Psychotropic use in community residential care facilities: A prospective cohort study

Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: A scoping review

BACKGROUND

Psychotropic medication use in the elderly population is associated with significant adverse effects. Robust evidence for the efficacy of psychotropic medications for behavioural and psychological symptoms of dementia is lacking. Despite national bodies, governments, and policymakers employing interventions to optimise the use of psychotropic medicines in this population, there is little research on their overall impact.

OBJECTIVE

To identify and categorise system level strategies that have been implemented internationally and assess their impact on psychotropic medicine use in aged care facilities.

METHODS

A systematic search of health-related databases including Medline, Embase, CINAHL, Web of Science and Scopus was performed. Empirical studies published in English prior to March 2019 that reported on the impact of system level strategies on psychotropic medicine use in aged care facilities were included. Studies were mapped to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to measure impact and were assessed for risk of bias.

RESULTS

This review identified 36 studies which examined mandatory (n = 22) and non-mandatory (n = 14) system level strategies. The impact of strategies was highly dependent on implementation as well as organisational and patient factors. Mandatory strategies had greater evidence of impact on drug utilisation patterns compared to non-mandatory strategies which primarily focussed on adoption and implementation, rather than outcomes. The Omnibus Budget Reconciliation Act 1987 (OBRA-87) in the United States of America had the greatest reach and implementation of the interventions examined, with an observed reduction in psychotropic medicine use post-implementation. There was no substantive body of evidence reporting on the sustainability of strategies or the influence of cost on outcomes.

CONCLUSIONS

Despite the implementation of system level strategies, psychotropic medicine use in aged care facilities remains problematic. There is a need for revised or novel system level strategies which consider sustainability, economic influences and patient outcomes in their design and implementation.

Persistent use of psychotropic drugs in nursing home residents in Norway

Background

The prevalence of psychotropic drug (PTD) use in NH residents is high, but few have explored prevalence and persistency in PTD in NH residents and factors associated with persistency. This at the same time as we know that risk of side events may be higher with long- term use in older adults. Thus, the aim of this study was to describe the prevalence and persistence in use of PTD and to explore factors associated with persistence in use of PTD at two consecutive time points in nursing home (NH) residents.

Methods

We included 1163 NH residents in a 72-month longitudinal study with five assessments. Use of PTD, neuropsychiatric symptoms (NPS), severity of dementia and physical health were assessed each time.

Results

The prevalence over time and persistent use of antipsychotic drugs, antidepressants, anxiolytics and sedatives at two consecutive time points were high in residents with and without dementia. There was an association between greater NPS at the first time point, and persistent use of these drugs, but changes in NPS between time points, did not explain such use. A longer NH stay increased the odds for persistent use of antipsychotics.

Conclusion

Psychotropic drugs are frequently used as a long-term treatment among NH residents and are associated with severity of neuropsychiatric symptoms, but not with severity of dementia. Closer attention should be paid to follow-up of psychotropic drug treatment, and especially for long –term use of antipsychotics, since the duration of such treatment should be as short as possible.

Influence of central nervous system-acting drugs on results of cognitive testing in geriatric inpatients

INTRODUCTION

Growing evidence shows a high correlation between extensive use of central nervous system-acting drugs (CNSADs) in elderly patients and adverse drug reactions (ADRs) such as falls, fractures, and mortality.

RESEARCH QUESTION

Are results of cognitive testing with the Mini Mental Status Examination (MMSE) influenced by use of CNSADs?

SETTING

Geriatric inpatient service for acute, subacute, and rehabilitation care.

METHODS

Secondary combined analysis of two prospective, single-center study cohorts (PROPSYC, 2011 and AGE OUT, 2012) with identical procedure for the MMSE at a tertiary hospital.

RESULTS

Overall, 395 patients were included, 144 male (M) and 251 female (F). Mean age was 80.0 ± 8.4 years (M 76.7 ± 9.1, F 81.9 ± 7.3, p = 0.0000). Mean MMSE points were 22.9 ± 4.8 (M 23.2 ± 4.6, F 22.6 ± 5.0, p = 0.211). In total, 258 patients (65.3 %) used drugs with potential adverse cognitive properties. Analgesics with central activity were given to 117 of 395 patients (29.6 %). Low-potency opioids (tramadol hydrochloride, tilidine) were identified in 60 patients and high-potency opioids in 57 patients. Antidepressants were used in 66 patients, benzodiazepines in 26, and hypnotics in 11, while 38 patients received other CNSADs. We only found significant correlations with the results of cognitive testing for sedatives (diazepam and oxazepam, Pearson's r - 0.79, p = 0.05), but not for lorazepam.

