Prescribing of antipsychotic drugs in patients with dementia: a comparison with age-matched and sex-matched non-demented controls

A bitter pill to swallow - Polypharmacy and psychotropic treatment in people with advanced dementia

BACKGROUND

Polypharmacy is common in people with dementia. The use of psychotropic drugs (PDs) and other, potentially inappropriate medications is high. The aims of this cross-sectional study were 1) to investigate the use of drugs in people with advanced dementia (PWAD), living at home or in long term care (LTC); 2) to focus on PD use; and 3) to identify determinants of PD use.

METHODS

The study was performed in the context of EPYLOGE (IssuEs in Palliative care for people in advanced and terminal stages of YOD and LOD in Germany). 191 PWAD were included. All drugs that were administered at the date of the examination were recorded. Multiple logistic regression analysis identified determinants of PD use.

RESULTS

96% of PWAD received medication with a median number of four drugs. 49.7% received five or more drugs. According to the Beers Criteria 39% of PWAD ≥ 65 years received at least one potentially inappropriate medication. 79% of PWAD were treated with PDs. Older PWAD and PWAD living in LTC facilities received significantly more drugs than younger PWAD, and PWAD living at home, respectively. Dementia etiology was significantly associated with the use of antipsychotics, antidepressants and sedative substances. Place of living was associated with the use of pain medication. Behavioral disturbances were associated with the use of antipsychotics and sedative substances.

CONCLUSIONS

To mitigate the dangers of polypharmacy and medication related harm, critical examination is required, whether a drug is indicated or not. Also, the deprescribing of drugs should be considered on a regular basis.

TRIAL REGISTRATION

Clinicaltrial.gov, NCT03364179 . Registered 6 December 2017.

Medications use among women with dementia: a cohort study

BACKGROUND

Older population with dementia use huge range of medications. In this study, we aimed to determine the prevalence of commonly used medications a year before and after first recorded dementia diagnosis among older Australian women.

METHODS

The study utilized Australian Longitudinal Study on Women's Health (ALSWH) data from 2090 women with known dementia, linked with administrative health datasets. The Pharmaceutical Benefits Scheme (PBS) data provided detailed information about prescribed medications. We applied latent class analysis (LCA) to the post-dementia data to identify patterns of medication use. Logistic regression model was used to explore the impact of potential predictors for medication utilization.

RESULTS

Antipsychotic use increased from 5% before dementia to 19% after dementia, while antidementia medication use increased from < 1 to 28%. There was a modest increase in benzodiazepines and antidepressants. Post-dementia, four distinct groups were identified using LCA (names based on probabilities of medications use) as: "High Psychotropic-Low Cardiovascular" (16% of the sample); "Moderate Psychotropic-High Cardiovascular" (12%); "Low Psychotropic-High Cardiovascular" (27%); and "Low Psychotropic-Low Cardiovascular" (45%). Living in Residential Aged Care (RAC) and frailty were associated with increased odds of being in the higher psychotropic use groups.

CONCLUSIONS

Substantial utilization of psychotropic medications by older people with dementia indicates a need for a careful review of the use of these medications. Appropriate alternative approaches to the management of dementia should be practiced with a special focus on RAC residents with frailty.

Impact of an interdisciplinary intervention for distress behaviors in dementia on psychotropic drug use in Veterans Health Administration Community Living Centers: STAR-VA impact on psychotropic drug utilization

STAR-VA is an interdisciplinary behavioral approach for managing distress behaviors in residents with dementia, implemented at Veterans Health Administration nursing homes. This study evaluated the impact of STAR-VA implementation on psychotropic drug use. The study design is a retrospective, quasi-experimental cohort analysis of residents enrolled as STAR-VA training cases compared with eligible residents at untrained sites to evaluate treatment effects on psychotropic medication use. We matched 229 STAR-VA cases with 1,163 comparisons. STAR-VA cases experienced an average reduction of 0.92 "as-needed" doses per month (95% confidence interval [CI] -1.82, -0.02) compared with controls. No significant effect on non-STAR-VA cases in trained facilities was detected. STAR-VA programs are an important option for reducing potentially inappropriate psychotropic use.

