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Sönnerstam E, Gustafsson M, Lövheim H. Potentially inappropriate medications in relation to length of nursing home stay among older adults. BMC Geriatr 2022; 22:70. [PMID: 35065614 PMCID: PMC8783464 DOI: 10.1186/s12877-021-02639-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 11/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background To investigate the use of potentially inappropriate medications and their relation to the length of nursing home stay among older adults. Methods Questionnaire surveys using the Multi-Dimensional Dementia Assessment scale were sent out to all nursing homes in Västerbotten county in northern Sweden in 2007 and 2013. In total, 3186 adults (1881 from 2007 and 1305 from 2013) ≥65 years old were included and 71.8% of those had cognitive impairment. Potentially inappropriate medications were identified using drug-specific quality indicators according to Swedish National Board of Health and Welfare. Results Potentially inappropriate medications were used by 48.0% of the 2007 study sample and by 28.4% of the 2013 study sample. The prevalence of glibenclamide use 2007 and antipsychotic drug use 2013 increased linearly (β = 0.534E− 3, 95% CI: 0.040E− 3-0.103E− 2, p = 0.034 and β = 0.155E− 2, 95% CI: 0.229E− 3-0.288E− 2, p = 0.022, respectively) with the length of nursing home stay. No significant association was found between the prevalence of propiomazine, codeine, long-acting benzodiazepines, anticholinergics, NSAIDs, tramadol or the total use of potentially inappropriate medications and the length of stay in nursing homes in 2007 or 2013. Antipsychotics were the most commonly prescribed of the drug classes investigated and used by 22.6% of the residents 2007 and by 16.0% of the residents 2013. Conclusions These results indicate that treatment with potentially inappropriate medications is common among older adults living in nursing homes, but it seems to be related to the length of nursing home stay only to a smaller extent. Drug treatment should regularly be reviewed and followed-up among nursing home residents regardless of their length of nursing home stay, in order to prevent unnecessary adverse events. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02639-3.
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Lim AG, Garriock J, Moody I, Frischtak H, Montayre J, Arroll B. Potentially inappropriate medicines for older adults with intellectual disability: Clinical implications from a medication audit. Australas J Ageing 2021; 40:e207-e214. [PMID: 33523552 DOI: 10.1111/ajag.12900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/12/2020] [Accepted: 11/19/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate medications that have the potential to be inappropriately prescribed for people with intellectual disability (ID) and to explore possible issues surrounding the potential harm that can result from the use of groups of medicines for people with ID who are ageing and living longer. METHODS An audit of medical case records of 350 patients under the care of an organisation in New Zealand was undertaken to examine existing medication profiles. RESULTS Of the 350 patients, 95% were prescribed at least five or more medicines, with 7% of patients have 10 or more medicines. Increasing prescriptions are evident for those 56 years old and above. CONCLUSIONS Medicines that may have been appropriate for people with intellectual disability when they were younger may have the potential to cause harm when they age. It is therefore important that monitoring and evaluation of medications for ageing individuals with intellectual disability are regularly undertaken.
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Affiliation(s)
- Anecita Gigi Lim
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Judy Garriock
- Health and Disability Sector, Spectrum Care, Auckland, New Zealand
| | | | | | - Jed Montayre
- School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, Australia
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
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Sedative Load in Community-Dwelling Older Adults with Mild-Moderate Alzheimer's Disease: Longitudinal Relationships with Adverse Events, Delirium and Falls. Drugs Aging 2020; 37:829-837. [PMID: 32924095 DOI: 10.1007/s40266-020-00800-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older adults are frequently prescribed medications with sedative effects, which are associated with numerous adverse consequences. However, the prevalence and longitudinal associations of sedative medication use in community-dwelling older adults with mild-moderate Alzheimer's disease (AD) has not been explored to date. OBJECTIVES Our objective was to assess the prevalence of sedative medication use in community-dwelling older adults with mild-moderate AD and examine the longitudinal association between sedative medication use and adverse events (AEs). METHODS The association between baseline sedative load (SL) and AEs, unscheduled healthcare utilisation, delirium and falls was assessed in older adults with mild-moderate AD over 18 months using secondary analysis of NILVAD trial data (collected from 2014 to 2016). Baseline medication use was assessed, and the SL model was applied to each participant's medication individually. The SL model classifies medications into one of four categories: (1) primary sedatives, (2) medications with a sedating component or prominent side effect, (3) medications with sedation as a potential adverse reaction and (4) all other medications with no known sedative side effects. Medications in group 1 were assigned an SL score of 2, those in group 2 were assigned an SL score of 1, and those in categories 3 and 4 an SL score of 0. SL scores for each medication participants were taking were summed and the total SL calculated as an arithmetic sum of individual medications score. A total SL score ≥ 3 was classed as high. Statistical analysis was conducted using Poisson regression and mixed-effects linear regression, with adjustment for important clinical covariates. We also assessed the impact of SL on dementia progression and cognitive decline. RESULTS Over half (55.7% [284/510]) of those with mild-moderate AD (age 72.8 ± 8.3 years, 61.9% female) were prescribed a regular medication with sedation as a primary effect or prominent side effect, with 22.2% (113/510) having a high SL (≥ 3). The most common medications contributing to SL were antidepressants, antipsychotics, anxiolytics and hypnotics. Over 18 months, increasing baseline SL was associated with incident AEs (incidence rate ratio [IRR] 1.15; 95% confidence interval [CI] 1.11-1.19; p < 0.001), serious AEs (IRR 1.23; 95% CI 1.11-1.36; p < 0.001) and unscheduled general practitioner visits (IRR 1.23; 95% CI 1.13-1.34; p < 0.001). Further, increasing SL was associated with a greater likelihood of incident delirium (IRR 1.30; 95% CI 1.11-1.53; p < 0.001) and falls (IRR 1.20; 95% CI 1.03-1.42; p = 0.02). Associations persisted after robust covariate adjustment. SL was not associated with accelerated cognitive decline or AD progression. CONCLUSIONS In the current study, over half of older adults with mild-moderate AD were prescribed at least one drug with a sedative effect, and a significant minority had a high SL. Increasing baseline SL was associated with a greater likelihood of incident AEs, delirium and falls, highlighting the need for optimal prescribing in this potentially vulnerable cohort.
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Wang HI, Wang JC, Chung CH, Tsai SH, Huang KH, Chen WK, Chien WC. Association between dementia and unintentional poisoning in Taiwan. Eur Geriatr Med 2018; 9:819-827. [PMID: 34674479 DOI: 10.1007/s41999-018-0113-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/20/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Older people with dementia are a particularly vulnerable group and have an increased risk of poisoning. We investigated the correlation between dementia and the risk of unintentional poisoning in a retrospective, longitudinal and nationwide population-based study. METHODS Overall, 27,438 patients with dementia were selected from the National Health Insurance Research Database of Taiwan between 1 January 2000 to 31 December 2010, and 109,752 controls were propensity score-matched by gender, age, index year, and presence of heart failure, liver disease, renal disease, and cancers. After adjustment for confounding factors, Cox proportional hazards analysis was used to compare the risk of poisoning during follow-up. RESULTS Among dementia patients, 100 (0.36%) had unintentional poisoning events compared to 350 (0.32%) controls. Cox proportional hazards regression revealed that the patients were more likely to develop poisoning than the controls (hazard ratio [HR]: 2.721, 95% CI = 2.162-3.424, p < 0.001). After adjustment for sex, age, monthly income, urbanization level, geographic region, and comorbidities, the HR for poisoning was 2.385 (95% CI = 1.883-3.021, p < 0.001). CONCLUSIONS Patients with dementia have a high risk of unintentional poisoning, and appropriate prescription medications and careful review of dementia patient compliance are important.
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Affiliation(s)
- Hsiang-I Wang
- Department of Emergency Medicine, Taichung Armed Forces General Hospital, Taichung, 41168, Taiwan, Republic of China
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, 11490, Taiwan, Republic of China
- Department of Health Service Administration, College of Public Health, China Medical University, Taichung, 40447, Taiwan, Republic of China
| | - Jen-Chun Wang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, 11490, Taiwan, Republic of China
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, 11221, Taiwan, Republic of China
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan, Republic of China
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei, 11490, Taiwan, Republic of China
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, 11490, Taiwan, Republic of China
| | - Kuang-Hua Huang
- Department of Health Service Administration, College of Public Health, China Medical University, Taichung, 40447, Taiwan, Republic of China
| | - Wei Kung Chen
- Department of Emergency Medicine, China Medical University Hospital, No.2, Yude Rd, North Dist, Taichung, 40447, Taiwan, Republic of China.
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, 11490, Taiwan, Republic of China.
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei, 11490, Taiwan, Republic of China.
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, 7115R, No. 325, Section 2, Cheng-Kung Road, Neihu District, Taipei, 11490, Taiwan, Republic of China.
