip/femur fracture: a population-based case-control study. Osteoporos Int 2009; 20:1499-506. [PMID: 19156348 PMCID: PMC2728222 DOI: 10.1007/s00198-008-0826-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 12/04/2008] [Indexed: 12/19/2022]
Abstract
UNLABELLED This case-control study showed that current use of conventional antipsychotics, but not atypical antipsychotics, seems to be associated with an increased risk of a hip/femur fracture, possibly related to the pharmacological properties of conventional antipsychotics. Furthermore, no evidence for a dose effect was found. INTRODUCTION The aim of this study was to assess the risk of hip/femur fracture associated with antipsychotic use, with particular reference to any difference in risk with conventional versus atypical antipsychotics, dose, and pharmacological properties. METHODS A case-control study was conducted using data from the PHARMO Record Linkage System among individuals aged 18 years and older between 1991 and 2002. Cases had a record of a hip or femur fracture, while controls had no evidence of ever having sustained any fracture. RESULTS Most cases were elderly (77.6% aged > or = 70 years). We found an increased risk for hip/femur fracture associated with the use of antipsychotic drugs. The risk for current users (OR(adj) 1.68 [1.43, 1.99]) was significantly greater than with past use (OR(adj) 1.33 [1.14, 1.56]; p = 0.036). Current use of conventional antipsychotics (OR(adj) 1.76 [1.48, 2.08]) but not atypical antipsychotics (OR(adj) 0.83 [0.42, 1.65]) was associated with an increased risk. We did not find evidence for a dose effect. CONCLUSION The use of conventional, but not atypical antipsychotics, seems to be associated with an increased risk of hip/femur fracture, possibly related to the pharmacological properties of conventional antipsychotics. However, the numbers of atypical antipsychotic users were small, and therefore this observation needs further attention in other study populations.
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Affiliation(s)
- S. Pouwels
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - T. P. van Staa
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton, UK
| | - A. C. G. Egberts
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H. G. M. Leufkens
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - C. Cooper
- MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton, UK
- Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - F. de Vries
- Department of Pharmacoepidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- MRC Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton, UK
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Use and misuse of antipsychotic drugs in patients with dementia in Alzheimer special care units. Int Clin Psychopharmacol 2009; 24:97-104. [PMID: 21456106 DOI: 10.1097/yic.0b013e328323aaf0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to estimate the prevalence of antipsychotic use and investigate their association with behavioural and psychological symptoms of dementia (BPSD) and other clinical predictors. Patients with dementia, aged 65 and above and resident in 35 Alzheimer special care units were sequentially enrolled into a 18-month prospective observational study. Data on sociodemographic, cognitive, functional, behavioural and clinical characteristics and drug exposure were collected at baseline and at 6-month intervals up to 18 months. The prevalence of antipsychotic use and the association with BPSD and clinical predictors were analysed. Of the 349 patients with dementia enrolled in the study, 209 (60%) were taking at least one antipsychotic. Risperidone and promazine were the most frequently prescribed antipsychotic; 40.7% simultaneously received a benzodiazepine, 20% an antidepressant. More than 50% were still taking antipsychotics at 18 months of follow-up. No associations were found between antipsychotic use and level of cognitive impairment, basal activity of daily living disability and comorbidity. Multivariate analysis showed that the use of antipsychotics was highest in patients in the highest quartiles of Neuropsychiatric Inventory Scale score (III quartile, odds ratio: 1.63; 95% confidence interval: 1.19-2.23; IV quartile, odds ratio: 2.27; 95% confidence interval: 1.61-3.26). This study found high rate of use of antipsychotics in patients with dementia resident in Alzheimer special care units, frequent associations with other psychotropic medications and a strong correlation with BPSD.
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Antipsychotics for BPSD: an audit of prescribing practice in a specialist psychiatric inpatient unit. Int Psychogeriatr 2008; 20:790-9. [PMID: 18307825 DOI: 10.1017/s1041610208006819] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Antipsychotics are widely used for the treatment of behavioral and psychological symptoms of dementia (BPSD). In the light of the increased risk of cerebrovascular events, many countries have issued guidelines concerning their use in treating BPSD. METHODS We carried out an audit of antipsychotic prescribing practice for inpatients with BPSD at a tertiary referral centre using standards derived from two U.K. dementia guidelines. We collated case note and prescription data and interviewed consultant psychiatrists. RESULTS Of the 60 patients with dementia 50 (83%) had BPSD; of these, 28 (56%) were receiving antipsychotics. Those prescribed antipsychotics were more likely to have severe BPSD and to be aggressive and/or agitated. Audit of the 28 patients receiving antipsychotics for BPSD showed generally satisfactory results but there was room for improvement in case note documentation of off-label usage, screening for risk factors of cerebrovascular disease, consultation with relatives and use of an appropriate starting dose and slow titration of the antipsychotic. CONCLUSION Audit of the use of antipsychotics for BPSD is important given the increased mortality associated with their use. Simple audit tools as used in this study can inform clinical practice. Even at a tertiary referral centre prescribing practice could be improved.