The Prevalence of and Documented Indications for Antipsychotic Prescribing in Irish Nursing Homes

Background: Antipsychotic medications are often used ‘off-licence’ to treat neuropsychiatric symptoms and disorders of aging and to manage behavioural and psychological symptoms of dementia despite the warnings of adverse effects. Objective: To establish the prevalence of and documented indication for antipsychotic medication use in the Irish nursing home setting. Setting: This study was conducted in six nursing homes located in Co. Cork, Ireland. Method: A retrospective, cross-sectional study was employed. All patients who met the inclusion criteria (≥65 years, residing in a nursing home on a long-term basis) were eligible for inclusion. There were 120 nursing home residents recruited to the study. Main Outcome Measure: The prevalence of antipsychotic medication use in nursing home residents (with and without dementia). Results: The overall prevalence of antipsychotic prescribing was found to be 48% and patients with dementia were significantly more likely to be prescribed an antipsychotic compared to those without dementia (67% vs. 25%) (χ² (1, N = 120) = 21.541, p < 0.001). In the cohort of patients with dementia, there was a trend approaching significance (p = 0.052) of decreasing antipsychotic use with increasing age (age 65–74 = 90%; age 75–84 = 71%; age 85 and over = 58%). An indication was documented for 84% of the antipsychotic prescriptions in this cohort. Conclusions: The findings of this study highlight that high rates of antipsychotic medication use remains an issue in Irish nursing homes. Further work should explore factors in influencing prescribing of these medications in such settings.

Polypharmacy in chronic neurological diseases: Multiple sclerosis, dementia and Parkinson's disease

Polypharmacy is an important aspect of medication management and particularly affects elderly and chronically ill people. Patients with dementia, Parkinson's disease (PD) or multiple sclerosis (MS) are at high risk for multimedication due to their complex symptomatology. Our aim was to provide an overview of different definitions of polypharmacy and to present the current state of research on polypharmacy in patients with dementia, PD or MS. The most common definition of polypharmacy in the literature is the concomitant use of ≥5 medications (quantitative definition approach). Polypharmacy rates of up to >50% have been reported for patients with dementia, PD or MS, although MS patients are on average significantly younger than those with dementia or PD. The main predictor of polypharmacy is the complex symptom profile of these neurological disorders. Potentially inappropriate medication (PIM), drug-drug interactions, poor treatment adherence, severe disease course, cognitive impairment, hospitalisation, poor quality of life, frailty and mortality have been associated with polypharmacy in patients with dementia, PD or MS. For patients with polypharmacy, either the avoidance of PIM (selective deprescribing) or the substitution of PIM with more suitable drugs (appropriate polypharmacy) is recommended to achieve a more effective therapeutic management.

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care at baseline

Background

Little is known about the use of psychotropic drugs in older adults receiving domiciliary care. The first aim was to describe the prevalence and persistency of use of psychotropic drugs in older adults (≥ 70 years) with and without dementia receiving domiciliary care. Furthermore, the second aim was to explore factors associated with persistent drug use at two consecutive time-points. Lastly, we aimed to examine if use of psychotropic drugs changed after admission to a nursing home.

Methods

In total, 1001 community-dwelling older adults receiving domiciliary care at inclusion participated in the study. Information about psychotropic drug use was collected at baseline, after 18 months and after 36 months. The participants’ cognitive function, neuropsychiatric symptoms (NPS) and physical health were assessed at the same assessments. Participants were evaluated for dementia based on all gathered information. Formal level of care (domiciliary care or in a nursing home) was registered at the follow-up assessments.

Results

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care was high. Participants with dementia more often used antipsychotics and antidepressants than participants without dementia. The majority of the participants using antipsychotic drugs used traditional antipsychotics. Younger age was associated with higher odds for persistent use of antipsychotics and antidepressants, and lower odds for persistent use of sedatives. Severity of NPS was associated with persistent use of antidepressants. The odds for use of antipsychotics and antidepressants were higher in those admitted to a nursing home as compared to the community-dwelling participants at the last follow-up.

Conclusion

There was a high prevalence and persistency of use of psychotropic drugs. The prevalence of use of traditional antipsychotics was surprisingly high, which is alarming. Monitoring the effect and adverse effects of psychotropic drugs is an important part of the treatment, and discontinuation should be considered when possible due to the odds for severe adverse effects of such drugs in people with dementia.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1126-y) contains supplementary material, which is available to authorized users.