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Nguyen TA, Pham T, Vu HTT, Nguyen TX, Vu TT, Nguyen BTT, Nguyen NQ, Nguyen BT, Nguyen BT, Nguyen TN, Phan SV, Nguyen AT, Pham TL, Dang HT, Kalisch-Ellett L, Gillam M, Pratt N, Qiang S, Wang H, Kanjanarach T, Hassali MAA, Babar ZUD, Razak AA, Chinwong D, Roughead EE. Use of Potentially Inappropriate Medications in People With Dementia in Vietnam and Its Associated Factors. Am J Alzheimers Dis Other Demen 2018; 33:423-432. [PMID: 29642720 PMCID: PMC10852524 DOI: 10.1177/1533317518768999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
This study examined the use of potentially inappropriate medicines that may affect cognition (PIMcog) in people with dementia and its associated factors. Medical records of all outpatients with dementia attending a tertiary hospital in Vietnam between January 1, 2015, and December 31, 2016, were examined. Medicine use was assessed against a list of PIMcog. Variables associated with having a PIMcog were assessed using a multiple logistic regression. Of the 128 patients, 41% used a PIMcog, 39.1% used cholinesterase inhibitors (CEIs) concomitantly with anticholinergics, and 18% used antipsychotics. The number of hospital visits (adjusted odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.02-1.16) and number of treating specialists (adjusted OR: 0.61; 95% CI: 0.45-0.83) were associated with PIMcog use. This study highlights a high-level use of medicines that can further impair cognition or reduce the effectiveness of CEIs in people with dementia. Efforts to improve quality use of medicines for this population are warranted.
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Affiliation(s)
- Tuan Anh Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Thang Pham
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | - Trinh Thi Vu
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | | | | | | | | | | | - Tuan Le Pham
- Hanoi Medical University and Ministry of Health of Vietnam, Hanoi, Vietnam
| | - Ha Thu Dang
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sun Qiang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | - Haipeng Wang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | | | | | | | - Asrenee Ab Razak
- Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Dujrudee Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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Zahirovic I, Torisson G, Wattmo C, Londos E. Psychotropic and anti-dementia treatment in elderly persons with clinical signs of dementia with Lewy bodies: a cross-sectional study in 40 nursing homes in Sweden. BMC Geriatr 2018; 18:50. [PMID: 29454305 PMCID: PMC5816356 DOI: 10.1186/s12877-018-0740-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elderly persons with a dementia diagnosis often suffer from different neuropsychiatric symptoms (NPS) such as delusions, hallucinations, depression, anxiety, irritability and agitation. Currently, the medical treatment for NPS consists mostly of psychotropic medication such as hypnotics/sedatives, anxiolytics and antipsychotics. In elderly persons with dementia, usage of antipsychotics is less appropriate because of the risk of side effects such as parkinsonism, rapid cognitive decline, cerebrovascular events and finally mortality. Furthermore, elderly persons with dementia with Lewy bodies (DLB) are often hypersensitive to antipsychotics with numerous serious adverse events such as somnolence, sedation, extra-pyramidal symptoms, delirium and increased mortality. The aim of this study was to investigate the usage of psychotropics with a focus on antipsychotics and anti-dementia medication (according to the Anatomical Therapeutic Chemical Classification System) in elderly persons with clinical signs of DLB living in dementia nursing homes (NHs) in Sweden. METHODS Between 2012 and 2013, we applied a specially designed questionnaire that covered the clinical DLB features according to the consensus criteria of DLB. We also collected computerized medical lists from the Swedish National Medication Dispensing System from the same period. All dementia NHs (n = 40) in Malmö, the third largest city in Sweden, were covered. Of 650 eligible residents, 610 (94%) were included with 576 medical lists. The mean age was 86 years and 76% were women. RESULTS Treatment with antipsychotics was seen in 22% of residents, hypnotics/sedatives in 41%, antidepressants in 50% and anxiolytics in 58%. We also found an increasing usage of antipsychotics from 25% to 43% in residents with the increasing number of DLB features. Anti-dementia medications were found in 45% of the elderly with a dementia diagnosis. However, residents with two or more DLB features had less anti-dementia medication (37%) than the rest of the dementia-diagnosed NH residents (62-69%). CONCLUSIONS Residents with 2-4 DLB clinical features in Swedish NHs receive an unfavourable medical treatment with high antipsychotic usage and insufficient anti-dementia medication. These findings show the importance of identifying elderly persons with DLB features more effectively and improving the collaboration with nursing care to provide better medical prescription.
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Affiliation(s)
- Iris Zahirovic
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden. .,Memory Clinic, Skåne University Hospital, SE-205 02, Malmö, Sweden.
| | - Gustav Torisson
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Memory Clinic, Skåne University Hospital, SE-205 02, Malmö, Sweden
| | - Carina Wattmo
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Memory Clinic, Skåne University Hospital, SE-205 02, Malmö, Sweden
| | - Elisabet Londos
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Memory Clinic, Skåne University Hospital, SE-205 02, Malmö, Sweden
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Karlsson S, Rahm Hallberg I, Midlöv P, Fagerström C. Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia - a review of the Swedish context. BMC Psychiatry 2017; 17:251. [PMID: 28705243 PMCID: PMC5513361 DOI: 10.1186/s12888-017-1409-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 06/29/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to explore trends in treatment with antipsychotic medication in Swedish dementia care in nursing homes as reported in the most recent empirical studies on the topic, and to relate these trends to directives from the national authorities. METHODS The study included two scoping review studies based on searches of electronic databases as well as the Swedish directives in the field. RESULTS During the past decade, directives have been developed for antipsychotic medication in Sweden. These directives were generic at first, but have become increasingly specific and restrictive with time. The scoping review showed that treatment with antipsychotic drugs varied between 6% and 38%, and was higher in younger older persons and in those with moderate cognitive impairment and living in nursing homes for people with dementia. A decreasing trend in antipsychotic use has been seen over the last 15 years. CONCLUSIONS Directives from the authorities in Sweden may have had an impact on treatment with antipsychotic medication for people with dementia. Treatment with antipsychotic medication has decreased, while treatment with combinations of psychotropic medications is common. National directives may possibly be even more effective, if applied in combination with systematic follow-ups.
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Affiliation(s)
- Staffan Karlsson
- Department of Health Sciences, Lund University, -221 00 Lund, SE Sweden
- School of Health and Welfare, Halmstad University, -301 18 Halmstad, SE Sweden
| | | | - Patrik Midlöv
- Department of Clinical Sciences, Malmo, Lund University, -221 00 Lund, SE Sweden
| | - Cecilia Fagerström
- Blekinge Centre of Competence, -371 81 Karlskrona, SE Sweden
- Department of Health and Caring Sciences, Linnaeus University, -391 82 Kalmar, SE Sweden
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Breining A, Bonnet-Zamponi D, Zerah L, Micheneau C, Riolacci-Dhoyen N, Chan-Chee C, Deligne J, Harlin JM, Boddaert J, Verny M, Leperre-Desplanques A. Exposure to psychotropics in the French older population living with dementia: a nationwide population-based study. Int J Geriatr Psychiatry 2017; 32:750-760. [PMID: 27237864 DOI: 10.1002/gps.4517] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 02/24/2016] [Accepted: 05/05/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Little is known about the level of psychotropic chronic exposure in all patients living with dementia. The aim of the study was to quantify chronic psychotropic exposure in older adults with dementia compared with the general population of the same age. METHODS This prospective cohort study was conducted in France between 2009 and 2011. Aged at least 65 years, 10,781,812 individuals (440,215 of them with dementia) either community based or nursing home residents were included. The numbers of single or combined prescriptions, per year for antipsychotics, antidepressants, anxiolytics, or hypnotics were measured. RESULTS Of patients with dementia, 15.5% are exposed to antipsychotics compared with 2.2% of the age-matched population (relative risk [RR] = 6.44, 95% confidence interval [CI] [6.39-6.48]), 39.5% to antidepressants compared with 12.6% (RR = 4.10, 95% CI [.4.07-4.12]), and 39.6% to anxiolytics or hypnotics compared with 26.9% (RR = 1.74, 95% CI [1.72-1.75]). Among older adults with dementia, 13.8% simultaneously consumed at least three psychotropics. All class age of older patients with dementia is more exposed to all psychotropics except for long-acting benzodiazepines. During the study period, chronic anxiolytic/hypnotic and antipsychotic exposure slightly decreased in population with dementia while chronic exposure to antidepressant drugs tended to increase. CONCLUSION This nationwide, population-based, drug-used study showed for the first time that older patients with dementia are chronically overexposed not only to antipsychotics but also to psychotropics.
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Affiliation(s)
- Alice Breining
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France
| | - Dominique Bonnet-Zamponi
- OMEDIT Ile de France, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, UMR 1123 INSERM, Paris, France
| | - Lorène Zerah
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | | | | | | | - Jean Deligne
- Régime Social des Indépendants, Saint Denis la Plaine, France
| | - Jean-Marc Harlin
- Caisse Centrale de la Mutualité Sociale Agricole, Bagnolet, France
| | - Jacques Boddaert
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
| | - Marc Verny
- APHP, DHU FAST, Groupe Hospitalier Pitié Salpêtrière - Charles Foix, Centre de Gériatrie, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06 and CNRS, UMR 8256 B2A, Paris, France
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9
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Brännström J, Boström G, Rosendahl E, Nordström P, Littbrand H, Lövheim H, Gustafson Y. Psychotropic drug use and mortality in old people with dementia: investigating sex differences. BMC Pharmacol Toxicol 2017; 18:36. [PMID: 28545507 PMCID: PMC5445267 DOI: 10.1186/s40360-017-0142-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/10/2017] [Indexed: 01/08/2023] Open
Abstract
Background Psychotropic drugs are common among old people with dementia, and have been associated with increased mortality. Previous studies have not investigated sex differences in this risk. This study was conducted to analyse associations between the use of antipsychotics, antidepressants, and benzodiazepines and 2-year mortality in old people with dementia, and to investigate sex differences therein. Methods In total, 1037 participants (74% women; mean age, 89 years) with dementia were included from four cohort studies and followed for 2 years. Data were collected through home visits and medical records. Cox proportional hazard regression models were used to analyse associations between ongoing baseline drug use and mortality. Multiple possible confounders were evaluated and adjusted for. Results In fully adjusted models including data from the whole population, no association between baseline psychotropic drug use and increased 2-year mortality was seen. Significant sex differences were found in mortality associated with antidepressant use, which was protective in men, but not in women (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.40–0.92 and HR 1.09, 95% CI 0.87–1.38, respectively). The interaction term for sex was significant in analyses of benzodiazepine use, with a higher mortality risk among men than among women. Conclusions Among old people with dementia, ongoing psychotropic drug use at baseline was not associated with increased mortality in analyses adjusted for multiple confounders. Sex differences in mortality risk associated with antidepressant and benzodiazepine use were seen, highlighting the need for further investigation of the impact of sex. Electronic supplementary material The online version of this article (doi:10.1186/s40360-017-0142-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jon Brännström
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden.
