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Mok PLH, Carr MJ, Guthrie B, Morales DR, Sheikh A, Elliott RA, Camacho EM, van Staa T, Avery AJ, Ashcroft DM. Multiple adverse outcomes associated with antipsychotic use in people with dementia: population based matched cohort study. BMJ 2024; 385:e076268. [PMID: 38631737 PMCID: PMC11022137 DOI: 10.1136/bmj-2023-076268] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To investigate risks of multiple adverse outcomes associated with use of antipsychotics in people with dementia. DESIGN Population based matched cohort study. SETTING Linked primary care, hospital and mortality data from Clinical Practice Research Datalink (CPRD), England. POPULATION Adults (≥50 years) with a diagnosis of dementia between 1 January 1998 and 31 May 2018 (n=173 910, 63.0% women). Each new antipsychotic user (n=35 339, 62.5% women) was matched with up to 15 non-users using incidence density sampling. MAIN OUTCOME MEASURES The main outcomes were stroke, venous thromboembolism, myocardial infarction, heart failure, ventricular arrhythmia, fracture, pneumonia, and acute kidney injury, stratified by periods of antipsychotic use, with absolute risks calculated using cumulative incidence in antipsychotic users versus matched comparators. An unrelated (negative control) outcome of appendicitis and cholecystitis combined was also investigated to detect potential unmeasured confounding. RESULTS Compared with non-use, any antipsychotic use was associated with increased risks of all outcomes, except ventricular arrhythmia. Current use (90 days after a prescription) was associated with elevated risks of pneumonia (hazard ratio 2.19, 95% confidence interval (CI) 2.10 to 2.28), acute kidney injury (1.72, 1.61 to 1.84), venous thromboembolism (1.62, 1.46 to 1.80), stroke (1.61, 1.52 to 1.71), fracture (1.43, 1.35 to 1.52), myocardial infarction (1.28, 1.15 to 1.42), and heart failure (1.27, 1.18 to 1.37). No increased risks were observed for the negative control outcome (appendicitis and cholecystitis). In the 90 days after drug initiation, the cumulative incidence of pneumonia among antipsychotic users was 4.48% (4.26% to 4.71%) versus 1.49% (1.45% to 1.53%) in the matched cohort of non-users (difference 2.99%, 95% CI 2.77% to 3.22%). CONCLUSIONS Antipsychotic use compared with non-use in adults with dementia was associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was wider than previously highlighted in regulatory alerts, with the highest risks soon after initiation of treatment.
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Affiliation(s)
- Pearl L H Mok
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew J Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Daniel R Morales
- Population Health and Genomics, University of Dundee, Dundee, UK
| | - Aziz Sheikh
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rachel A Elliott
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Manchester Centre for Health Economics, Division of Population Health, Manchester, UK
| | - Elizabeth M Camacho
- Manchester Centre for Health Economics, Division of Population Health, Manchester, UK
| | - Tjeerd van Staa
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Anthony J Avery
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
- Centre for Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, M13 9PT, UK
- Manchester Academic Health Science Centre, Manchester, UK
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK
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Carcavilla-González N, Escalada San Adrián G, Minobes-Molina E, Pàmies-Tejedor S, Roncal-Belzunce V, Atarés-Rodríguez L, García-Navarro JA. A Paradigm Shift on Deinstitutionalization and Dementia Care: A Narrative Review. J Alzheimers Dis 2024; 99:829-841. [PMID: 38759003 DOI: 10.3233/jad-231180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
This narrative explores the impact of deinstitutionalization policies on the quality of life and care outcomes for individuals with Alzheimer's disease and related dementias. We offer a historical perspective on these policies, their implications on dementia care, and the barriers to deinstitutionalization. The potential benefits of deinstitutionalization, such as improved quality of life and access to community-based support and services, are highlighted. Challenges and controversies surrounding safety, caregiver burden, and resource allocation are also examined. Ethical considerations related to the autonomy and decision-making capacity of people living with dementia are discussed. We present best practices and innovative models in dementia care that balance deinstitutionalization with appropriate care. We further put forth recommendations for future research and policy development in dementia care and deinstitutionalization, emphasizing the need for a balanced approach that respects the autonomy and preferences of people living with dementia while ensuring their safety and well-being.