CONCLUSION

Our analysis shows an influence of sedatives (diazepam and oxazepam, but not lorazepam) on cognitive testing with the MMSE in users of CNSADs.

Evaluation of a pet-assisted living intervention for improving functional status in assisted living residents with mild to moderate cognitive impairment: a pilot study

BACKGROUND

In older adults with cognitive impairment (CI), decreased functional status and increased behavioral symptoms require relocation from assisted living (AL) to nursing homes. Studies support positive effects of pets on health/function.

PURPOSE

Evaluate the effectiveness of the Pet AL (PAL) intervention to support physical, behavioral, and emotional function in AL residents with CI.

METHODS

Cognitively impaired AL residents randomized to 60-90 minute sessions [PAL (n = 22) or reminiscing (n = 18)] twice/week for 12 weeks. PAL interventionist encourages residents to perform skills with the visiting dog; reminiscing interventionist encourages residents to reminisce. Monthly assessment of physical (energy expenditure, activities of daily living), emotional (depression, apathy), and behavioral (agitation) function.

RESULTS

In linear mixed models, physical activity depressive symptoms improved more with PAL.

CONCLUSION

Evidence supports that the PAL program helps preserve/enhance function of AL residents with CI. Additional study is required to evaluate the duration and predictors of effectiveness of the PAL intervention.

Potential benefits of reducing medication-related anticholinergic burden for demented older adults: a prospective cohort study

AIM

Medication-related anticholinergic burden is a quality indicator for geriatric pharmacotherapy; however, little is known regarding the benefits of reducing anticholinergic burden for demented patients

METHODS

Demented residents in a Veteran Home were enrolled for this study and an educational program was held for primary care physicians providing services at the Veterans Home. Residents were assigned to the intervention group if the primary care team could adhere to the research protocol and the remaining residents were assigned to the reference group receiving conventional care. Anticholinergic burden was estimated by Clinician-Rated Anticholinergic Score (CR-ACHS). Healthcare outcomes; for example, hospitalizations, mortality, cognitive and physical function, were compared between groups.

RESULTS

Overall, 53 of the 67 demented residents (mean age 83.4 ± 4.4 years) completed this study. Anticholinergic exposure was found in 38 participants (56.7%) at baseline, in which antipsychotics (n=29, 76.3%) and antidepressants (n=19, 50%) were the most common agents. Compared with participants in the reference group, CR-ACHS was significantly reduced in the intervention group at 12-week follow up (intervention group vs reference group=0.5 ± 1.1 vs 1.1 ± 1.3, P=0.021), whereas the mean Mini-Mental State Examination and Barthel Index were similar between groups. In contrast, no clinical complication was observed regarding medication adjustments during the study period.

CONCLUSIONS

Anticholinergic burden can be successfully and safely reduced through an educational program for primary care physicians, but the benefit of reducing anticholinergic burden remained unclear within the first 12 weeks. Further investigation is required to evaluate the long-term benefits of reducing anticholinergic burden for demented older adults.

Prevalence and correlates of antipsychotic polypharmacy: a systematic review and meta-regression of global and regional trends from the 1970s to 2009

OBJECTIVE

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.

METHODS

Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.

RESULTS

Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR=42-100%]), the median APP rate was 19.6% (IQR=12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs)+second-generation antipsychotics (SGAs) (42.4%, IQR=0.0-71.4%) followed by FGAs+FGAs (19.6%, IQR=0.0-100%) and SGAs+SGAs (1.8%, IQR=0.0-28%). APP rates were not different between decades (1970-1979:28.8%, IQR=7.5-44%; 1980-1989:17.6%, IQR=10.8-38.2; 1990-1999:22.0%, IQR=11-40; 2000-2009:19.2% IQR=14.4-29.9, p=0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p<0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p=0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p=0.03), with non-significant changes in Europe. APP was associated with inpatient status (p<0.001), use of FGAs (p<0.0001) and anticholinergics (<0.001), schizophrenia (p=0.01), less antidepressant use (p=0.02), greater LAIs use (p=0.04), shorter follow-up (p=0.001) and cross-sectional vs. longitudinal study design (p=0.03). In a meta-regression, inpatient status (p<0.0001), FGA use (0.046), and schizophrenia diagnosis (p=0.004) independently predicted APP (N=66, R(2)=0.44, p<0.0001).