| | - Gustaf Boström
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Erik Rosendahl
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Peter Nordström
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Håkan Littbrand
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Yngve Gustafson
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
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10
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Frohnhofen H, Schlitzer J, Netzer N. Schlaf und Schlafstörungen beim alten Menschen. SOMNOLOGIE 2017. [DOI: 10.1007/s11818-017-0102-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Nørgaard A, Jensen-Dahm C, Gasse C, Hansen ES, Waldemar G. Psychotropic Polypharmacy in Patients with Dementia: Prevalence and Predictors. J Alzheimers Dis 2017; 56:707-716. [DOI: 10.3233/jad-160828] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ane Nørgaard
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christina Jensen-Dahm
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christiane Gasse
- National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Elsebet Steno Hansen
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Gunhild Waldemar
- Danish Dementia Research Centre (DDRC), Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Patterns of psychotropic prescribing and polypharmacy in older hospitalized patients in Ireland: the influence of dementia on prescribing. Int Psychogeriatr 2016; 28:1807-1820. [PMID: 27527842 DOI: 10.1017/s1041610216001307] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Neuropsychiatric Symptoms (NPS) are ubiquitous in dementia and are often treated pharmacologically. The objectives of this study were to describe the use of psychotropic, anti-cholinergic, and deliriogenic medications and to identify the prevalence of polypharmacy and psychotropic polypharmacy, among older hospitalized patients in Ireland, with and without dementia. METHODS All older patients (≥ 70 years old) that had elective or emergency admissions to six Irish study hospitals were eligible for inclusion in a longitudinal observational study. Of 676 eligible patients, 598 patients were recruited and diagnosed as having dementia, or not, by medical experts. These 598 patients were assessed for delirium, medication use, co-morbidity, functional ability, and nutritional status. We conducted a retrospective cross-sectional analysis of medication data on admission for 583/598 patients with complete medication data, and controlled for age, sex, and co-morbidity. RESULTS Of 149 patients diagnosed with dementia, only 53 had a previous diagnosis. At hospital admission, 458/583 patients experienced polypharmacy (≥ 5 medications). People with dementia (PwD) were significantly more likely to be prescribed at least one psychotropic medication than patients without dementia (99/147 vs. 182/436; p < 0.001). PwD were also more likely to experience psychotropic polypharmacy (≥ two psychotropics) than those without dementia (54/147 vs. 61/436; p < 0.001). There were no significant differences in the prescribing patterns of anti-cholinergics (23/147 vs. 42/436; p = 0.18) or deliriogenics (79/147 vs. 235/436; p = 0.62). CONCLUSIONS Polypharmacy and psychotropic drug use is highly prevalent in older Irish hospitalized patients, especially in PwD. Hospital admission presents an ideal time for medication reviews in PwD.
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Abstract
BACKGROUND Antidepressant treatment may increase the risk of death. The association between antidepressants and mortality has been evaluated in community-dwelling older people, but not in representative samples of very old people, among whom dementia, multimorbidity, and disability are common. METHODS Umeå 85+/GERDA study participants (n = 992) aged 85, 90, and ≥95 years were followed for up to five years. Cox proportional hazard regression models were used to analyze mortality risk associated with baseline antidepressant treatment, adjusted for potential confounders. RESULTS Mean age was 89 years; 27% of participants had dementia, 20% had stroke histories, 29% had heart failure, and 16% used antidepressants. In age- and sex-adjusted analyses, antidepressant use was associated with a 76% increased mortality risk (hazard ratio [HR] = 1.76; 95% confidence interval [CI], 1.41-2.19). Adding adjustment for Geriatric Depression Scale score, HR was 1.62 (95% CI, 1.29-2.03). The association was not significant when adjusting for additional confounding factors (HR = 1.08; 95% CI, 0.85-1.38). Interaction analyses in the fully adjusted model revealed a significant interaction between sex and antidepressant use (HR: 1.76; 95% CI, 1.05-2.94). Among male and female antidepressant users, the HRs for death were 0.76 (95% CI, 0.47-1.24) and 1.28 (95% CI, 0.97-1.70), respectively. CONCLUSION Among very old people, baseline antidepressant treatment does not seem to be independently associated with increased mortality risk. However, the risk may be different in men and women. This difference and the potential risk of initial treatment require further investigation in future cohort studies of very old people.
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Wang C, Gao S, Hendrie HC, Kesterson J, Campbell NL, Shekhar A, Callahan CM. Antidepressant Use in the Elderly Is Associated With an Increased Risk of Dementia. Alzheimer Dis Assoc Disord 2016; 30:99-104. [PMID: 26295747 PMCID: PMC4760914 DOI: 10.1097/wad.0000000000000103] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A retrospective cohort study was conducted including 3688 patients age 60 years or older without dementia enrolled in a depression screening study in primary care clinics. Information on antidepressant use and incident dementia during follow-up was retrieved from electronic medical records. The Cox proportional hazard models were used to compare the risk for incident dementia among 5 participant groups: selective serotonin re-uptake inhibitors (SSRI) only, non-SSRI only (non-SSRI), mixed group of SSRI and non-SSRI, not on antidepressants but depressed, and not on antidepressants and not depressed. SSRI and non-SSRI users had significantly higher dementia risk than the nondepressed nonusers (hazard ratio [HR]=1.83, P=0.0025 for SSRI users and HR=1.50, P=0.004 for non-SSRI users). In addition, SSRIs users had significantly higher dementia risk than non-users with severe depression (HR=2.26, P=0.0005). Future research is needed to confirm our results in other populations and to explore potential mechanism underlying the observed association.
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Affiliation(s)
- Chenkun Wang
- Department of Biostatistics, Indiana University School of Medicine. Indianapolis, IN
- Richard M. Fairbank School of Public Health, Indiana University, Indianapolis, IN
| | - Sujuan Gao
- Department of Biostatistics, Indiana University School of Medicine. Indianapolis, IN
- Richard M. Fairbank School of Public Health, Indiana University, Indianapolis, IN
- Indiana University Center for Aging Research. Indianapolis, IN
| | - Hugh C. Hendrie
- Department of Psychiatry, Indiana University School of Medicine. Indianapolis, IN
- Regenstrief Institute, Inc. Indianapolis, IN
- Indiana University Center for Aging Research. Indianapolis, IN
| | | | - Noll L. Campbell
- Regenstrief Institute, Inc. Indianapolis, IN
- Indiana University Center for Aging Research. Indianapolis, IN
- Department of Pharmacy Practice, Purdue University School of Pharmacy, West Lafayette, IN
| | - Anantha Shekhar
- Department of Psychiatry, Indiana University School of Medicine. Indianapolis, IN
| | - Christopher M. Callahan
- Regenstrief Institute, Inc. Indianapolis, IN
- Indiana University Center for Aging Research. Indianapolis, IN
- Department of Medicine, Indiana University School of Medicine. Indianapolis, IN
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Sköldunger A, Fastbom J, Wimo A, Fratiglioni L, Johnell K. The impact of dementia on drug costs in older people: results from the SNAC study. BMC Neurol 2016; 16:28. [PMID: 26923675 PMCID: PMC4770687 DOI: 10.1186/s12883-016-0547-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/17/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND We aimed to investigate the impact of dementia on drug costs in older people, after adjustment for socio-demographic factors, residential setting and co-morbidities. METHODS We included 4,129 individuals aged ≥ 60 years from The Swedish National Study on Aging and Care (SNAC) in Kungsholmen and Nordanstig 2001-2004. A generalized linear model (GLM) was used to investigate how much dementia was associated with drug costs. RESULTS Overall drug costs for persons with and without dementia were 6147 SEK (816 USD) and 3810 SEK (506 USD), respectively. The highest drug cost was observed for nervous system drugs among persons with dementia. The adjusted GLM showed that dementia was not associated with higher overall drug costs (β = 1.119; ns). Comorbidities and residential setting were the most important factors for overall drug costs. CONCLUSION We found that the observed higher overall drug costs for persons with dementia were due to comorbidities and residential setting.
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Affiliation(s)
- Anders Sköldunger
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden. .,Bollebergsvägen, 5, 820 70, Bergsjö, Sweden.
| | - Johan Fastbom
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden. .,Stockholm Gerontology Research Center, Stockholm, Sweden.
| | - Anders Wimo
- Division of Neurogeriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.
| | - Laura Fratiglioni
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden. .,Stockholm Gerontology Research Center, Stockholm, Sweden.
| | - Kristina Johnell
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden. .,Stockholm Gerontology Research Center, Stockholm, Sweden.