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Affiliation(s)
- Nuria Carcavilla-González
- Department of Health Sciences, Public University of Navarra, Campus de Arrosadia, Pamplona, Spain
- Spanish Society of Geriatrics and Gerontology, Madrid, Spain
| | | | - Eduard Minobes-Molina
- Spanish Society of Geriatrics and Gerontology, Madrid, Spain
- Research group on Methodology, Methods, Models and Outcomes of Health and Social Sciences (M3O), Faculty of Health Sciences and Welfare. Center for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Victoria, Spain
- Institute for Research and Innovation in Life Sciences and Health in Central Catalonia (IRIS-CC), Victoria, Spain
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Psychotropic Drug Prescription in Nursing Homes During the COVID-19 Pandemic. Drugs Aging 2022; 39:467-475. [PMID: 35726042 PMCID: PMC9208968 DOI: 10.1007/s40266-022-00948-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
Abstract
Background To limit the introduction of coronavirus disease 2019 (COVID-19) into nursing homes, restrictive measures and social distancing were implemented; however, these caused an increase in affective disorders such as depression and anxiety and an alteration of the behavioral and psychological symptoms of dementia. Therefore, it is expected that prescription trends of psychotropic drugs in nursing homes during the pandemic may have changed significantly. Objective This study aims to compare patterns of prescribing psychotropic drugs in nursing homes during the COVID-19 pandemic to those of the pre-pandemic period. Methods This cross-sectional multicenter study was conducted in geriatric units and psychogeriatric units in seven nursing homes in Gipuzkoa, Spain. On 1 March, 2020, data regarding 511 residents in geriatric units and 163 in psychogeriatric units were recorded. This study examined utilization percentages for psychotropic drugs before the pandemic (April 2018–March 2020) and during the pandemic (April 2020–March 2021) in light of projected usage based on previous years. Following the Anatomical, Therapeutic, Chemical Classification System, four therapeutic groups were analyzed: antipsychotics (N05A), benzodiazepines (N05B and N05C), antidepressants (N06A), and antiepileptic drugs (N03A). Results In the case of geriatric units, a downward trend of prescription was reversed for antipsychotics (−0.41; 95% confidence interval [CI] −1.41, 0.60). Benzodiazepine use also decreased less than expected (−2.00; 95% CI −3.00, −1.00). Antidepressant use increased more than predicted (0.02; 95% CI −0.97, 1.01), as did antiepileptic drug use (2.93; 95% CI 2.27, 3.60). In the psychogeriatric units, the drop in antipsychotic utilization was less than expected (−2.31; 95% CI −3.68, −0.93). Although it was expected that the prescription of benzodiazepines would decrease, usage remained roughly the same (−0.28; 95% CI −2.40, 2.34). Utilization of antidepressants (8.57; 95% CI 6.89, 10.24) and antiepileptic drugs (6.10; 95% CI 3.20, 9.00) increased significantly, which was expected, based on the forecast. Conclusions For all categories, usage of psychotropic drugs was higher than anticipated based on the forecast; this increase might be related to the worsening of emotional and behavioral disorders caused by the restrictive measures of the COVID-19 pandemic.
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Hølmkjær P, Holm A, Overbeck G, Rozing MP. A cluster-randomized trial of a complex intervention to encourage deprescribing antidepressants in nursing home residents with dementia: a study protocol. Trials 2022; 23:410. [PMID: 35578351 PMCID: PMC9109433 DOI: 10.1186/s13063-022-06368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background The effectiveness of psychotropic medication on behavioral and psychological symptoms of dementia (BPSD) is limited, while associated with a higher risk of adverse events. Non-pharmacological treatment of BPSD is advocated as treatment of first choice. However, many general practitioners (GPs) find it difficult to initiate deprescribing, and when attempting to discontinue psychotropic medication in nursing home residents, they face many barriers. Therefore, we hypothesize that an intervention aimed at improving communication with and involvement of nursing home staff, relatives, and patients by GPs can optimize the pharmacological treatment of BPSD. The aim is to reduce the use of antidepressants in nursing home residents with dementia without increasing morbidity or mortality. Objective The primary outcome is reduction of antidepressant. Secondary outcomes include difference in use of other psychotropic medication, mortality, morbidity, and severity of BPSD. Method The study is a cluster-randomized controlled trial based in general practices in Denmark. We aim to include 22 practices, each of which will recruit up to 15 patients with dementia living in nursing homes. The intervention period is 3 months, and the total study period is 1 year. Randomization is 1:1 to intervention and control group by computer algorithm. Both groups receive education on BPSD and its evidence-based treatment. The intervention includes three tailored components; (1) teaching material and training to be used by the GP to educate nursing home staff on BPSD, (2) a pre-visit reflection tool to encourage nursing home staff to evaluate symptoms and reflect on relatives involvement in the discontinuation process; and (3) a dialog tool to facilitate shared decision making on optimization of BPSD treatment during the visits at the nursing home. The control group includes enhanced care as usual. The primary and secondary outcomes will be assessed at the end of the study period. A process evaluation will be conducted to assess the implementability. Discussion We anticipate that the intervention will optimize the treatment of BPSD with antidepressants for nursing homes residents and enhance compliance with reduction of medication. The process evaluation should provide insights into the barriers and facilitators to changing the current practice of deprescribing. Trial registration Clinicaltrials.gov NCT04985305. Registered on 30 July 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06368-9.
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McConeghy KW, Curyto K, Jedele J, Intrator O, Mohr DC, Wiechers IR, Karel MJ. 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. Geriatr Nurs 2021; 42:1533-1540. [PMID: 34739929 DOI: 10.1016/j.gerinurse.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Kevin W McConeghy
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, United States; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, United States.