Cardiovascular and metabolic comorbidities in patients with Alzheimer's disease and vascular dementia compared to a psychiatric control cohort

BACKGROUND

Multimorbidity in dementia is associated with an increased risk of complications and a higher need for care. Having knowledge of cardiovascular and metabolic comorbidities is crucial when making decisions about diagnostic procedures and therapies. We compared the prevalence of comorbidities in hospitalized patients with Alzheimer's disease (AD), vascular dementia, and psychiatric diseases other than dementia. Additionally, we compared clinically relevant health-care indicators (length of hospital stay, rate of re-hospitalization) between these groups.

METHODS

We used information from a database of treatment-relevant indicators from psychiatric and psychosomatic hospitals throughout Germany. This database contains routinely recorded data collected from 85 German hospitals from 2011 to 2015. In total, 14 411 AD cases, 7156 vascular dementia cases, and 34 534 cases involving non-demented psychiatric patients (used as controls) were included. To analyze comorbidities and health-care indicators, χ² tests and t-tests were used.

RESULTS

Diabetes mellitus, lipoprotein disorders, coronary artery diseases, cardiac arrhythmia and insufficiency, and atherosclerosis were significantly more prevalent in patients with vascular dementia than in those with AD and psychiatric controls. Hypertension and coronary artery diseases were less frequently associated with AD than with non-demented psychiatric controls (P < 0.001). Additionally, dementia patients with cardiovascular or metabolic diseases exhibited longer hospital stays (+ 1.4 days, P < 0.001) and were more often re-hospitalized within 3 weeks (P < 0.001) and 1 year (P < 0.001) compared to dementia patients without these comorbidities.

CONCLUSIONS

Awareness of somatic comorbidities in patients with dementia is crucial to avoid complications during inpatient treatment. The occurrence of comorbid disorders was associated with longer and more frequent hospital stays, which potentially lead to higher health-care costs. Further studies should evaluate the causative association between somatic comorbidities and inpatient costs in dementia patients.

Antipsychotic treatment of community-dwelling and institutionalised patients with dementia in Germany

OBJECTIVE

A restrictive use of antipsychotic drugs in patients with Alzheimer's disease (AD) is recommended due to an increased risk of cerebrovascular events and mortality. We hypothesise that the prescription of antipsychotics is associated with the patients' socio-demographic and clinical status (e.g., dementia severity).

METHODS

The prescription of antipsychotics was cross-sectionally evaluated in 272 community-dwelling and 123 institutionalised patients with AD across all severity stages of dementia. The patients' clinical characteristics covered the cognitive status, neuropsychiatric symptoms, daily activities, and quality of life (HrQoL). To determine associations with the use of antipsychotics bivariate and logistic regression analyses were conducted.

RESULTS

Totally, 25% of the patients were treated with antipsychotics. significantly less frequently than nursing home inhabitants (15.1% vs. 45.5%). Severely demented patients (MMSE 0-9) received antipsychotics most often (51.5%). Additionally, multiple regression analyses revealed a higher chance of prescription for participants with depressive symptoms (OR 2.3, 95% CI: 1.019-5.160) and those treated by neuropsychiatric specialists (OR 3.4, 95% CI: 1.408-8.328).

CONCLUSIONS

Further longitudinal studies are required to assess the appropriateness of indications for antipsychotics and the reasons for a higher use in nursing home inhabitants and patients with severe dementia and depression.

Community-Dwelling People Screened Positive for Dementia in Primary Care: A Comprehensive, Multivariate Descriptive Analysis Using Data from the DelpHi-Study

BACKGROUND

Efficient help and care for people with dementia (PWD) is dependent on knowledge about PWD in primary care.

OBJECTIVE

This analysis comprehensively describes community-dwelling PWD in primary care with respect to various dementia care specific variables.

METHODS

The analyses are based on baseline data of the ongoing general practitioner-based, randomized, controlled intervention trial DelpHi-MV (Dementia: life- and person-centered help). 6,838 patients were screened for dementia in 136 GP practices; 17.1% were screened positive, 54.4% of those agreed to participate and data could be assessed in n = 516 subjects. We assessed age, sex, living situation, cognitive status, functional status, level of impairment, comorbidities, formal diagnosis of dementia, depression, neuropsychiatric symptoms, quality of life, utilization of medical support, and pharmacological therapy.