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Pasqualetti G, Tognini S, Calsolaro V, Polini A, Monzani F. Potential drug-drug interactions in Alzheimer patients with behavioral symptoms. Clin Interv Aging 2015; 10:1457-66. [PMID: 26392756 PMCID: PMC4573195 DOI: 10.2147/cia.s87466] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The use of multi drug regimens among the elderly population has increased tremendously over the last decade although the benefits of medications are always accompanied by potential harm, even when prescribed at recommended doses. The elderly populations are particularly at an increased risk of adverse drug reactions considering comorbidity, poly-therapy, physiological changes affecting the pharmacokinetics and pharmacodynamics of many drugs and, in some cases, poor compliance due to cognitive impairment and/or depression. In this setting, drug–drug interaction may represent a serious and even life-threatening clinical condition. Moreover, the inability to distinguish drug-induced symptoms from a definitive medical diagnosis often results in addition of yet another drug to treat the symptoms, which in turn increases drug–drug interactions. Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, are the most widely prescribed agents for Alzheimer’s disease (AD) patients. Behavioral and psychological symptoms of dementia, including psychotic symptoms and behavioral disorders, represent noncognitive disturbances frequently observed in AD patients. Antipsychotic drugs are at high risk of adverse events, even at modest doses, and may interfere with the progression of cognitive impairment and interact with several drugs including anti-arrhythmics and acetylcholinesterase inhibitors. Other medications often used in AD patients are represented by anxiolytic, like benzodiazepine, or antidepressant agents. These agents also might interfere with other concomitant drugs through both pharmacokinetic and pharmacodynamic mechanisms. In this review we focus on the most frequent drug–drug interactions, potentially harmful, in AD patients with behavioral symptoms considering both physiological and pathological changes in AD patients, and potential pharmacodynamic/pharmacokinetic drug interaction mechanisms.
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Affiliation(s)
- Giuseppe Pasqualetti
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sara Tognini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Calsolaro
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Polini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Wastesson JW, Ringbäck Weitoft G, Johnell K. Educational disparities in antipsychotic drug use among older people with and without dementia in Sweden. Acta Psychiatr Scand 2015; 132:20-8. [PMID: 25532774 DOI: 10.1111/acps.12378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Antipsychotic drugs are commonly used to treat behavioural and psychological symptoms of dementia. The aim was to investigate if socioeconomic position was associated with antipsychotic drug treatment among older adults with and without dementia. METHOD By record linkage of the Swedish Prescribed Drug Register, Patient Register, and Educational Register, we obtained information on antipsychotics, dementia status, and educational level for 641,566 persons aged 75-89 year old in Sweden 2005. RESULTS Among persons diagnosed with dementia (n = 32 092), 21% used antipsychotics compared with 4% in the total sample (n = 641,566). Lower education was associated with a higher probability of antipsychotic use in the total sample (adjusted odds ratio [OR] low vs. high education: 1.56; 95% confidence interval [CI]: 1.48-1.64). In the dementia subpopulation, lower education was also associated with a higher likelihood of use of antipsychotics (adjusted OR(low vs. high) 1.43; 95% CI: 1.28-1.59). CONCLUSION People with dementia were five times more likely to use antipsychotic drugs than the general population of older adults. Also, lower education was associated with a higher use of antipsychotics, both in the general population and in the subgroup of persons with dementia. This finding highlights the importance of investigating healthcare inequalities also among cognitively impaired older adults.
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Affiliation(s)
- J W Wastesson
- Aging Research Center, Karolinska Institutet, Stockholm University, Stockholm, Sweden
| | | | - K Johnell
- Aging Research Center, Karolinska Institutet, Stockholm University, Stockholm, Sweden
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Rabkin SW. Aging effects on QT interval: Implications for cardiac safety of antipsychotic drugs. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2014; 11:20-5. [PMID: 24748877 PMCID: PMC3981979 DOI: 10.3969/j.issn.1671-5411.2014.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 03/20/2014] [Accepted: 03/22/2014] [Indexed: 11/24/2022]
Abstract
Objectives To explore the effect of aging on cardiac toxicity specifically the interaction of age and antipsychotic drugs to alter the QT interval. Methods The Medline databases were searched using the OvidSP platforms with the search strategy: “QT interval” or “QT” and “age” or “aging”. The entry criteria were: over 10,000 apparently healthy individuals with data on both sexes; QT interval corrected for heart rate (QTc) and an expression of its variance for multiple age decades extending into the older ages. Results QTc increased in duration with increasing age. Considering a modest one SD increment in QTc in the normal population, the addition of Chlorpromazine produced a QTc on average greater than 450 ms for ages 70 years and older. Risperidone, that did not on average alter QTc, would be expected to produce a QTc of 450 ms in persons in their mid 70 years under some circumstances. QTc prolongation > 500 ms with antipsychotic drugs is more likely for persons with QTc initially at the 99th percentile. It may occur with Haloperidol which does not on average alter QTc. Conclusions The range of values for the QT interval in apparently normal older men or women, when combined with the range of expected QT interval changes induced by antipsychotic drugs, can readily be associated with prolonged QTc. Individuals with QTc at the 99th percentile may have serious QTc prolongation with antipsychotic drugs even those that are not usually associated with QTc prolongation.
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Affiliation(s)
- Simon W Rabkin
- Department of Medicine (Cardiology), University of British Columbia, 9th Floor 2775 Laurel St., Vancouver, B.C., V5Z 1M9, Canada
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Meguro K, Kasai M, Akanuma K, Meguro M, Ishii H, Yamaguchi S. Donepezil and life expectancy in Alzheimer's disease: a retrospective analysis in the Tajiri Project. BMC Neurol 2014; 14:83. [PMID: 24720852 PMCID: PMC3997195 DOI: 10.1186/1471-2377-14-83] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 04/01/2014] [Indexed: 01/04/2023] Open
Abstract
Background Cholinesterase inhibitors (ChEIs) such as donepezil have the effect of delaying progression of Alzheimer’s disease (AD), but their effect on life expectancy is unclear. We analyzed the influence of donepezil on life expectancy after onset of AD, together with the effects of antipsychotic drugs and residency in a nursing home. Methods All outpatients at the Tajiri Clinic from 1999–2012 with available medical records and death certificates were included in a retrospective analysis. The entry criteria were a dementia diagnosis based on DSM-IV criteria and diagnosis of AD using NINCDS-ADRDA criteria; medical treatment for more than 3 months; and follow up until less than 1 year before death. Results We identified 390 subjects with medical records and death certificates, of whom 275 had a diagnosis of dementia that met the entry criteria. Of 100 patients diagnosed with AD, 52 had taken donepezil and 48 patients had not received the drug due to treatment prior to the introduction of donepezil in 1999 in Japan. The lifetime expectancies after onset were 7.9 years in the donepezil group and 5.3 years in the non-donepezil group. There was a significant drug effect with a significant covariate effect of nursing home residency. Other covariates did not reach a significant level. Conclusions Although this report has the limitation of all retrospective analyses: the lack of randomization, we found a positive effect of donepezil on lifetime expectancy after onset of AD. This may be due to a decreased mortality rate caused by reduction of concomitant diseases such as pneumonia. The similar life expectancies in patients taking donepezil at home and those not taking donepezil in a nursing home indicated a positive health economic effect of the drug.
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Affiliation(s)
- Kenichi Meguro
- Division of Geriatric Behavioral Neurology, CYRIC, Tohoku University, Sendai, Miyagi 980-8575, Japan.
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Huybrechts KF, Gerhard T, Franklin JM, Levin R, Crystal S, Schneeweiss S. Instrumental variable applications using nursing home prescribing preferences in comparative effectiveness research. Pharmacoepidemiol Drug Saf 2014; 23:830-8. [PMID: 24664805 DOI: 10.1002/pds.3611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 02/02/2014] [Accepted: 02/17/2014] [Indexed: 11/12/2022]
Abstract
PURPOSE Nursing home residents are of particular interest for comparative effectiveness research given their susceptibility to adverse treatment effects and systematic exclusion from trials. However, the risk of residual confounding because of unmeasured markers of declining health using conventional analytic methods is high. We evaluated the validity of instrumental variable (IV) methods based on nursing home prescribing preference to mitigate such confounding, using psychotropic medications to manage behavioral problems in dementia as a case study. METHODS A cohort using linked data from Medicaid, Medicare, Minimum Data Set, and Online Survey, Certification and Reporting for 2001-2004 was established. Dual-eligible patients ≥65 years who initiated psychotropic medication use after admission were selected. Nursing home prescribing preference was characterized using mixed-effects logistic regression models. The plausibility of IV assumptions was explored, and the association between psychotropic medication class and 180-day mortality was estimated. RESULTS High-prescribing and low-prescribing nursing homes differed by a factor of 2. Each preference-based IV measure described a substantial proportion of variation in psychotropic medication choice (β(IV → treatment): 0.22-0.36). Measured patient characteristics were well balanced across patient groups based on instrument status (52% average reduction in Mahalanobis distance). There was no evidence that instrument status was associated with markers of nursing home quality of care. CONCLUSION Findings indicate that IV analyses using nursing home prescribing preference may be a useful approach in comparative effectiveness studies, and should extend naturally to analyses including untreated comparison groups, which are of great scientific interest but subject to even stronger confounding.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Barry HE, Parsons C, Passmore AP, Hughes CM. Community pharmacists and people with dementia: a cross-sectional survey exploring experiences, attitudes, and knowledge of pain and its management. Int J Geriatr Psychiatry 2013; 28:1077-85. [PMID: 23348866 DOI: 10.1002/gps.3931] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 12/19/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To explore community pharmacists' experiences with and attitudes towards people with dementia, and to determine the knowledge they have about pain and its management in this patient population. METHODS A questionnaire comprising five sections, including the Approaches to Dementia Questionnaire, was mailed, on two occasions, during February and March 2011, to all community pharmacies in Northern Ireland (n = 530). RESULTS The response rate was 34.3%. A greater proportion of pharmacists provided pharmaceutical care to people with dementia living at home (91.2%) than those living in care homes (40.1%). Respondents most frequently encountered queries relating to starting and stopping medications, compliance with medication, and availability of formulation types. The mean total score for the Approaches to Dementia Questionnaire measure was 72.8, indicating a positive attitude towards people with dementia, and respondents demonstrated a strong person-centred approach towards this patient population. The majority of respondents recognised the difficulty of assessing pain in people with dementia; however, younger pharmacists (p = 0.041) and pharmacists who provided pharmaceutical care to people with dementia (p = 0.012) were more likely to be aware of the pain assessment tools for use in people with dementia. Pharmacists appeared uncertain about how to appropriately manage pain in people with dementia. CONCLUSIONS The study has revealed that community pharmacists often encounter people with dementia, especially those living in their own homes, and they have positive attitudes towards the patient population. However, training in the assessment and management of pain in people with dementia must be developed to further improve their knowledge in this area.