| | - Kim Curyto
- Department of Veterans Affairs, VA Western NY Healthcare System, Center for Integrated Healthcare, NY, United States
| | - Jenefer Jedele
- Serious Mental Illness Treatment Resource Evaluation Center, Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Ann Arbor, MI, United States
| | - Orna Intrator
- Geriatrics and Extended Care Data Analysis Center, Office of Geriatrics and Extended Care, US Department of Veterans Affairs, Washington, DC, United States; Canandaigua Veterans Affairs Medical Center, Canandaigua, NY, United States; Department of Public Health Sciences, University of Rochester, Rochester NY, United States
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States; Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Ilse R Wiechers
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, MI, United States; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Michele J Karel
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, MI, United States
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Wang GHM, Man KKC, Chang WH, Liao TC, Lai ECC. Use of antipsychotic drugs and cholinesterase inhibitors and risk of falls and fractures: self-controlled case series. BMJ 2021; 374:n1925. [PMID: 34503972 PMCID: PMC8427404 DOI: 10.1136/bmj.n1925] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the association between the use of antipsychotic drugs and cholinesterase inhibitors and the risk of falls and fractures in elderly patients with major neurocognitive disorders. DESIGN Self-controlled case series. SETTING Taiwan's National Health Insurance Database. PARTICIPANTS 15 278 adults, aged ≥65, with newly prescribed antipsychotic drugs and cholinesterase inhibitors, who had an incident fall or fracture between 2006 and 2017. Prescription records of cholinesterase inhibitors confirmed the diagnosis of major neurocognitive disorders; all use of cholinesterase inhibitors was reviewed by experts. MAIN OUTCOME MEASURES Conditional Poisson regression was used to derive incidence rate ratios and 95% confidence intervals for evaluating the risk of falls and fractures for different treatment periods: use of cholinesterase inhibitors alone, antipsychotic drugs alone, and a combination of cholinesterase inhibitors and antipsychotic drugs, compared with the non-treatment period in the same individual. A 14 day pretreatment period was defined before starting the study drugs because of concerns about confounding by indication. RESULTS The incidence of falls and fractures per 100 person years was 8.30 (95% confidence interval 8.14 to 8.46) for the non-treatment period, 52.35 (48.46 to 56.47) for the pretreatment period, and 10.55 (9.98 to 11.14), 10.34 (9.80 to 10.89), and 9.41 (8.98 to 9.86) for use of a combination of cholinesterase inhibitors and antipsychotic drugs, antipsychotic drugs alone, and cholinesterase inhibitors alone, respectively. Compared with the non-treatment period, the highest risk of falls and fractures was during the pretreatment period (adjusted incidence rate ratio 6.17, 95% confidence interval 5.69 to 6.69), followed by treatment with the combination of cholinesterase inhibitors and antipsychotic drugs (1.35, 1.26 to 1.45), antipsychotic drugs alone (1.33, 1.24 to 1.43), and cholinesterase inhibitors alone (1.17, 1.10 to 1.24). CONCLUSIONS The incidence of falls and fractures was high in the pretreatment period, suggesting that factors other than the study drugs, such as underlying diseases, should be taken into consideration when evaluating the association between the risk of falls and fractures and use of cholinesterase inhibitors and antipsychotic drugs. The treatment periods were also associated with a higher risk of falls and fractures compared with the non-treatment period, although the magnitude was much lower than during the pretreatment period. Strategies for prevention and close monitoring of the risk of falls are still necessary until patients regain a more stable physical and mental state.
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Affiliation(s)
- Grace Hsin-Min Wang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kenneth K C Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Wei-Hung Chang
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Psychiatry, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
| | - Tzu-Chi Liao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Music and Nursing Home Residents with Dementia: A Literature Review. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Dai L, Zuo Q, Chen F, Chen L, Shen Y. The Association and Influencing Factors between Antipsychotics Exposure and the Risk of VTE and PE: A Systematic Review and Meta-analysis. Curr Drug Targets 2021; 21:930-942. [PMID: 32321400 DOI: 10.2174/1389450121666200422084414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Different clinical studies have given inconsistent results on whether the use of antipsychotics increases the risk of thromboembolism. In this paper, we reviewed all relevant literature to provide suggestions for clinical diagnosis and treatment. METHODS PubMed, Web of Science, EMBASE, MEDLINE, Cochrane and Scopus databases were thoroughly searched up to June 2019. Two researchers independently searched the literature, extracted data. Data were analyzed by Stata 12.0 software. RESULTS A total of 22 studies involving 31514226 subjects were included. This meta-analysis showed that patients taking the first- or second-generation antipsychotics had a higher risk of venous thromboembolism and pulmonary embolism than those who did not, and low potency first-generation agents increased the risk of venous thromboembolism more than high potency antipsychotics, and olanzapine, clozapine, haloperidol, perphenazine and risperidone also significantly increased the risk of it. The risk of venous thrombosis in obese people was higher than that in overweight people, patients not less than 65 years old had an increased risk compared with younger patients. In addition, women taking antipsychotics had a higher risk of pulmonary embolism than men. CONCLUSION The use of antipsychotics will increase the risk of venous thromboembolism and pulmonary embolism, which will be affected by the type of antipsychotics and patient characteristics.
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Affiliation(s)
- Luqi Dai
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiunan Zuo
- Department of Geriatric Respiratory Medicine, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, Sichuan 610072, China
| | - Fangying Chen
- Department of Tuberculosis, the Third People's Hospital of Tibet Autonomous Region, Lhasa 850000, China
| | - Lei Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yongchun Shen
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
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Mota-Romero E, Tallón-Martín B, García-Ruiz MP, Puente-Fernandez D, García-Caro MP, Montoya-Juarez R. Frailty, Complexity, and Priorities in the Use of Advanced Palliative Care Resources in Nursing Homes. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:70. [PMID: 33466767 PMCID: PMC7830978 DOI: 10.3390/medicina57010070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 12/28/2022]
Abstract
Background and objectives: This study aimed to determine the frailty, prognosis, complexity, and palliative care complexity of nursing home residents with palliative care needs and define the characteristics of the cases eligible for receiving advanced palliative care according to the resources available at each nursing home. Materials and Methods: In this multi-centre, descriptive, and cross-sectional study, trained nurses from eight nursing homes in southern Spain selected 149 residents with palliative care needs. The following instruments were used: the Frail-VIG index, the case complexity index (CCI), the Diagnostic Instrument of Complexity in Palliative Care (IDC-Pal), the palliative prognosis index, the Barthel index (dependency), Pfeiffer's test (cognitive impairment), and the Charlson comorbidity index. A consensus was reached on the complexity criteria of the Diagnostic Instrument of Complexity in Palliative Care that could be addressed in the nursing home (no priority) and those that required a one-off (priority 2) or full (priority 1) intervention of advanced palliative care resources. Non-parametric tests were used to compare non-priority patients and patients with some kind of priority. Results: A high percentage of residents presented frailty (80.6%), clinical complexity (80.5%), and palliative care complexity (65.8%). A lower percentage of residents had a poor prognosis (10.1%) and an extremely poor prognosis (2%). Twelve priority 1 and 14 priority 2 elements were identified as not matching the palliative care complexity elements that had been previously identified. Of the studied cases, 20.1% had priority 1 status and 38.3% had priority 2 status. Residents with some kind of priority had greater levels of dependency (p < 0.001), cognitive impairment (p < 0.001), and poorer prognoses (p < 0.001). Priority 1 patients exhibited higher rates of refractory delirium (p = 0.003), skin ulcers (p = 0.041), and dyspnoea (p = 0.020). Conclusions: The results indicate that there are high levels of frailty, clinical complexity, and palliative care complexity in nursing homes. The resources available at each nursing home must be considered to determine when advanced palliative care resources are required.