RESULTS

Concerning clinical-, dementia-, and health-related variables, the sample under examination was on average mildly cognitively and functionally impaired (MMSE, m = 22.2; BADL, m = 3.7). A level of care was assigned in 38.0%. Depression was identified in 15.4% and other frequent comorbidities were high blood pressure (83.3%), coronary heart diseases (37.1%), cerebrovascular diseases (22.3%), among others. In 48.6%, neuropsychiatric symptoms were present in a clinically relevant severity. Pharmacological treatment with antidementia medication was received by 25.8% and antidepressant medication by 14.0%. Utilization of services was generally low.

CONCLUSION

The comprehensive description of people screened positive for dementia in primary care reveals a complex and unique population of patients. They are considerably underdiagnosed and in their majority mildly to moderately affected. More in-depth analyses are needed to study relations, associations and interactions between different variables.

International trends in antipsychotic use: A study in 16 countries, 2005-2014

The objective of this study was to assess international trends in antipsychotic use, using a standardised methodology. A repeated cross-sectional design was applied to data extracts from the years 2005 to 2014 from 16 countries worldwide. During the study period, the overall prevalence of antipsychotic use increased in 10 of the 16 studied countries. In 2014, the overall prevalence of antipsychotic use was highest in Taiwan (78.2/1000 persons), and lowest in Colombia (3.2/1000). In children and adolescents (0-19 years), antipsychotic use ranged from 0.5/1000 (Lithuania) to 30.8/1000 (Taiwan). In adults (20-64 years), the range was 2.8/1000 (Colombia) to 78.9/1000 (publicly insured US population), and in older adults (65+ years), antipsychotic use ranged from 19.0/1000 (Colombia) to 149.0/1000 (Taiwan). Atypical antipsychotic use increased in all populations (range of atypical/typical ratio: 0.7 (Taiwan) to 6.1 (New Zealand, Australia)). Quetiapine, risperidone, and olanzapine were most frequently prescribed. Prevalence and patterns of antipsychotic use varied markedly between countries. In the majority of populations, antipsychotic utilisation and especially the use of atypical antipsychotics increased over time. The high rates of antipsychotic prescriptions in older adults and in youths in some countries merit further investigation and systematic pharmacoepidemiologic monitoring.

Antipsychotic drug use in nursing home residents with and without dementia: keep an eye on the pro re nata medication

Behavioral and psychological symptoms of dementia often lead to the prescription of antipsychotics, especially in nursing homes, but their use remains controversial. This study aimed to assess antipsychotic drug use in residents with dementia compared with those without dementia. Data were obtained through the cross-sectional 'inappropriate medication in patients with renal insufficiency in nursing homes' (IMREN) study including data from 21 nursing homes. Descriptive statistics were used and factors associated with the prescription of antipsychotics were identified by logistic regression. Overall, 57.5% of the 837 residents had a diagnosis of dementia and 47.0% of residents with dementia and 19.5% of those without dementia received antipsychotics. 35.9% of all antipsychotics in residents with dementia were prescribed as pro re nata (PRN) compared with 23.0% for residents without dementia. Typical antipsychotics were prescribed more commonly than atypical ones. The adjusted logistic regression showed a significant association between the prescription of antipsychotics and dementia (odds ratio: 3.58, 95% confidence interval: 2.45-5.25) as well as severe care dependency (odds ratio: 1.68, 95% confidence interval: 1.10-2.55). Despite safety warnings, antipsychotics are still frequently prescribed to residents with dementia. Almost half received antipsychotics and about a third of the antipsychotics are prescribed as PRN. Further studies should assess the use of PRN antipsychotics and guidelines for PRN prescriptions are clearly needed.

Inequalities in receipt of mental and physical healthcare in people with dementia in the UK

Background

UK Dementia Strategies prioritise fair access to mental and physical healthcare. We investigated whether there are inequalities by deprivation or gender in healthcare received by people with dementia, and compared healthcare received by people with and without dementia.

Methods

we investigated primary care records of 68,061 community dwelling dementia patients and 259,337 people without dementia (2002–13). We tested hypotheses that people with dementia from more deprived areas, and who are women receive more psychotropic medication, fewer surgery consultations, are less likely to receive annual blood pressure, weight monitoring and an annual review, compared with those from less deprived areas and men.

Results

only half of people with dementia received a documented annual review. Deprivation was not associated with healthcare received. Compared to men with dementia, women with dementia had lower rates of surgery consultations (adjusted incidence rate ratio (IRR) 0.90, 95% CI 0.90–0.91), of annual blood pressure monitoring (adjusted IRR 0.96, 95% CI 0.95–0.97) and of annual weight monitoring (adjusted IRR 0.91, 95% CI 0.90–0.93). Men with dementia were less likely to be taking psychotropic medication than women with dementia. People with dementia had fewer surgery consultations and were less likely to have their weight and blood pressure monitored at least annually, compared to the non-dementia group.