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Affiliation(s)
- Heather E Barry
- Clinical and Practice Research Group, School of Pharmacy, Queen's University, Belfast, UK
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Physicians' practice and familiarity with treatment for agitation associated with dementia in Israeli nursing homes. Int Psychogeriatr 2013; 25:236-44. [PMID: 23174135 DOI: 10.1017/s104161021200172x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To clarify physicians' actual practice in treating agitation in the nursing home and to elucidate the relationship between background factors, familiarity with interventions, and practice. METHODS A survey of actual practice for agitation in persons with dementia was administered to 67 physicians aged 31-70+ working in nursing homes in Israel. Questionnaires were administered by personal interview, self-completed, or a combination of the two. RESULTS Psychotropic medications are prescribed by 92.5% of physicians for treating agitation, most notably, Haloperidol (39%). Non-pharmacological treatment was also reported to be common, though to a lesser extent, with environmental change being the most prevalent non-pharmacological intervention. Generally, physicians showed low familiarity levels with non-pharmacological interventions, with higher levels noted for physicians with a specialty in geriatrics compared to those who were non-specialized. Physicians who were non-Israeli and younger also reported higher familiarity levels compared to their respective counterparts (i.e. Israeli and older) but this difference did not reach significance. CONCLUSION The findings indicate that, despite current guidelines, psychotropic medications are the treatment of choice among nursing home physicians in Israel. While rates of use of non-pharmacological interventions are substantial, their in-practice application may be hindered by lack of familiarity as well as system barriers. The results have implications for system and education changes.
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Johnell K, Fastbom J. Comparison of Prescription Drug Use between Community-Dwelling and Institutionalized Elderly in Sweden. Drugs Aging 2012; 29:751-8. [DOI: 10.1007/s40266-012-0002-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE Despite serious safety concerns, antipsychotic medications continue to be used widely in US nursing homes. The objective of this study was to quantify the variation in antipsychotic treatment choice across US nursing homes, and to characterize its correlates. METHODS Prescribing practices were assessed in a cohort of 65,618 patients 65 years or older in 45 states who initiated treatment with an antipsychotic medication after nursing home admission between 2001 and 2005, using merged Medicaid; Medicare; Minimum Data Set; and Online Survey, Certification, and Reporting data. We fit mixed-effects logistic regression models to examine how antipsychotic treatment choice at the patient-level depends on patient and nursing home fixed and random effects. RESULTS Among antipsychotic medication users, 9% of patients initiated treatment with a conventional agent. After adjustment for case-mix and facility characteristics, 95% of nursing homes had a predicted conventional antipsychotic prescribing rate between 2% and 20%. Individually, patient characteristics accounted for 36% of the explained variation, facility characteristics for 23%, and nursing home prescribing tendency for 81%. Results were consistent in the subgroup of nursing home patients with a diagnosis of dementia. The prescribing physician was not considered as a determinant of treatment choice owing to data limitations. CONCLUSION These findings indicate that antipsychotic treatment choice is to some extent influenced by a nursing home's underling prescribing "culture." This culture may reveal strategies for targeting quality improvement interventions. In addition, these findings suggest that a nursing home's tendency for specific antipsychotics merits further exploration as an instrumental variable for improved confounding adjustment in comparative effectiveness studies.
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Psychotropic drug use in relation to mental disorders and institutionalization among 95-year-olds: a population-based study. Int Psychogeriatr 2011; 23:1270-7. [PMID: 21447258 DOI: 10.1017/s1041610211000524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The prevalence of psychotropic drug use is high among the elderly, but research on how psychotropic drugs are used among individuals aged 90 years and older is limited. An increased knowledge on this topic may contribute to improved prescribing patterns in this vulnerable population. The aim of this study was to assess the use of psychotropic drugs in relation to mental disorders and institutionalization among 95-year-olds and to identify use of potentially inappropriate psychotropic drugs. METHODS All 95-year-olds born in 1901-1903 living in nursing homes or community settings in Gothenburg, Sweden were invited to participate. The response rate was 65% and 338 95-year-olds were examined (263 women, 75 men). Psychotropic drug use in relation to mental disorders and institutionalization was assessed. Information on drug use was collected primarily from multi-dose drug dispensing lists. Participants were examined by trained psychiatrists using the Comprehensive Psychopathological Rating Scale and a battery of cognitive tests. Dementia, depression, anxiety and psychotic disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R). RESULTS Sixty percent of the 95-year-old participants used psychotropic drugs; hypnotics were most common (44%). Potentially inappropriate psychotropics were observed in one third (33%). Antidepressants were used by 7% of the participants without dementia who fulfilled criteria for a depressive disorder, while 56% used hypnotics and 30% used anxiolytics. CONCLUSIONS The high prevalence of psychotropic drug use and the nonspecific nature of these treatments among 95-year-olds indicate a need for improvement in prescribing patterns.
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Parsons C, Haydock J, Mathie E, Baron N, Machen I, Stevenson E, Amador S, Goodman C. Sedative load of medications prescribed for older people with dementia in care homes. BMC Geriatr 2011; 11:56. [PMID: 21958366 PMCID: PMC3197480 DOI: 10.1186/1471-2318-11-56] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 09/30/2011] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The objective of this study was to determine the sedative load and use of sedative and psychotropic medications among older people with dementia living in (residential) care homes. METHODS Medication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model. RESULTS At baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives. CONCLUSIONS Sedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care home for support and medication review are required.
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Affiliation(s)
- Carole Parsons
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Jane Haydock
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Elspeth Mathie
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Natasha Baron
- General Practice & Primary Care Research Unit, Institute of Public Health, Robinson Way, Cambridge, CB2 0SR, UK
| | - Ina Machen
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Elizabeth Stevenson
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Sarah Amador
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
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Musicco M, Palmer K, Russo A, Caltagirone C, Adorni F, Pettenati C, Bisanti L. Association between prescription of conventional or atypical antipsychotic drugs and mortality in older persons with Alzheimer's disease. Dement Geriatr Cogn Disord 2011; 31:218-24. [PMID: 21474930 DOI: 10.1159/000326213] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2011] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND/AIMS To evaluate whether dementia patients prescribed antipsychotic drugs have a higher mortality compared to unexposed patients, and to investigate whether there are differences in mortality associated with exposure to conventional versus atypical antipsychotic drugs. METHODS Retrospective population cohort study with information gathered from the Italian Health Information System. All 4,369 residents of Milan (Italy) aged 60 years or older who were newly prescribed an antidementia drug (donepezil, rivastigmine or galantamine) from January 2002 to June 2008 were included. All new users of antipsychotic drugs in this cohort were categorized according to conventional (n = 156) or atypical (n = 806) drug exposure. The mortality risks of users of conventional or atypical antipsychotics compared to nonusers were evaluated with survival analysis, considering exposure to antipsychotic drugs as a time-dependent variable. RESULTS Mortality was increased two- and fivefold in users of atypical and conventional antipsychotics, respectively, with respect to nonusers. CONCLUSIONS Dementia patients prescribed antipsychotic drugs had a higher risk of death. This risk was highest for those prescribed conventional antipsychotics. At least part of the excess mortality may be due to the underlying neuropsychiatric symptoms that prompted the use of antipsychotics rather than a direct medication effect.
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Affiliation(s)
- Massimo Musicco
- Institute of Biomedical Technologies, National Research Council, Via Fratelli Cervi 93, Segrate, Italy.