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Affiliation(s)
- Emilio Mota-Romero
- Primary Care Center Dr. Salvador Caballero García Andalusian, Health Service, Government of Andalusia, 18012 Granada, Andalusia, Spain;
| | | | | | - Daniel Puente-Fernandez
- Doctoral Program in Clinical Medicine and Public Health, University of Granada, 18016 Granada, Andalusia, Spain
| | - María P. García-Caro
- Department of Nursing, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Andalusia, Spain; (M.P.G.-C.); (R.M.-J.)
| | - Rafael Montoya-Juarez
- Department of Nursing, Mind, Brain and Behaviour Research Institute, University of Granada, 18016 Granada, Andalusia, Spain; (M.P.G.-C.); (R.M.-J.)
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Thomas KS, Wretman CJ, Sloane PD, Carder P, Schwartz L, Beeber AS, Zimmerman S. To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living? J Am Med Dir Assoc 2021; 22:1813-1818.e3. [PMID: 33382990 DOI: 10.1016/j.jamda.2020.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs. DESIGN Observational, cross-sectional AL data linked to publicly reported NH measures. SETTING AND PARTICIPANTS Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states. METHODS We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects. RESULTS The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = -0.03; 95% confidence interval (CI) -0.50 to -0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16-0.70; P = .002). CONCLUSIONS AND IMPLICATIONS This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.
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Affiliation(s)
- Kali S Thomas
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA.
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Paula Carder
- OHSU-PSU School of Public Health, Portland State University, Portland, OR, USA
| | - Lindsay Schwartz
- Center for Health Policy Evaluation in Long-Term Care; American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Anna S Beeber
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research; School of Social Work; University of North Carolina at Chapel Hill, NC, USA
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Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017. Int Clin Psychopharmacol 2020; 35:270-278. [PMID: 32324610 DOI: 10.1097/yic.0000000000000312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.
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Parfitt G, Post D, Kalisch Ellett L, Lim R, Penington A, Corlis M, Roughead E. A cross-sectional assessment of the relationship between sedative medication and anticholinergic medication use and the movement behaviour of older adults living in residential aged care. PeerJ 2020; 8:e9605. [PMID: 32775054 PMCID: PMC7384436 DOI: 10.7717/peerj.9605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/04/2020] [Indexed: 11/20/2022] Open
Abstract
Objectives Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care. Materials and Methods Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants’ medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman’s Rho correlations were conducted, as the data were not normally distributed. Results Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA (p < .02). Conclusion The findings of this study showed a negative association between sedative load, due to medicines, and an individual’s movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances.
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Affiliation(s)
- Gaynor Parfitt
- Allied Health and Human Performance, Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
| | - Dannielle Post
- Allied Health and Human Performance, Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | | | - Megan Corlis
- Helping Hand Organisation, Adelaide, South Australia, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Abdeljalil AB, de Mauléon A, Baziard M, Vellas B, Lapeyre-Mestre M, Soto M. Antidepressant Use and Progression of Mild to Moderate Alzheimer's Disease: Results from the European ICTUS Cohort. J Am Med Dir Assoc 2020; 22:433-439. [PMID: 32736994 DOI: 10.1016/j.jamda.2020.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/02/2020] [Accepted: 06/09/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Neuropsychiatric symptoms (NPS) are a core and troubling feature among patients with Alzheimer disease (AD). Because of growing safety warnings against antipsychotics, the use of antidepressants (ATD) in AD has increased extensively. We investigated the potential long-term associations between ATD exposure and functional and cognitive progression in patients with mild to moderate AD. DESIGN Two-year prospective multicenter cohort ICTUS (Impact of Cholinergic Treatment USe) study with biannual assessments. SETTING Twenty-nine memory clinics from 12 European countries. PARTICIPANTS Community-dwelling patients with mild to moderate AD. METHODS Global cognitive function was measured using the Mini Mental State Examination (MMSE) and the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog). Functional impairment was measured using the Activities of Daily Living (ADL). Assessments were performed biannually for 2 years. Antidepressant exposure was defined by an ATD prescription for a minimum period of 6 months. Linear mixed models were used to study the associations between ATD exposure and cognitive and functional progression. RESULTS Antidepressant exposure was not associated with cognitive decline [MMSE: β-coefficients of the linear mixed models (Coef) = 0.06, 95% confidence interval (CI) -0.65 to 0.76, P = .87; ADAS-Cog: Coef = -13.9, 95% CI -34.80 to 7.03, P = .19] or with functional decline (ADL: Coef = -0.05, 95% CI -0.21 to 0.09, P = .48) at 2-year follow-up. Antipsychotic exposure at baseline was associated with a greater functional decline in the ADL score (Coef = -0.39, 95% CI - 0.68 to 0.10, P < .01). CONCLUSIONS AND IMPLICATIONS Antidepressant exposure was not associated with a faster rate of cognitive or functional decline in patients with mild to moderate AD. Antidepressants might be appropriate alternatives to antipsychotics in the management of NPS in mild to moderate AD.