Conclusions

people with dementia, in particular women, appear to receive less primary healthcare, but take more psychotropic medication that may negatively impact their physical health. Reducing these inequalities and improving access of people with dementia to preventative healthcare could improve the health of people with dementia.

Regional changes in psychotropic use among Finnish persons with newly diagnosed Alzheimer's disease in 2005-2011

Objectives

To describe and compare temporal changes in prevalence and incidence of psychotropic use (antipsychotics, antidepressants and benzodiazepines and related drugs; BZDRs) in persons with newly diagnosed Alzheimer’s disease (AD) between university hospital districts of Finland during 2005–2011.

Methods

The MEDALZ study includes all community-dwellers of Finland who received a clinically verified AD diagnosis in 2005–2011 (N = 70,718). Prevalent and incident use of psychotropics among those who had received AD diagnosis less than one year ago were compared in 2005–2011.

Results

Regional differences in psychotropic use between university hospital districts were more evident in 2005 than 2011 for prevalent use of any psychotropic, antipsychotic and BZDRs and incident use of any psychotropic and antipsychotics. Regional differences in prevalent antidepressant use and incident BZDR use remained similar during the follow-up, while differences in incident antidepressant use increased during the follow-up. The prevalence of any psychotropic use in 2005 varied between 44.7–50.7% and between 45.0–47.9% in 2011. Incidence of any psychotropic use in 2005 was between 8.6–12.1% and 6.2–8.2% in 2011. In 2005, the distribution of incident psychotropic use followed a large scale spatial variation that, however, did not correspond to university hospital districts. During the study period from 2005 to 2011 the cyclic spatial variation disappeared. No sign of adjacent hospital districts being more or less closely related to each other compared to hospital districts in general was detected.

Conclusions

Except for antidepressants, regional differences in psychotropic use have mainly diminished between 2005 and 2011. Our findings highlight the importance of acknowledging regional differences in a country with relatively homogeneous healthcare system and conducting future studies assessing the reasons behind these differences.

Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.

Trends, correlates, and disease patterns of antipsychotic use among elderly persons in Taiwan

INTRODUCTION

We used the population-based database to investigate the trends, correlates, and disease patterns of antipsychotic use among elderly people in Taiwan.

METHODS

The National Health Research Institutes provided a database of 1,000,000 random subjects for health service studies. We analyzed a sample of subjects over the age of 65 years from 1997 to 2005. The trends in and factors associated with antipsychotic use were detected. We also examined the proportions of antipsychotics used for psychiatric and medical disorders.

RESULTS

The 1-year prevalence of antipsychotic use in elderly persons increased from 9.8% in 1997 to 12.8% in 2005. The prevalence of first-generation antipsychotic (FGA) use increased from 9.8% to 11.6%, and the prevalence of second-generation antipsychotic (SGA) use increased greatly from 0.01% to 2.02%. Higher prevalence of both FGAs and SGAs were associated with age and higher Charlson Comorbidity Index scores. Psychiatric disorders were commonly found in SGA users (80.8%), whereas only 19.3% of the FGA users had psychiatric disorders. Among the major psychiatric disorders, greater proportions of antipsychotic use were for senile and presenile organic psychotic conditions, other organic psychotic conditions, and affective psychoses. FGAs were much more commonly prescribed for nonpsychiatric disorders, including diseases of symptoms, signs, and ill-defined conditions, the digestive system, and the respiratory system.

DISCUSSION

The prevalence of antipsychotic use, particularly the use of SGAs, increased greatly from 1997 to 2005 among elderly persons in Taiwan. SGAs were most used by subjects with psychiatric disorders, and FGAs were most used by those with nonpsychiatric disorders.

Does being assisted by care workers affect antipsychotics prescription among older people discharged from hospital?

AIM

Several factors can affect antipsychotic prescriptions, among which, caregivers. However, whether being assisted by a care worker might increase the rate of antipsychotic prescriptions at discharge from acute care hospital has not been previously investigated. We aimed to investigate whether being assisted by a care worker is associated with increased use of antipsychotics among older patients discharged from acute care hospitals.