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Langballe EM, Engdahl B, Selbaek G, Nordeng H. Concomitant use of anti-dementia drugs with psychotropic drugs in Norway-a population-based study. Pharmacoepidemiol Drug Saf 2011; 20:1319-26. [DOI: 10.1002/pds.2211] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 04/05/2011] [Accepted: 06/22/2011] [Indexed: 11/07/2022]
Affiliation(s)
| | - Bo Engdahl
- Division of Mental Health; Norwegian Institute of Public Health; Oslo Norway
| | - Geir Selbaek
- Research Centre for Old Age Psychiatric Research; Innlandet Hospital Trust; Ottestad Norway
- The Norwegian Centre for Dementia Research; Ullevaal University Hospital; Ullevaal Norway
| | - Hedvig Nordeng
- Division of Mental Health; Norwegian Institute of Public Health; Oslo Norway
- Department of Pharmacy; School of Pharmacy; University of Oslo; Blindern Norway
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Haasum Y, Fastbom J, Fratiglioni L, Kåreholt I, Johnell K. Pain treatment in elderly persons with and without dementia: a population-based study of institutionalized and home-dwelling elderly. Drugs Aging 2011; 28:283-93. [PMID: 21428463 DOI: 10.2165/11587040-000000000-00000] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Several previous studies have reported an undertreatment of pain in elderly persons with dementia. It has also been suggested that persons with dementia may be at risk for inappropriate treatment of pain with psychotropics. OBJECTIVES The objective of this study was to investigate if persons with dementia are as likely as persons without dementia to receive pharmacological pain treatment, after taking into account residential setting and pain-related disorders. We also aimed to investigate whether use of psychotropics is related to pain in persons with and without dementia. METHODS We used baseline data from the SNAC-K (Swedish National Study of Aging and Care - Kungsholmen). We analysed use of analgesics and psychotropics, prevalence of pain-related diagnoses, self-reported pain, dementia status and residential setting in 2610 participants aged > 65 years. RESULTS Of the persons with dementia, 46% used at least one analgesic drug compared with 25% of those without dementia. Although persons with dementia reported pain less frequently than persons without dementia, the prevalence of pain-related diagnoses was similar. After adjustment for individual factors and residential setting (own home/institution), persons with dementia had a higher probability of use of paracetamol (acetaminophen) and psychotropics, whereas there were no significant differences in use of any analgesic, opioids and NSAIDs. Furthermore, having a pain-related diagnosis was associated with use of psychotropics in persons with dementia. CONCLUSIONS Persons with dementia had a higher probability of use of paracetamol and were about as likely as persons without dementia to use any analgesic, opioids and NSAIDs, after adjustment for confounders. This may reflect a recent increased awareness of pain and pain management in persons with dementia, compared with previous studies that have reported an underuse of analgesics in persons with dementia. However, further research is needed to analyse if persons with dementia are appropriately treated for pain with regard to type of analgesic drug, pain intensity, indication, dosage and regimen.
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Affiliation(s)
- Ylva Haasum
- Aging Research Center, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet and Stockholm University, Stockholm, Sweden.
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Lowry E, Woodman RJ, Soiza RL, Mangoni AA. Clinical and demographic factors associated with antimuscarinic medication use in older hospitalized patients. Hosp Pract (1995) 2011; 39:30-6. [PMID: 21441756 DOI: 10.3810/hp.2011.02.371] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Antimuscarinic drug prescribing scoring systems might better identify patients at risk of adverse drug reactions. The recently developed Anticholinergic Risk Scale (ARS) score is significantly associated with the number of antimuscarinic side effects in older outpatients. We sought to identify the clinical and demographic patient-level correlates of the ARS, including a modified version adjusted for daily dose, in elderly hospitalized patients. METHODS Clinical and demographic patient characteristics known to be associated with antimuscarinic prescribing, ARS and dose-adjusted ARS scores, and full medication exposure on admission were recorded in 362 consecutive patients (aged 83.6 ± 6.6 years) admitted to 2 geriatric units (NHS Grampian, Aberdeen, Scotland, UK) between February 1, 2010 and June 30, 2010. RESULTS Each year of increasing age was associated with reduced number of antimuscarinic drugs (incidence rate ratio [IRR], 0.963; 95% confidence interval [CI], 0.948-0.980; P < 0.001), non-antimuscarinic drugs (IRR, 0.991; 95% CI, 0.985-0.997; P = 0.006), and total number of drugs (IRR, 0.988; 95% CI, 0.983-0.994; P < 0.001). Multivariate Poisson regression showed that increasing age and history of dementia were negatively associated with the ARS score (IRR, 0.97; 95% CI, 0.94-0.99; P = 0.001 and IRR, 0.62; 95% CI, 0.41-0.92; P = 0.019, respectively). By contrast, institutionalization (IRR, 1.32; 95% CI, 1.00-1.74; P = 0.050), Charlson comorbidity index (IRR, 1.06; 95% CI, 1.01-1.11; P = 0.015), and total number of non-antimuscarinic drugs (IRR, 1.13; 95% CI, 1.08-1.18; P < 0.001) were all positively associated with the ARS score. Similar results were observed for the dose-adjusted ARS score. CONCLUSION Institutionalization, comorbidities, and non-antimuscarinic polypharmacy show independent positive associations with the ARS and dose-adjusted ARS scores in older hospitalized patients. Increasing age and dementia are negatively associated with the ARS score.
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Affiliation(s)
- Estelle Lowry
- Division of Applied Medicine, University of Aberdeen, Aberdeen, Scotland, United Kingdom
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Huybrechts KF, Rothman KJ, Silliman RA, Brookhart MA, Schneeweiss S. Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. CMAJ 2011; 183:E411-9. [PMID: 21444611 DOI: 10.1503/cmaj.101406] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite safety-related concerns, psychotropic medications are frequently prescribed to manage behavioural symptoms in older adults, particularly those with dementia. We assessed the comparative safety of different classes of psychotropic medications used in nursing home residents. METHODS We identified a cohort of patients who were aged 65 years or older and had initiated treatment with psychotropics after admission to a nursing home in British Columbia between 1996 and 2006. We used proportional hazards models to compare rates of death and rates of hospital admissions for medical events within 180 days after treatment initiation. We used propensity-score adjustments to control for confounders. RESULTS Of 10,900 patients admitted to nursing homes, atypical antipsychotics were initiated by 1942, conventional antipsychotics by 1902, antidepressants by 2169 and benzodiazepines by 4887. Compared with users of atypical antipsychotics, users of conventional antipsychotics and antidepressants had an increased risk of death (rate ratio [RR] 1.47, 95% confidence interval [CI] 1.14-1.91 for conventional antipsychotics and RR 1.20, 95% CI 0.96-1.50 for antidepressants), and an increased risk of femur fracture (RR 1.61, 95% CI 1.03-2.51 for conventional antipsychotics and RR 1.29, 95% CI 0.86-1.94 for antidepressants). Users of benzodiazepines had a higher risk of death (RR 1.28, 95% CI 1.04-1.58) compared with users of atypical antipsychotics. The RR for heart failure was 1.54 (95% CI 0.89-2.67), and for pneumonia it was 0.85 (95% CI 0.56-1.31). INTERPRETATION Among older patients admitted to nursing homes, the risks of death and femur fracture associated with conventional antipsychotics, antidepressants and benzodiazepines are comparable to or greater than the risks associated with atypical antipsychotics. Clinicians should weigh these risks against the potential benefits when making prescribing decisions.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass., USA.
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Nishtala PS, McLachlan AJ, Bell JS, Chen TF. Determinants of antipsychotic medication use among older people living in aged care homes in Australia. Int J Geriatr Psychiatry 2010; 25:449-57. [PMID: 19670391 DOI: 10.1002/gps.2359] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate determinants of antipsychotic medication use among older people living in aged care homes in Australia. DESIGN Retrospective study of a random sample of de-identified medication reports using cross-sectional data gathered between 1 January 2008 and 30 June 2008 in Australia. SUBJECTS The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five per cent were females. MEASURES Resident demographics, clinical characteristics, medical diagnoses and prescribed medication were systematically recorded. Logistic regression (LR) models were used to determine predictors for any antipsychotic, atypical and conventional antipsychotic use. RESULTS Twenty-three per cent of the residents were prescribed one or more antipsychotics. In the LR model, factors for predicting the odds ratio and 95% confidence interval (CI) for any antipsychotic medication use were agitation (7.11, 95% CI 3.15-16.03), challenging behaviours (7.47, 95% CI 2.53-22.10), dementia (2.35, 95% CI 1.36-4.06), dementia with mood disorder (0.39, 95% CI 0.16-0.92), paranoia (6.70, 95% CI 1.08-41.55), psychosis (14.79, 95% CI 3.64-60.00) and any psychiatric diagnosis (3.30, 95% CI 1.82-6.00). Use of atypical antipsychotic medication was significant for agitation (4.58, 95% CI 2.05-10.23), aggression (2.25, 95% CI 1.05-4.78), challenging behaviours (8.01, 95% CI 2.76-23.24), dementia (3.64, 95% CI 1.99-6.67), dementia with mood disorder (0.16, 95% CI 0.06-0.43), psychosis (16.51, 95% CI 4.28-63.66) and any psychiatric diagnosis (4.44, 95% CI 2.33-8.46). CONCLUSIONS Psychiatric diagnosis, psychosis and dementia were associated with significantly greater odds for the use of antipsychotic medications. Older people suffering from dementia and comorbid mood disorders treated with antidepressants were less likely to be prescribed atypical antipsychotics.
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Olsson J, Bergman Å, Carlsten A, Oké T, Bernsten C, Schmidt IK, Fastbom J. Quality of Drug Prescribing in Elderly People in Nursing Homes and Special Care Units for Dementia. Clin Drug Investig 2010; 30:289-300. [DOI: 10.2165/11534320-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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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The association between dementia and long-term use of benzodiazepine in the elderly: nested case-control study using claims data. Am J Geriatr Psychiatry 2009; 17:614-20. [PMID: 19546656 DOI: 10.1097/jgp.0b013e3181a65210] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to examine the association between long-term benzodiazepines (BZDs) use and the risk of dementia. DESIGN Population-based nested case-control study of dementia. SETTING All subjects were aged 45 and older and enrolled in the National Health Insurance Research Database in Taiwan, 1997-2004. PARTICIPANTS Cases (N = 779) were patients who were identified with dementia at least two times in their outpatient claims. They were individually matched to six comparison subjects (N = 4,626) based on age and gender. MEASUREMENTS BZD usage (average dosage per year, average days per year, and cumulative dose and periods) and potential confounding comobidities, including cardiovascular and psychiatric diseases. RESULTS Subjects with dementia had higher cumulative dose, longer duration of BZDs exposure, and more likelihood to be long-term BZDs users. CONCLUSION Our findings suggest that long-term use of BZDs is associated with an increased risk for dementia, but the underlying mechanisms remain unclear, and further investigations are needed. Long-term use of BZDs should be avoided among the elderly, who may be at a higher risk for developing dementia, in addition to other health problems.