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Affiliation(s)
- Anne-Bahia Abdeljalil
- Department of Geriatric Medicine, Institute of Ageing, Toulouse University Hospital, Toulouse, France; University of Toulouse III, F-31073, Toulouse, France.
| | - Adélaïde de Mauléon
- Department of Geriatric Medicine, Institute of Ageing, Toulouse University Hospital, Toulouse, France; University of Toulouse III, F-31073, Toulouse, France
| | - Marion Baziard
- Department of Geriatric Medicine, Institute of Ageing, Toulouse University Hospital, Toulouse, France; University of Toulouse III, F-31073, Toulouse, France
| | - Bruno Vellas
- Department of Geriatric Medicine, Institute of Ageing, Toulouse University Hospital, Toulouse, France; University of Toulouse III, F-31073, Toulouse, France; Inserm URM 1027, F-31073, Toulouse, France
| | - Maryse Lapeyre-Mestre
- University of Toulouse III, F-31073, Toulouse, France; Inserm URM 1027, F-31073, Toulouse, France; Department of Epidemiology and Public Health, Toulouse University Hospital, Toulouse, France
| | - Maria Soto
- Department of Geriatric Medicine, Institute of Ageing, Toulouse University Hospital, Toulouse, France; University of Toulouse III, F-31073, Toulouse, France; Inserm URM 1027, F-31073, Toulouse, France
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A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes. J Am Med Dir Assoc 2020; 21:817-822. [PMID: 32493650 DOI: 10.1016/j.jamda.2020.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/25/2020] [Accepted: 04/06/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels. DESIGN Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories. SETTING AND PARTICIPANTS Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study. MEASURES Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use. INTERVENTION Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis. RESULTS At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms. CONCLUSIONS/IMPLICATIONS The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.
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15
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Omissions of Care in Nursing Home Settings: A Narrative Review. J Am Med Dir Assoc 2020; 21:604-614.e6. [DOI: 10.1016/j.jamda.2020.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
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16
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de Bruijn W, Daams JG, van Hunnik FJG, Arends AJ, Boelens AM, Bosnak EM, Meerveld J, Roelands B, van Munster BC, Verwey B, Figee M, de Rooij SE, Mocking RJT. Physical and Pharmacological Restraints in Hospital Care: Protocol for a Systematic Review. Front Psychiatry 2020; 10:921. [PMID: 32184738 PMCID: PMC7058582 DOI: 10.3389/fpsyt.2019.00921] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 11/19/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Physical and pharmacological restraints, defined as all measures limiting a person in his or her freedom, are extensively used to handle unsafe or problematic behavior in hospital care. There are increasing concerns as to the extent with which these restraints are being used in hospitals, and whether their benefits outweigh their potential harm. There is currently no comprehensive literature overview on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in the hospital setting. METHODS A systematic review of the existing literature will be performed on the beneficial and/or adverse effects of physical and pharmacological restraints in the hospital setting. Relevant databases will be systematically searched. A dedicated search strategy was composed. A visualization of similarities (VOS) analysis was used to further specify the search. Observational studies, and if available, randomized controlled trials reporting on beneficial and/or adverse effects of physical and/or pharmacological restraints in the general hospital setting will be included. Data from included articles will be extracted and analyzed. If the data is suitable for quantitative analysis, meta-analysis will be applied. DISCUSSION This review will provide data on the beneficial and/or adverse effects of the use of physical and pharmacological restraints in hospital care. With this review we aim to guide health professionals by providing a critique of the available evidence regarding their choice to either apply or withhold from using restraints. A limitation of the current review will be that we will not specifically address ethical aspects of restraint use. Nevertheless, the outcomes of our systematic review can be used in the composition of a multidisciplinary guideline. Furthermore, our systematic review might determine knowledge gaps in the evidence, and recommendations on how to target these gaps with future research. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42019116186.
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Affiliation(s)
- Wendy de Bruijn
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Joost G. Daams
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - A. M. Boelens
- Department of Geriatrics, UMCG, Groningen, Netherlands
| | - Ellen M. Bosnak
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Barbara C. van Munster
- Department of Internal Medicine/Geriatrics, Gelre Hospitals and UMCG, Groningen, Netherlands
| | - Bas Verwey
- Department of Hospital Psychiatry, NVvP, Utrecht, Netherlands
| | - Martijn Figee
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Department of Psychiatry, Icahn Medical School at Mount Sinai, New York, NY, United States
| | | | - Roel J. T. Mocking
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Hershkovitz A, Nissan R. The Association Between Antipsychotic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study. J Appl Gerontol 2020; 40:661-669. [DOI: 10.1177/0733464820904564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Antipsychotic (AP) use may lead to numerous side effects which may affect rehabilitation outcomes. A retrospective cohort study was carried out on 448 hip fractured patients admitted to a post-acute geriatric rehabilitation center. Functional improvement was measured by the Functional Independence Measure (FIM), motor FIM (mFIM), and mFIM effectiveness. A multiple linear regression model and regression analysis was used to evaluate the level of association between AP use and achievement of favorable functional gain. AP users exhibited lower functional ability on admission and at discharge, achieved a significantly lower functional gain and required longer rehabilitation time compared with nonusers. AP use by post-acute hip fractured patients negatively affects their chances of achieving favorable rehabilitation outcome after adjustment for confounders.