METHODS

The present series consisted of 928 patients not taking antipsychotics at admission in seven acute care wards of geriatric medicine in Italy (mean age 80.8 ± 7.2 years, 54.9% women). The outcome of the study was defined as receiving an antipsychotic prescription at discharge. Patients were grouped according to their living conditions as follows: (i) living alone; (ii) living only with care worker; (iii) living with care worker and family members; and (iv) living only with family members. The association between study variables and antipsychotic prescription at discharge was investigated by logistic regression analysis.

RESULTS

After adjusting for potential confounders, being assisted by care workers was significantly associated with the outcome (OR 2.64, 95% CI 1.21-5.75). Diagnosis of dementia (OR 2.73, 95% CI 1.65-4.51), instrumental activities of daily living limitations (OR 1.12, 95% CI 1.05-1.21) and delirium during stay (OR 3.87, 95% CI 2.01-7.47) also qualified as independent correlates of antipsychotic prescription at discharge.

CONCLUSIONS

Being assisted by care workers could increase the likelihood of receiving antipsychotics at discharge from acute care hospitals. Geriatr Gerontol Int 2017; 17: 1707-1713.

Comparative risk of death in older adults treated with antipsychotics: A population-based cohort study

Although the use of antipsychotics has been associated with an increased risk of death, data on the safety of individual substances is scarce. We thus aimed to compare the risk of death in new users of individual antipsychotics aged =>65 years and conducted a cohort study in the German Pharmacoepidemiological Research Database between 2005 and 2011. Patients were followed from initiation of treatment until death, 90 days after cohort entry, end of insurance or the end of the study period. Multivariable cox regression was used to estimate confounder adjusted hazard ratios (aHR) of death for 14 individual antipsychotics compared to risperidone. In sensitivity analyses, we also applied high-dimensional propensity score (HDPS) methods to explore possible unmeasured confounding. In a cohort of 137,713 new users of antipsychotics, a higher risk of death was found for haloperidol (aHR: 1.45; 95% confidence interval: 1.35-1.55), levomepromazine (aHR: 1.34; 1.16-1.54), zuclopenthixol (aHR: 1.32; 1.02-1.72) and to a lesser extent for melperone (aHR: 1.13; 1.07-1.19) compared to risperidone. Lower risks were observed for quetiapine, prothipendyl, olanzapine, tiapride, clozapine, perazine and flupentixol. In subgroup analyses, levomepromazine and chlorprothixene were only associated with a higher risk of death in patients aged =>80 years and with dementia. The application of HDPS methods did not substantially change the results. In conclusion, our study suggests that initiation of haloperidol, levomepromazine, zuclopenthixol and chlorprothixene treatment is associated with an increased risk of death compared to risperidone and should be avoided in older patients except in palliative care when treatment alternatives are available.

Treatment patterns and characteristics of older antipsychotic users in Germany

The aim of this study was to investigate the characteristics and treatment patterns of older antipsychotic (AP) users in Germany. We carried out a cohort study in the German Pharmacoepidemiological Research Database and identified new AP users aged at least 65 years between 2005 and 2011. Possible indications, comedication, and information on persistence and adherence, concurrent multiple use, and switch of APs were assessed. Overall, 298,847 individuals were included in the cohort. Almost 70% entered the cohort with a typical antipsychotic (TAP). Melperone (23.4%) was used most frequently, followed by promethazine (18.3%), sulpiride (11.0%), and risperidone (10.3%). AP users had a low prevalence of schizophrenia and bipolar disorders in contrast to dementia. Initiators of atypical antipsychotics had more treatment episodes compared with TAPs (median 3 vs. 2), but lower median persistence (14 vs. 22 days). Persistence was also lower in patients with, rather than without, dementia. The overall percentage of concurrent multiple use and switch to other APs was low with 5.6%, but higher in patients with, rather than without, dementia. In conclusion, APs were used for a broad range of indications, mostly other than schizophrenia and bipolar disorders. Low persistence and a high number of treatment episodes suggest frequent 'as-needed' treatment, especially in dementia patients.

Incidence of Tube Feeding in 7174 Newly Admitted Nursing Home Residents With and Without Dementia

BACKGROUND

Tube feeding is a common form of long-term nutritional support, especially for nursing home residents, of whom many have dementia.

OBJECTIVE

Estimating the incidence of feeding tube placement in nursing home residents with and without dementia.