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Lesén E, Petzold M, Andersson K, Carlsten A. To what extent does the indicator “concurrent use of three or more psychotropic drugs” capture use of potentially inappropriate psychotropics among the elderly? Eur J Clin Pharmacol 2009; 65:635-42. [DOI: 10.1007/s00228-009-0623-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 01/13/2009] [Indexed: 11/24/2022]
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Abstract
OBJECTIVES Few studies have examined the association between anxiety symptoms and objectively measured sleep quality in older adults. The authors determined this association in a large cohort of very old community-dwelling women. DESIGN Cross-sectional. SETTING Participants' homes, sites of the Study of Osteoporotic Fractures. PARTICIPANTS Three thousand forty women (mean age: 83.6 years) enrolled in a prospective study of aging. MEASUREMENTS Participants completed the Goldberg Anxiety Scale (ANX), the 15-item Geriatric Depression Scale (GDS), and > or = 3 nights of actigraphy--a method of measuring sleep by recording wrist movement with a device called an actigraph. Elevated anxiety symptoms were defined as ANX > or = 6. Elevated depressive symptoms were defined as GDS > or = 6. RESULTS Participants' mean ANX score was 1.4 (standard deviation: 2.2); 9.2% (N = 280) had ANX > or = 6. Elevated anxiety symptoms were associated with greater odds of poor sleep efficiency (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 1.34, 2.23) and time awake after sleep onset (OR: 1.64, 95% CI: 1.27, 2.11). Associations remained after adjustment for GDS > or = 6, antianxiety medications, and other potential confounders (sleep efficiency OR: 1.50, 95% CI: 1.15, 1.97; time awake after sleep onset OR: 1.33, 95% CI: 1.01, 1.75). Anxiety symptoms were not associated with other sleep parameters. CONCLUSION Findings suggest that elevated anxiety symptoms are independently associated with poor objectively measured sleep efficiency and elevated sleep fragmentation in very old women, after accounting for significant depressive symptoms, medical comorbidities, and use of antianxiety medications.
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Schneeweiss S, Setoguchi S, Brookhart MA, Kaci L, Wang PS. Assessing residual confounding of the association between antipsychotic medications and risk of death using survey data. CNS Drugs 2009; 23:171-80. [PMID: 19173375 PMCID: PMC3067056 DOI: 10.2165/00023210-200923020-00006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Nonrandomised studies on the causal effects of psychotropic medications may be biased by patient characteristics that are not fully adjusted. OBJECTIVE Studies using linked claims databases found that typical antipsychotic medications were associated with increased short-term mortality compared with atypical antipsychotics. It has been suggested that such results may be due to residual confounding by factors that cannot be measured in claims databases. Using detailed survey data we identified the direction and magnitude of such residual confounding. DESIGN Cross-sectional survey data. PARTICIPANTS 17 776 participants aged > or =65 years from the Medicare Current Beneficiary Survey (MCBS). MEASUREMENTS To determine the association between typical antipsychotic use and potential confounding factors we assessed five factors not measured in Medicare claims data but in the MCBS, i.e. body mass index, smoking, activities of daily living (ADL) score, cognitive impairment and Rosow-Breslau physical impairment scale. We estimated adjusted associations between these factors and antipsychotic use. Combined with literature estimates of the independent effect of confounders on death, we computed the extent of residual confounding caused by a failure to adjust for these factors. RESULTS Comparing typical antipsychotic users with atypical antipsychotic users, we found that not adjusting for impairments in the ADL score led to an underestimation of the association with death (-13%), as did a failure to adjust for cognitive impairment (-7%). The combination of all five unmeasured confounders resulted in a net confounding of -5% (range -19% to +2%). After correction, the reported association between typical antipsychotic use and death compared with atypical antipsychotic use was slightly increased from a relative risk (RR) of 1.37 to 1.44 (95% CI 1.33, 1.56). Comparing any antipsychotic use with non-users would result in overestimations of >50% if cognitive impairment remained unadjusted. CONCLUSION Claims data studies tend to underestimate the association of typical antipsychotics with death compared with atypical antipsychotics because of residual confounding by measures of frailty. Studies comparing antipsychotic use with non-users may substantially overestimate harmful effects of antipsychotics.
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Affiliation(s)
- Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Lövheim H, Karlsson S, Gustafson Y. The use of central nervous system drugs and analgesics among very old people with and without dementia. Pharmacoepidemiol Drug Saf 2008; 17:912-8. [DOI: 10.1002/pds.1600] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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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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Knol W, van Marum RJ, Jansen PAF, Souverein PC, Schobben AFAM, Egberts ACG. Antipsychotic drug use and risk of pneumonia in elderly people. J Am Geriatr Soc 2008; 56:661-6. [PMID: 18266664 DOI: 10.1111/j.1532-5415.2007.01625.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To investigate the association between antipsychotic drug use and risk of pneumonia in elderly people. DESIGN A nested case-control analysis. SETTING Data were used from the PHARMO database, which collates information from community pharmacies and hospital discharge records. PARTICIPANTS A cohort of 22,944 elderly people with at least one antipsychotic prescription; 543 cases of hospital admission for pneumonia were identified. Cases were compared with four randomly selected controls matched on index date. MEASUREMENTS Antipsychotic drug use in the year before the index date was classified as current, recent, or past use. No prescription for an antipsychotic in the year before the index date was classified as no use. The strength of the association between use of antipsychotics and the development of pneumonia was estimated using multivariate logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Current use of antipsychotics was associated with an almost 60% increase in the risk of pneumonia (adjusted OR=1.6, 95% CI=1.3-2.1). The risk was highest during the first week after initiation of an antipsychotic (adjusted OR=4.5, 95% CI=2.8-7.3). Similar associations were found after exclusion of elderly people with a diagnosis of delirium. Current users of atypical agents showed a higher risk of pneumonia (adjusted OR=3.1, 95% CI=1.9-5.1) than users of conventional agents (adjusted OR=1.5, 95% CI=1.2-1.9). There was no clear dose-response relationship. CONCLUSION Use of antipsychotics in elderly people is associated with greater risk of pneumonia. This risk is highest shortly after the initiation of treatment, with the greatest increase in risk found for atypical antipsychotics.
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Affiliation(s)
- Wilma Knol
- Department of Geriatrics, University Medical Center Utrecht, Utrecht, The Netherlands
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Alanen HM, Finne-Soveri H, Noro A, Leinonen E. Use of Antipsychotics in Older Home Care Patients in Finland. Drugs Aging 2008; 25:335-42. [DOI: 10.2165/00002512-200825040-00006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Schneeweiss S, Setoguchi S, Brookhart A, Dormuth C, Wang PS. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007; 176:627-32. [PMID: 17325327 PMCID: PMC1800321 DOI: 10.1503/cmaj.061250] [Citation(s) in RCA: 263] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Public health advisories have warned that the use of atypical antipsychotic medications increases the risk of death among elderly patients. We assessed the short-term mortality in a population-based cohort of elderly people in British Columbia who were prescribed conventional and atypical antipsychotic medications. METHODS We used linked health care utilization data of all BC residents to identify a cohort of people aged 65 years and older who began taking antipsychotic medications between January 1996 and December 2004 and were free of cancer. We compared the 180-day all-cause mortality between residents taking conventional antipsychotic medications and those taking atypical antipsychotic medications. RESULTS Of 37 241 elderly people in the study cohort, 12 882 were prescribed a conventional antipsychotic medication and 24 359 an atypical formulation. Within the first 180 days of use, 1822 patients (14.1%) in the conventional drug group died, compared with 2337 (9.6%) in the atypical drug group (mortality ratio 1.47, 95% confidence interval [CI] 1.39-1.56). Multivariable adjustment resulted in a 180-day mortality ratio of 1.32 (1.23-1.42). In comparison with risperidone, haloperidol was associated with the greatest increase in mortality (mortality ratio 2.14, 95% CI 1.86-2.45) and loxapine the lowest (mortality ratio 1.29, 95% CI 1.19-1.40). The greatest increase in mortality occurred among people taking higher (above median) doses of conventional antipsychotic medications (mortality ratio 1.67, 95% CI 1.50-1.86) and during the first 40 days after the start of drug therapy (mortality ratio 1.60, 95% CI 1.42-1.80). Results were confirmed in propensity score analyses and instrumental variable estimation, minimizing residual confounding. INTERPRETATION Among elderly patients, the risk of death associated with conventional antipsychotic medications is comparable to and possibly greater than the risk of death associated with atypical antipsychotic medications. Until further evidence is available, physicians should consider all antipsychotic medications to be equally risky in elderly patients.
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Affiliation(s)
- Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 021205, USA.