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Affiliation(s)
- Avital Hershkovitz
- “Beit Rivka” Geriatric Rehabilitation Center, Petah Tikva, Israel
- Tel Aviv University, Israel
| | - Ran Nissan
- “Beit Rivka” Geriatric Rehabilitation Center, Petah Tikva, Israel
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18
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Prins M, Willemse BM, Heijkants CH, Pot AM. Nursing home care for people with dementia: Update of the design of the Living Arrangements for people with Dementia (LAD)-study. J Adv Nurs 2019; 75:3792-3804. [PMID: 31566778 PMCID: PMC6900200 DOI: 10.1111/jan.14199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/10/2019] [Indexed: 11/29/2022]
Abstract
AIM The aim of the current study is to describe the extended design of the Living Arrangements for people with Dementia (LAD)-study. BACKGROUND The demand for long-term care in care homes increases with the growing number of people with dementia. However, quality of care in care homes needs improvement. It is important to monitor quality of care in care homes for the purposes of conducting scientific research, providing input for policy, and promoting practice improvement. DESIGN The Living Arrangements for people with Dementia -study monitors changes in - quality of - care in care homes since 2008. With its extended design, the Living Arrangements for people with Dementia -study now also focuses on additional topics that are considered to improve quality of care: implementation of person-centred care, involvement of family carers and volunteers and reducing psychotropic drugs and physical restraints using a multidisciplinary approach. METHODS The data collection of the Living Arrangements for people with Dementia -study entails an interview with the manager and questionnaires are completed by care staff, family carers, volunteers, and multidisciplinary team members. This study is partly funded by the Dutch Ministry of Health, Welfare and Sports, grant number 323,088 and partly funded by the participating care homes. DISCUSSION Results of the Living Arrangements for people with Dementia -study will shed more light on variables related to quality of care in care homes for people with dementia. IMPACT Based on the obtained information, appropriate efforts to improve quality of care can be discussed and implemented. Furthermore, the results of this study guide policy making, because it expands knowledge about the effects of changing policies and exposes topics that need further attention. TRIAL REGISTRATION Not applicable. This article does not report the results of a healthcare intervention on human participants.
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Affiliation(s)
- Marleen Prins
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.,Department of Clinical, Neuro & Developmental Psychology, Section Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bernadette M Willemse
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Ceciel H Heijkants
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Anne Margriet Pot
- Department of Clinical, Neuro & Developmental Psychology, Section Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,Optentia, North-West University, Johannesburg, South Africa.,School of Psychology, University of Queensland, Brisbane, Qld., Australia
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Assessing the Relative Contribution of Resident Versus Facility Characteristics Associated With Antipsychotic Medication Receipt Among Nursing Facility Residents. Med Care 2019; 57:822-829. [PMID: 31415339 DOI: 10.1097/mlr.0000000000001183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE In 2012 Centers for Medicare and Medicaid Services (CMS) launched a multifaceted initiative aimed at reducing the unnecessary use of antipsychotic medications in nursing facilities due to evidence these medications are associated with little or uncertain benefit and substantial risk. Yet, little is known about whether efforts to reduce antipsychotic medication should be focused on residents with targeted characteristics, or on nursing facility regulation (eg, staffing levels). Our objective was to identify the relative contribution of resident and facility characteristics to potentially inappropriate antipsychotic use. METHODS We examined 1,156,875 long stay residents in 14,699 US nursing facilities in 2014 and predicted resident antipsychotic use controlling sequentially for resident and facility characteristics and calculated the incremental variation explained. RESULTS We found significant variability in unadjusted rates of potentially inappropriate antipsychotic use among nursing facilities (mean=18.0%; interquartile range: 11.3%-23.7%; SD: 11.1). Regression results indicated that 93% of the explained variation in antipsychotic use was attributed to resident characteristics and 7% was attributed to facility-level factors. At the facility level, worker hours per resident day was not significantly associated with antipsychotic use. Simulations indicated that applying the effect sizes achieved by the best performing facilities to the existing case mix across all nursing facilities would result in no more than a 1 percentage point change in population-level antipsychotic use. CONCLUSIONS Efforts to reduce antipsychotic use may have greater impact by developing new clinical strategies to address specific diagnoses rather than regulations related to facility-level attributes.
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20
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Ah YM, Han E, Jun K, Yu YM, Lee JY. Change in sedative burden after dementia onset using difference-in-difference estimations. PLoS One 2019; 14:e0220582. [PMID: 31374112 PMCID: PMC6677315 DOI: 10.1371/journal.pone.0220582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
Background Sedative agents are avoided in older adults because of potential risks including cognitive impairment, fall, frailty, and mortality. However, no studies addressing both prediagnostic and postdiagnostic period of dementia have evaluated sedative agent usage over an extended period. Objectives To describe a longitudinal change in sedative medication use before and after the diagnosis with dementia over 10 years compared to patients without dementia. Methods We conducted a retrospective cohort study using longitudinal claims data for senior national health insurance beneficiaries. After 1:4 propensity score matching, 54,165 older patients (≥60 years) were included. Difference-in-difference (DID) of sedative burden and use of sedative agents pre- and post-dementia diagnosis were estimated, and compared to those of patients without dementia. The yearly average daily sedative load (adSL) for each individual was calculated after applying duration, dose, and sedative score of medications from the sedative load model. The medication use for each sedative category was calculated using the defined daily dose (DDD) per 1000 patient-days. Results The adSL in patients with dementia was consistently high before and after diagnosis and significantly increased after diagnosis, compared to those of patients without dementia (DID 0.123 unit/day, 95% confidence interval 0.117–0.129). DID of medication use was the highest for antidepressants (64.764 DDD/1000 patient-days) followed by Z-drugs and antipsychotics. Atypical antipsychotic and antidepressant usage steeply increased after dementia diagnosis. Conclusion Sedative burden in patients with dementia before and after dementia diagnosis was higher than that in patients without dementia, and was further increased after dementia diagnosis.