METHODS

Using claims data, we studied a cohort of newly admitted nursing home residents aged 65 years and older between 2004 and 2009. Analyses were stratified by dementia. We estimated incidence rates and performed multivariate Cox regression analyses.

RESULTS

The study cohort included 7174 nursing home residents. Over a mean follow-up of 1.3 years, 273 people received a feeding tube. The incidence per 1000 person-years was 28.4, with higher estimates for patients with dementia. When adjusting for age, sex, and level of care as a time-dependent covariate, influence of dementia decreased to a nonsignificant hazard ratio.

CONCLUSION

It seems that not dementia itself but the overall clinical condition might be a predictor of tube feeding placement.

Long-term use of antipsychotics among community-dwelling persons with Alzheimer׳s disease: A nationwide register-based study

Antipsychotics are recommended only for short-term treatment of severe behavioral and psychological symptoms of dementia. Our objective was to study the duration of antipsychotic use and factors associated with long-term use (365 days or over) among community-dwelling persons with Alzheimer׳s disease (AD) during a 7-year follow-up. This was a nationwide register-based cohort study including all community-dwelling residents in Finland diagnosed with AD in 2005 (n=7217). The follow-up for antipsychotic use started 3 years before the diagnosis of AD and we applied a 7-year washout period to ascertain truly incident antipsychotic use. Follow-up ended on institutionalization, death or at the end of study period (December 31, 2009). Duration of antipsychotic use was modeled from individual purchase histories recorded in the Finnish Prescription Register. During the 7-year follow-up, 34% (2287/6740) of persons initiated antipsychotic use. Median duration of the first antipsychotic use period was 219 (interquartile range 85-583) days. Of those who discontinued antipsychotic use (n=1303), 44% restarted use later. Among users with at least one year of follow-up time after initiating antipsychotic use, prevalence of long-term use was 57% (893/1563). Long-term use was associated with initiation of use after AD diagnosis and choice of antipsychotic. Duration of use was more likely to be shorter among haloperidol users and longer among quetiapine users compared with risperidone users. In conclusion, long-term use of antipsychotics is frequent among community-dwelling persons with AD. Duration of use is not in line with the guidelines recommending time-limited use of antipsychotics.

Persistence of racial disparities in prescription of first-generation antipsychotics in the USA

PURPOSE

The aim of this study was to estimate the prevalence of first-generation antipsychotics (FGA) prescribed for treatment of psychiatric and neurological conditions and use of benztropine to reduce extrapyramidal side effects (EPS) by patient race/ethnicity in a nationally representative sample of adult outpatient visits.

METHODS

The study sample included all outpatient visits (N = 8154) among patients aged 18-69 years where a prescription for one or more antipsychotics was recorded across 6 years of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (2005-2010). Use of FGA was compared by race/ethnicity using multiple logistic regression models accounting for patient and clinical characteristics stratified by neighborhood poverty rate. Frequency of EPS was determined by use of benztropine to reduce or prevent EPS.

RESULTS

Black patients were significantly more likely than White patients to use FGA (odds ratio = 1.48, p = 0.040) accounting for psychiatric and neurological diagnoses, treatment setting, metabolic factors, neighborhood poverty, and payer source. Black patients were more than twice as likely as White patients to receive higher-potency FGA (haloperidol or fluphenazine), particularly in higher-poverty areas (odds ratio = 2.50, p < 0.001). Use of FGA, higher among Black than White patients, was positively associated with use of benztropine to reduce EPS.

CONCLUSIONS

Racial disparities in the pharmacological treatment of severe mental disorders persist 30 years after the introduction of second-generation antipsychotics. The relatively high frequency of FGA of use among Black patients compared with White patients despite more Food and Drug Administration-approved indications and lower EPS risk for second-generation antipsychotics requires additional research.

Evaluation and management of the elderly patient presenting with cognitive complaints

Cognitive complaints are common in the geriatric population. Older adults should routinely be asked about any concerns about their memory or thinking, and any cognitive complaint from the patient or an informant should be evaluated rather than be attributed to aging. Several screening instruments are available to document objective impairments and guide further evaluation. Management goals for patients with cognitive impairment are focused on maintaining function and independence, providing caregiver support, and advance care planning. There are currently no treatments to effectively prevent or treat dementia. Increasing appreciation of the heterogeneity of Alzheimer disease may lead to novel treatment approaches.