CONCLUSIONS

APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Anxiety symptoms among assisted living residents: implications of the "no difference" finding for participants with and without dementia

Anxiety is a distressing experience at any age but may be particularly disabling when coupled with dementia. Dementia-related anxiety is associated with a range of additional problems among community-dwelling older adults, but little is known about its occurrence in assisted living environments. The purpose of this article is to describe the prevalence of anxiety symptoms among older adults who participated in Phase I of the Maryland Assisted Living Study, a cross-sectional study of 198 participants who underwent comprehensive dementia evaluations. Participants with dementia diagnoses (n=134) were compared with those without dementia (n=64) using two measures of anxiety. Anxiety was common in both groups: 22% of each group were assessed to have one or more anxiety symptoms using proxyrated methods, and 45% had at least mild anxiety using direct observation and interview. Factors that contribute to variability in reports of dementia-related anxiety are reviewed.

Fatores associados ao uso de psicofármacos em idosos asilados

INTRODUÇÃO: As instituições de longa permanência para idosos (ILPI) apresentam altas prevalências de internados em uso de psicofármacos para o controle de distúrbios comportamentais. Há, porém, poucos estudos brasileiros sobre esse aspecto de abordagem terapêutica em ILPI. OBJETIVO: Avaliar os fatores associados ao uso de psicofármacos em pacientes idosos institucionalizados. MÉTODOS: Foi realizado estudo transversal e retrospectivo por meio de análise de prontuários de todos os idosos (60 anos ou mais) internados em um ILPI, independentemente das doenças apresentadas. Regressão logística foi realizada para verificar os fatores associados ao uso de psicofármacos na instituição. RESULTADOS: Foram avaliados 209 pacientes (73,2% mulheres), predominantemente portadores de síndromes demenciais, sequelas de acidentes vasculares cerebrais ou de traumas de crânio e hipertensão arterial sistêmica. Os psicofármacos estavam prescritos para 123 internados (58,9% do total), principalmente neurolépticos e antidepressivos. Após a regressão logística, encontrou-se associação entre a prescrição de neurolépticos e demência (p = 0,000), enquanto que o uso de antidepressivos esteve associado a maior número de medicamentos (p = 0,004) e presença de depressão (p = 0,000). O uso de psicofármacos em geral esteve fortemente associado com depressão (p = 0,000), presença de demência (p = 0,006) e presença de doenças psiquiátricas (p = 0,02). Não houve associação com as variáveis sexo, funcionalidade e idade. CONCLUSÃO: Há alto consumo de psicofármacos em ILPI. A associação destes com polifarmácia e depressão é significativa, e os portadores de demência foram os que mais fizeram uso dos neurolépticos. Fatores como idade e sexo, normalmente relevantes em pacientes ambulatoriais, não apresentaram associação em institucionalizados.

Comparison of behavioral and psychological symptoms of Alzheimer's disease among institution residents and memory clinic outpatients

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) cause caregiver distress and earlier institutionalization. We compared the prevalence and characteristics of BPSD between institution residents and memory clinic outpatients with Alzheimer's disease (AD) to test the hypothesis that there is more BPSD among institution residents than among their outpatient counterparts. We assessed BPSD by interviewing the patients' principal caregivers, either family or professionals, using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). Data from 138 patients with probable AD from the memory clinic and 173 residents with possible AD living in the long-term care facilities were collected. The diagnoses followed the NINCDS-ADRDA criteria.

RESULTS

BPSD profiles of the two groups were similar but not identical. The prevalence of at least one BPSD was high in both groups (community 81.9%, institution 74.9%). Activity disturbance was the most frequently reported BPSD in both groups (community 52.2%, institution 38.7%). Delusions, hallucinations, anxiety and aggressiveness were seen more frequently in memory clinic outpatients. The outpatients also had higher scores of BEHAVE-AD subscales in delusion/paranoid ideation, affective disturbance, and global rating of severity. With the increase of disease severity there were significantly more activity disturbance, psychosis, and aggressiveness in patients with AD.