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Affiliation(s)
- Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsangbuk-do, Republic of Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon, Republic of Korea
| | - Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Yun Mi Yu
- College of Pharmacy, Yonsei Institute for Pharmaceutical Research, Yonsei University, Incheon, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
- * E-mail:
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Impact des benzodiazépines sur les fonctions cognitives et le risque de démence. Revue des arguments de causalité issus des études observationnelles. Therapie 2019; 74:407-419. [DOI: 10.1016/j.therap.2018.09.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/03/2018] [Indexed: 01/18/2023]
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22
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Pont LG, Raban MZ, Jorgensen ML, Georgiou A, Westbrook JI. Leveraging new information technology to monitor medicine use in 71 residential aged care facilities: variation in polypharmacy and antipsychotic use. Int J Qual Health Care 2019; 30:810-816. [PMID: 29889231 DOI: 10.1093/intqhc/mzy098] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 05/22/2018] [Indexed: 12/26/2022] Open
Abstract
Objective The aim of this study was to use routinely collected electronic medicines administration (eMAR) data in residential aged care (RAC) to investigate the quality use of medicines. Design A cross-sectional analysis of eMAR data. Setting 71 RAC facilities in New South Wales and the Australian Capital Territory, Australia. Participants Permanent residents living in a participating facility on 1 October 2015. Intervention None. Main Outcome Measures Variation in polypharmacy (≥5 medications), hyper-polypharmacy (≥10 medications) and antipsychotic use across facilities was examined using funnel plot analysis. Results The study dataset included 4775 long-term residents. The mean resident age was 85.3 years and 70.6% of residents were female. The median facility size was 60 residents and 74.3% were in metropolitan locations. 84.3% of residents had polypharmacy, 41.2% hyper-polypharmacy and 21.0% were using an antipsychotic. The extent of polypharmacy (69.75-100% of residents), hyper-polypharmacy (38.81-76.19%) and use of antipsychotic medicines (0-75.6%) varied considerably across the 71 facilities. Conclusions Using eMAR data we found substantial variation in polypharmacy, hyper-polypharmacy and antipsychotic medicine use across 71 RAC facilities. Further investigation into the policies and practices of facilities performing above or below expected levels is warranted to understand variation and drive quality improvement.
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Affiliation(s)
- Lisa G Pont
- Faculty of Medicine and Health Science, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW Australia.,Graduate School of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia
| | - Magda Z Raban
- Faculty of Medicine and Health Science, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW Australia
| | - Mikaela L Jorgensen
- Faculty of Medicine and Health Science, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW Australia
| | - Andrew Georgiou
- Faculty of Medicine and Health Science, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW Australia
| | - Johanna I Westbrook
- Faculty of Medicine and Health Science, Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW Australia
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Abdeljalil AB, Arbus C, Montastruc F, de Souto Barreto P, André L, Vellas B, Rolland Y. Antidepressants in nursing homes for dependent older patients: the cross-sectional associations of institutional factors with prescription conformance. Eur Geriatr Med 2019; 10:421-430. [DOI: 10.1007/s41999-019-00189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/02/2019] [Indexed: 11/25/2022]
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Marras C, Austin PC, Bronskill SE, Diong C, Rochon PA. Antipsychotic Drug Dispensing in Older Adults With Parkinsonism. Am J Geriatr Psychiatry 2018; 26:1244-1257. [PMID: 30262407 DOI: 10.1016/j.jagp.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Antipsychotic drugs are commonly used to treat psychosis in patients with Parkinson disease; however, individuals with parkinsonism are at risk for serious adverse effects with antipsychotic use. The choice of antipsychotic is critical. OBJECTIVE To examine the frequency and pattern of antipsychotic prescribing to patients with Parkinson disease and parkinsonism over time. METHODS Individuals with parkinsonism aged 66 or older in Ontario were studied in a retrospective cohort study from 2005-2013 and followed for prevalent and/or incident antipsychotic drug dispensing. RESULTS In 2005, 15% of 22,837 individuals with prevalent parkinsonism were dispensed an antipsychotic drug. By 2013, the proportion was 11% of 34,262 individuals. Primary care physicians represented the vast majority of prescribers. Of individuals receiving antipsychotics in 2013, 20% were dispensed a typical antipsychotic drug. Among individuals with incident parkinsonism, living in a nursing home, older age, male sex, a greater number of comorbidities, and a prior diagnosis of dementia were significantly associated with an increased rate of receiving an antipsychotic during follow-up. Among those who received an antipsychotic, factors associated with typical antipsychotic exposure were absence of a prior diagnosis of dementia, higher Charlson comorbidity index, more concurrent medications, more recent year of first parkinsonism diagnosis and not having seen a neurologist, psychiatrist, or geriatrician. CONCLUSION A substantial proportion of individuals with parkinsonism are exposed to antipsychotic drugs, including typical antipsychotics. Given the risks of these drugs to individuals with parkinsonism, education of prescribers, particularly primary care physicians, is needed.