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Bergman A, Olsson J, Carlsten A, Waern M, Fastbom J. Evaluation of the quality of drug therapy among elderly patients in nursing homes. Scand J Prim Health Care 2007; 25:9-14. [PMID: 17354153 PMCID: PMC3389457 DOI: 10.1080/02813430600991980] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate drug therapy quality among elderly nursing home residents. Secondary aims were to compare quality in young and old elderly and to determine whether number of prescribers affected quality of drug therapy. DESIGN A cross-sectional population-based register study. SETTING Nursing home residents in the Gothenburg area using the multi-dose system (e.g. patients who get their drugs machine dispensed into one unit for each dose occasion, a service offered by the National Corporation of Pharmacies). SUBJECTS All nursing home residents aged 65 years and older. MAIN OUTCOME MEASURES The quality of drug therapy assessed using five quality indicators for the elderly recently introduced by the Swedish National Board of Health and Welfare; number of prescribed drugs per resident. RESULTS Over 70% of residents had one or more potentially inappropriate prescription. Younger nursing home residents (65-79 years) had significantly (p < 0.001) lower quality of drug therapy than older residents (80 + ). The average number of prescribing physicians per resident was high at almost four per resident. An increasing number of prescribers per resident was associated with a higher number of drugs prescribed and a lower quality of drug therapy. CONCLUSION Computerized quality assurance systems can provide support for healthcare providers. Quality indicators should be modified to give maximum support for users.
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Wang PS, Brookhart MA, Setoguchi S, Patrick AR, Schneeweiss S. Psychotropic medication use for behavioral symptoms of dementia. Curr Neurol Neurosci Rep 2006; 6:490-5. [PMID: 17074284 DOI: 10.1007/s11910-006-0051-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Behavioral disturbances associated with dementia are common and burdensome. Although no psychotropic medications are currently approved by the US Food and Drug Administration (FDA) to treat such behavioral symptoms, a variety of drug classes are commonly used for these purposes. Atypical antipsychotic medications may be somewhat effective and are generally considered the pharmacologic treatments of choice; however "black box" warnings have recently been added to their labels by the FDA, warning of significantly increased risks of short-term mortality. Older conventional antipsychotic medications may also be somewhat effective but appear to pose risks that can be at least as great as those of the newer atypical drugs. Although antidepressants, benzodiazepines, mood stabilizers, acetylcholinesterase inhibitors, and N-methyl-D-aspartate (NMDA) receptor antagonists may be considered, particularly in patients with specific types of symptomatology, even less is known about their effectiveness and safety. Also, although various psychotropic medications used for behavioral disturbances in dementia patients may be somewhat effective, they have been increasingly associated with important safety risks.
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Affiliation(s)
- Philip S Wang
- Department of Psychiatry, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA.
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Grimmer T, Kurz A. Effects of Cholinesterase Inhibitors on Behavioural Disturbances in Alzheimer???s Disease. Drugs Aging 2006; 23:957-67. [PMID: 17154660 DOI: 10.2165/00002512-200623120-00003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Behavioural disturbances, also termed neuropsychiatric symptoms, are a frequent clinical feature of dementia in Alzheimer's disease (AD). Many AD patients receive treatment with cholinesterase inhibitors (ChEIs). This review examines the evidence for behavioural effects of the four ChEIs that have been approved for the treatment of mild to moderate AD. A systematic search of the MEDLINE and EMBASE databases and the Cochrane Library was conducted to identify clinical trials that had a randomised, placebo-controlled design. Studies were included in this review if they enrolled patients who had received a diagnosis of probable AD, involved at least one ChEI, and used an appropriate instrument for the assessment of behavioural disturbances. Fourteen studies that matched the selection criteria were identified in the literature. A statistically significant difference between active treatment and placebo with regard to behavioural symptoms was observed in three of the 14 studies. Treatment effects varied between 2.0 and 6.2 points on the Neuropsychiatric Inventory. ChEIs have moderate effects when used as a blanket treatment for the cluster of behavioural disturbances in AD. With regard to the limitations of the available trials, and in view of the risks that are associated with the use of atypical antipsychotics, the potential of ChEIs for the management of specific neuropsychiatric symptoms in patients with AD should be explored in further studies.
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Affiliation(s)
- Timo Grimmer
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany.
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Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA. Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med 2005; 353:2335-41. [PMID: 16319382 DOI: 10.1056/nejmoa052827] [Citation(s) in RCA: 600] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Recently, the Food and Drug Administration (FDA) issued an advisory stating that atypical antipsychotic medications increase mortality among elderly patients. However, the advisory did not apply to conventional antipsychotic medications; the risk of death with these older agents is not known. METHODS We conducted a retrospective cohort study involving 22,890 patients 65 years of age or older who had drug insurance benefits in Pennsylvania and who began receiving a conventional or atypical antipsychotic medication between 1994 and 2003. Analyses of mortality rates and Cox proportional-hazards models were used to compare the risk of death within 180 days, less than 40 days, 40 to 79 days, and 80 to 180 days after the initiation of therapy with an antipsychotic medication. We controlled for potential confounding variables with the use of traditional multivariate Cox models, propensity-score adjustments, and an instrumental-variable analysis. RESULTS Conventional antipsychotic medications were associated with a significantly higher adjusted risk of death than were atypical antipsychotic medications at all intervals studied (< or =180 days: relative risk, 1.37; 95 percent confidence interval, 1.27 to 1.49; <40 days: relative risk, 1.56; 95 percent confidence interval, 1.37 to 1.78; 40 to 79 days: relative risk, 1.37; 95 percent confidence interval, 1.19 to 1.59; and 80 to 180 days: relative risk, 1.27; 95 percent confidence interval, 1.14 to 1.41) and in all subgroups defined according to the presence or absence of dementia or nursing home residency. The greatest increases in risk occurred soon after therapy was initiated and with higher dosages of conventional antipsychotic medications. Increased risks associated with conventional as compared with atypical antipsychotic medications persisted in confirmatory analyses performed with the use of propensity-score adjustment and instrumental-variable estimation. CONCLUSIONS If confirmed, these results suggest that conventional antipsychotic medications are at least as likely as atypical agents to increase the risk of death among elderly persons and that conventional drugs should not be used to replace atypical agents discontinued in response to the FDA warning.
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Affiliation(s)
- Philip S Wang
- Department of Psychiatry, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA.
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Rapoport M, Mamdani M, Shulman KI, Herrmann N, Rochon PA. Antipsychotic use in the elderly: shifting trends and increasing costs. Int J Geriatr Psychiatry 2005; 20:749-53. [PMID: 16035128 DOI: 10.1002/gps.1358] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The purpose of this study was to assess trends in utilization and costs of antipsychotic drugs among a population of older adults over time, with respect to the prevalence of users, shifts in prescribing patterns, and related financial implications. DESIGN Cross-sectional time series of quarterly and annual antipsychotic utilization and cost were obtained from administrative databases for calendar years 1993 through 2002. SETTING AND PARTICIPANTS A population-based study of more than 1.4 million residents of the province of Ontario aged 65 years or older. MEASUREMENTS Data sources used included the Ontario Drug Benefits (ODB) database and Statistics Canada census data. RESULTS The prevalence of antipsychotic users increased by 34.8% over the study period from 2.2% at the beginning of 1993 to 3.0% of the elderly at the end of 2002 (p < 0.01). This was associated with a 749% increase in total cost (from $3.7 million in 1993 to $31.4 million in 2002; p < 0.01). The atypical antipsychotics, which were not available in 1993, made up 82.5% of the antipsychotics dispensed and 95.2% of costs in 2002. CONCLUSIONS The modest increase in antipsychotic prevalence in the elderly over the last ten years has been associated with a substantial increase in cost, with a significant shift towards use of the atypical antipsychotics. As the atypical antipsychotics are increasingly used for patients with dementia, which is becoming more prevalent in the aging population, an understanding of the benefits of these medications must be balanced with a detailed understanding of the material and financial implications.
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Affiliation(s)
- Mark Rapoport
- Sunnybrook and Women's College Health Sciences Centre Departments of Psychiatry, Toronto, Canada.
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Hosia-Randell H, Pitkälä K. Use of Psychotropic Drugs in Elderly Nursing Home Residents with and without Dementia in Helsinki, Finland. Drugs Aging 2005; 22:793-800. [PMID: 16156683 DOI: 10.2165/00002512-200522090-00008] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Use of psychotropic medication is very common in nursing home residents. Our objective was to describe the use of psychotropic drugs in all long-term nursing home residents > or =65 years of age with and without dementia in Helsinki, Finland. METHOD The study was a cross-sectional assessment of the nursing home population. The residents' health status was assessed and data on their demographic factors, health and medication use were collected from medical charts in February 2003. RESULTS Of all nursing home residents in Helsinki, 82% (n = 1987) participated in the study. The nursing home residents' mean age was 83.7 (SD 7.7) years, 80.7% were female, and 69.5% were diagnosed with dementia. The mean number of drugs [corrected] given regularly was 7.9 (SD 3.6) per day per resident[corrected] Of the participants, 79.7% were regularly taking psychotropic medication. Conventional antipsychotics were administered to 18.9% of residents and atypical antipsychotics to 27.0%. Of the residents, 26.7% were on selective serotonin reuptake inhibitors (SSRIs), 3.1% on tricyclic antidepressants and 17.6% on other antidepressants. Altogether, 44.6% of residents were taking one or more antidepressant. More than a quarter (26.3%) were taking at least one anxiolytic drug. Hypnotics were used by 27.5%. However, only moderate dosages of psychotropic drugs were being taken. Only 10.4% of individuals with dementia were regularly taking cholinesterase inhibitors and four residents were taking memantine. CONCLUSIONS Use of psychotropic drugs is very common in nursing homes in Helsinki, Finland, with four of five nursing home residents regularly receiving psychotropic drugs. Only one in ten residents were receiving cholinesterase inhibitors. Physicians caring for nursing home residents require further education on the benefits and adverse effects of psychotropic drugs in frail elderly people.
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Affiliation(s)
- Helka Hosia-Randell
- Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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