SveDem, the Swedish Dementia Registry - a tool for improving the quality of diagnostics, treatment and care of dementia patients in clinical practice

BACKGROUND

The Swedish Dementia Registry (SveDem) was developed with the aim to improve the quality of diagnostic work-up, treatment and care of patients with dementia disorders in Sweden.

METHODS

SveDem is an internet based quality registry where several indicators can be followed over time. It includes information about the diagnostic work-up, medical treatment and community support (www.svedem.se). The patients are diagnosed and followed-up yearly in specialist units, primary care centres or in nursing homes.

RESULTS

The database was initiated in May 2007 and covers almost all of Sweden. There were 28 722 patients registered with a mean age of 79.3 years during 2007-2012. Each participating unit obtains continuous online statistics from its own registrations and they can be compared with regional and national data. A report from SveDem is published yearly to inform medical and care professionals as well as political and administrative decision-makers about the current quality of diagnostics, treatment and care of patients with dementia disorders in Sweden.

CONCLUSION

SveDem provides knowledge about current dementia care in Sweden and serves as a framework for ensuring the quality of diagnostics, treatment and care across the country. It also reflects changes in quality dementia care over time. Data from SveDem can be used to further develop the national guidelines for dementia and to generate new research hypotheses.

High prevalence of psychotropic drug use among persons with and without Alzheimer's disease in Finnish nationwide cohort

Psychotropic drugs are used for treatment of behavioral and psychological symptoms of dementia (BPSD) although they are associated with serious adverse drug events. Objective of our study was to investigate prevalence of psychotropic drug use one year after diagnoses of Alzheimer's disease (AD), to compare prevalence to persons without AD and to assess changes in prevalence over time. Data from the MEDALZ (Medication use and Alzheimer's disease) cohort was utilized in the study including all 69,080 community-dwelling persons with new diagnosis of AD during years 2005-2011 in Finland. Four age-, gender- and region of residence-matched persons without AD were identified for each case. Register-based data included prescription drug purchases and comorbidities from Special Reimbursement Register. Annual prevalence of psychotropic drug use one year after diagnosis was determined for each person. Psychotropic drugs were used by 53% of persons with AD compared with 33% of persons without AD during one year after diagnoses. Persons with AD were six times more likely to use antipsychotics and three times more likely to use antidepressants whereas benzodiazepine and related drug (BZDR) use was comparable between persons with and without AD. According to year of AD diagnoses during 2005-2011, antipsychotic use increased from 18% to 20% (p<0.0001) and BZDR use declined from 31% to 26% (p<0.0001) among persons with AD. Widespread utilization of psychotropic drugs was observed among persons with AD. Despite safety warnings of antipsychotic use for BPSD, antipsychotic use increased from 2005 to 2011 among newly diagnosed persons with AD in Finland.

Antipsychotic, antidepressant, and cognitive-impairment properties of antipsychotics: rat profile and implications for behavioral and psychological symptoms of dementia

Many dementia patients exhibit behavioral and psychological symptoms (BPSD), including psychosis and depression. Although antipsychotics are frequently prescribed off-label, they can have marked side effects. In addition, comparative preclinical studies of their effects are surprisingly scarce, and strategies for discovery of novel pharmacotherapeutics are lacking. We therefore compared eight antipsychotics in rat behavioral tests of psychosis, antidepressant-like activity, and cognitive impairment as a basis for preclinical evaluation of new drug candidates. The methods used in this study include inhibition of MK-801-induced hyperactivity, forced swim test (FST), passive avoidance (PA), spontaneous locomotor activity, and catalepsy. The drugs exhibited antipsychotic-like activity in the MK-801 test but with diverse profiles in the other models. Risperidone impaired PA performance, but with some dose separation versus its actions in the MK-801 test. In contrast, clozapine, olanzapine, lurasidone, and asenapine showed little or no dose separation in these tests. Aripiprazole did not impair PA performance but was poorly active in the MK-801 test. Diverse effects were also observed in the FST: chlorpromazine was inactive and most other drugs reduced immobility over narrow dose ranges, whereas clozapine reduced immobility over a wider dose range, overlapping with antipsychotic activity. Although the propensity of second-generation antipsychotics to produce catalepsy was lower, they all elicited pronounced sedation. Consistent with clinical data, most currently available second-generation antipsychotics induced cognitive and motor side effects with little separation from therapeutic-like doses. This study provides a uniform in vivo comparative basis on which to evaluate future early-stage drug candidates intended for potential pharmacotherapy of BPSD.