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Affiliation(s)
- Connie Marras
- Edmond J. Safra Program in Parkinson's disease (CM), University Health Network, University of Toronto, Toronto.
| | - Peter C Austin
- the Institute for Clinical Evaluative Sciences (PCA, SEB, CD, PAR), Toronto; the Institute of Health Policy, Management and Evaluation (PCA, SEB), University of Toronto, Toronto
| | - Susan E Bronskill
- the Institute for Clinical Evaluative Sciences (PCA, SEB, CD, PAR), Toronto; the Institute of Health Policy, Management and Evaluation (PCA, SEB), University of Toronto, Toronto; Women's College Hospital Research Institute (SEB, PAR), Women's College Hospital, Toronto
| | - Christina Diong
- the Institute for Clinical Evaluative Sciences (PCA, SEB, CD, PAR), Toronto
| | - Paula A Rochon
- the Institute for Clinical Evaluative Sciences (PCA, SEB, CD, PAR), Toronto; Women's College Hospital Research Institute (SEB, PAR), Women's College Hospital, Toronto
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Effect of Exercise on Drug-Related Falls Among Persons with Alzheimer's Disease: A Secondary Analysis of the FINALEX Study. Drugs Aging 2018; 35:1017-1023. [PMID: 30315403 DOI: 10.1007/s40266-018-0594-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION No study has investigated how exercise modifies the effect of fall-related drugs (FRDs) on falls among people with Alzheimer's disease (AD). OBJECTIVE The aim of this study was to investigate how exercise intervention and FRDs interact with fall risk among patients with AD. METHODS In the FINALEX trial, community-dwelling persons with AD received either home-based or group-based exercise twice weekly for 1 year (n =129); the control group received normal care (n =65). The number of falls was based on spouses' fall diaries. We examined the incidence rate ratios (IRRs) for falls among both non-users and users of various FRDs (antihypertensives, psychotropics, drugs with anticholinergic properties [DAPs]) in both control and combined intervention groups. RESULTS Between the intervention and control groups, there was no difference in the number of falls among those without antihypertensives or psychotropics. In the intervention group taking antihypertensives, the IRR was 0.5 falls/person-year (95% confidence interval [CI] 0.4-0.6), while in the control group, the IRR was 1.5 falls/person-year (95% CI 1.2-1.8) [p < 0.001 for group, p = 0.067 for medication, p < 0.001 for interaction]. Among patients using psychotropics, the intervention group had an IRR of 0.7 falls/person-year (95% CI 0.6-0.9), while the control group had an IRR of 2.0 falls/person-year (95% CI 1.6-2.5) [p < 0.001 for group, p = 0.071 for medication, p < 0.001 for interaction]. There was a significant difference in falls between the intervention and control groups not using DAPs (0.6, 95% CI 0.5-0.7; 1.2, 95% CI 1.0-1.4), and between the intervention and control groups using DAPs (1.1, 95% CI 0.8-1.3; 1.5, 95% CI 1.0-2.1) [p < 0.001 for group, p = 0.014 for medication, p = 0.97 for interaction]. CONCLUSION Exercise has the potential to decrease the risk for falls among people with AD using antihypertensives and psychotropics. TRIAL REGISTRATION ACTRN12608000037303.
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Thu Trang D, Cool C, Laffon de Mazieres C, Lapeyre-Mestre M, Montastruc JL, Rascol O, Rolland Y, Sommet A. Mortality and Antipsychotic Drug Use in Elderly Patients With Parkinson Disease in Nursing Homes. J Am Med Dir Assoc 2017. [DOI: 10.1016/j.jamda.2017.04.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kerns JW, Winter JD, Winter KM, Kerns CC, Etz RS. Caregiver Perspectives About Using Antipsychotics and Other Medications for Symptoms of Dementia. THE GERONTOLOGIST 2017; 58:e35-e45. [DOI: 10.1093/geront/gnx042] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/24/2017] [Indexed: 01/22/2023] Open
Affiliation(s)
- John William Kerns
- VCU-Shenandoah Valley Family Practice Residency, Front Royal, Virgina
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
| | - Jonathan D Winter
- VCU-Shenandoah Valley Family Practice Residency, Front Royal, Virgina
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
| | | | - Christine C Kerns
- VCU-Shenandoah Valley Family Practice Residency, Front Royal, Virgina
| | - Rebecca S Etz
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond
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Baier RR, Mor V. Pragmatic trials may help to identify effective strategies to reduce nursing home antipsychotic medication use. Isr J Health Policy Res 2017; 6:5. [PMID: 28149500 PMCID: PMC5270358 DOI: 10.1186/s13584-016-0130-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/19/2016] [Indexed: 11/10/2022] Open
Abstract
Despite widespread agreement that nursing homes’ use of antipsychotic medications for residents without specific psychiatric diagnoses is a marker of poor quality of care, prevalence remains high. Additionally, variation suggests continued opportunity to improve care even in countries, like the United States, that have long-standing policies designed to decrease antipsychotic medication use. In a recent Israel Journal of Health Policy Research article, Frankenthal et al. presented results linking increased antipsychotic medication use prevalence in Tel Aviv nursing homes with facility characteristics, including some that “undermine quality of care,” and called for increased national focus on this area. While we agree with the authors that government focus can help to decrease antipsychotic medication use, experience in the United States shows that such efforts may not be sufficient: we present data showing significant variation among United States nursing homes’ antipsychotic medication use prevalence after more than ten years of national warnings and programs. This suggests that United States nursing home clinicians and caregivers continue to need effective non-pharmacologic interventions to substitute for antipsychotic medications. We suggest expanded use of cluster-randomized trials to test strategies to withdraw residents from antipsychotic medications and to implement alternate, non-pharmacological approaches for addressing the behavioral and psychological symptoms of dementia.
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Affiliation(s)
- Rosa R Baier
- Brown University School of Public Health, Box G-S121-6, 121 S. Main Street, Providence, RI 02912 USA
| | - Vincent Mor
- Brown University School of Public Health, Box G-S121-6, 121 S. Main Street, Providence, RI 02912 USA
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