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Use of antipsychotic medications in older home-care patients. Report from nine European countries. Aging Clin Exp Res 2008; 20:260-5. [PMID: 18594194 DOI: 10.1007/bf03324781] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Data on the use of antipsychotics among older people in need of regular home care services are rare. The aim of this study was to ascertain the differences in the use and type of antipsychotic medications between European home-care sites. METHODS A cross-sectional study was designed by means of RAI (Resident Assessment Instrument for Home Care) assessments. A random sample of 3251 assessments was gathered during the period September 2001-January 2002 from home care patients aged 65 and over in nine European countries (Czech Republic, Denmark, Finland, Germany, Iceland, Italy, Netherlands, Norway and United Kingdom). RESULTS Two hundred of the home care patients (6.2%) received antipsychotic medication. The prevalence of the use of one or more antipsychotics varied widely between study sites, ranging from 3.0% in Denmark to 12.4% in Finland. Factors independently associated with the use of antipsychotics were: delusions (OR 3.09, 95% CI 1.66-5.76), any diagnosis of dementia (OR 2.57, 95% CI 1.70-3.87), youngest age group (65-74 yrs) (OR 2.37, 95% CI 1.53-3.66) and hallucinations (OR 2.28, 95% CI 1.17-4.45). Concomitant use of anxiolytics (OR 2.32, 95% CI 1.58- 3.41), hypnotics (OR 2.08, 95% CI 1.44-3.03) and antidepressants (OR 2.06, 95% CI 1.41-3.00) together with signs of depression (OR 1.78, 95% CI 1.24- 2.56), moderate to severe cognitive impairment (OR 1.30, 95% CI 1.12-1.51) and residing in Finland (OR 2.52, 95% CI 1.21-5.24) or Italy (OR 2.15, 95% CI 1.10-4.19) were associated with the use of antipsychotics. The most commonly used antipsychotic agent was risperidone (n=42, 21%). CONCLUSIONS The frequency of antipsychotic drug use in older home-care patients varied considerably among the European countries studied. Antipsychotic drug treatment in older home-care recipients seems to be less common than in residents in long-term institutional care, and more common than among the independently-living elderly.
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Abstract
PURPOSE OF REVIEW An increasing proportion of the world's population is over the age of 65 years. Specialist mental health services for older people have been developed in many countries. The way services develop depends partly on how healthcare arrangements have evolved in that jurisdiction, as well as on finances, culture and attitudes towards elderly and disabled individuals. Health planners in developing countries recognize that considerable increases in their elderly populations and numbers of individuals with disability are imminent. It will be important to ensure that older people with mental disorders receive appropriate treatment. This review discusses recent findings and observations about psychogeriatric services in the community and in long-term care facilities, and aims to suggest how to improve or develop such services. RECENT FINDINGS The prevalence of mental disorders in long-term care facilities is high, but services to deal with them are usually not optimal. When appropriately staffed and organized, community psychogeriatric services, day care and collaborative care can be effective in reducing mental health problems and preventing admissions. SUMMARY Recent reviews and research have provided useful guidance regarding aspects of current psychogeriatric services that work well and those that need to be improved. A person-centred approach is favoured.
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Pekkarinen L, Elovainio M, Sinervo T, Finne-Soveri H, Noro A. Nursing working conditions in relation to restraint practices in long-term care units. Med Care 2007; 44:1114-20. [PMID: 17122716 DOI: 10.1097/01.mlr.0000237198.90970.64] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study examined the effects of nursing working conditions on the use of physical restraints and antipsychotics as restraints in long-term care units for elderly residents. DESIGN Cross-sectional data were obtained in Finland in 2002 from long-term care units that used the Resident Assessment Instrument (RAI) system and participated in a survey on working conditions. SETTING A sample of 91 inpatient units in 31 facilities (23 residential homes and 8 health centers). PARTICIPANTS Data included 2430 resident assessments and 977 nursing staff survey responses. MEASUREMENTS We measured unit-level mean scores of physical restraint and antipsychotics use as restraints and resident characteristics (activities of daily living, cognitive impairment, and daily behavioral problems) based on the RAI system as measured by the Minimum Data Set 2.0. Head nurses reported the structural factors (nurse staffing levels and unit size). Nursing working conditions were measured by the Job-Demands and Job-Control Scales in the staff survey questionnaire. RESULTS Controlling for resident characteristics, nurses' job demands and control had a combined effect on restraint practices. Job demands strongly increased the risk of physical restraint use in units where nurses reported low job control (odds ratio [OR] = 13.31, 95% confidence interval [CI] 1.55-114.30, P = 0.019), but not among high-control units (OR = 0.23, 95% CI 0.04-1.29, P = 0.090). Although the use of antipsychotics was not related to job demands in units with low control (OR = 1.11, 95% CI 0.26-4.99, P = 0.891), the antipsychotics use in particular decreased when high job demands were coupled with high job control (OR = 0.17, 95% CI 0.03-0.91, P = 0.038). CONCLUSION The results suggest that restraint use can be reduced by enhancing working conditions so that the nursing staff has possibilities for skill usage and decision-making.
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Affiliation(s)
- Laura Pekkarinen
- National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland.
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