CONCLUSIONS

Caregiver factor and institution effect were two possible reasons for the higher prevalence and the greater severity of BPSD in community patients. BPSD caused more distress to family caregivers than the professional caregivers. High levels of psychotropic prescriptions for patients living in the long-term care facilities may also play a role.

Psychotropic medication use and cognition in institutionalized older adults with mild to moderate dementia

BACKGROUND

Most studies examining psychotropic medication use on cognition in older persons with dementia include measures of global cognitive function. The present study examined the relationship between different types of psychotropic medication and specific cognitive functions in older people with dementia.

METHODS

Two hundred and six institutionalized older adults with dementia (180 women, mean age 85 years) were administered neuropsychological tests. Psychotropic medication use was extracted from their medical status and categorized as: sedatives, antidepressants and antipsychotics.

RESULTS

Analysis of covariance revealed that psychotropic consumers, and particularly those who used antipsychotics, performed worse on neuropsychological tests of executive/attentional functioning than non-consumers. There were no differences between consumers of other classes of psychotropic drugs and non-consumers. The number of psychotropic drugs used was inversely related to executive/attentional functioning.

CONCLUSIONS

These findings show that in institutionalized older adults with dementia, specific impairment of cognitive function, i.e. executive/attentional impairments, are associated with antipsychotic medication use. Future longitudinal studies are recommended.

Use and misuse of antipsychotic drugs in patients with dementia in Alzheimer special care units

The objective of this study was to estimate the prevalence of antipsychotic use and investigate their association with behavioural and psychological symptoms of dementia (BPSD) and other clinical predictors. Patients with dementia, aged 65 and above and resident in 35 Alzheimer special care units were sequentially enrolled into a 18-month prospective observational study. Data on sociodemographic, cognitive, functional, behavioural and clinical characteristics and drug exposure were collected at baseline and at 6-month intervals up to 18 months. The prevalence of antipsychotic use and the association with BPSD and clinical predictors were analysed. Of the 349 patients with dementia enrolled in the study, 209 (60%) were taking at least one antipsychotic. Risperidone and promazine were the most frequently prescribed antipsychotic; 40.7% simultaneously received a benzodiazepine, 20% an antidepressant. More than 50% were still taking antipsychotics at 18 months of follow-up. No associations were found between antipsychotic use and level of cognitive impairment, basal activity of daily living disability and comorbidity. Multivariate analysis showed that the use of antipsychotics was highest in patients in the highest quartiles of Neuropsychiatric Inventory Scale score (III quartile, odds ratio: 1.63; 95% confidence interval: 1.19-2.23; IV quartile, odds ratio: 2.27; 95% confidence interval: 1.61-3.26). This study found high rate of use of antipsychotics in patients with dementia resident in Alzheimer special care units, frequent associations with other psychotropic medications and a strong correlation with BPSD.

Dementia care in assisted living: needs and challenges

Assisted living (AL) is an increasingly popular long-term care option for older adults with dementia. Recent reports suggest that as many as 68% of AL residents have dementia, and that frequency of both behavioral symptoms and psychotropic medications are high. This pilot project explored the feasibility of research methods for use in AL facilities. Findings suggest that most AL residents with dementia have moderate to severe dementia, and the majority are taking one or more psychotropic medication. Descriptive and qualitative findings related to health records, caregiver perceptions of behavioral symptoms, and practicality of assessment methods undertaken are described and implications for psychiatric nursing practice and research are reviewed.

Psychiatric consultations for nursing home residents: a perspective from Turkey and the implications for comparable countries

BACKGROUND

No specialized geriatric psychiatry consultation services are available for elderly people in the institutional care system in Turkey. Our aim was to evaluate psychiatric consultations among the residents of three homes for the elderly in a country with a rapidly aging population, and to investigate possible problems regarding psychiatric consultations.

METHODS

The residents of three homes for the elderly, which served partially as "care and rehabilitation centers" (equivalent to nursing homes), were chosen for the study. Data on the use of psychiatric services (mainly patient consultations with a visiting psychiatrist) were collected and analyzed.

RESULTS

The percentage of patients in the three homes for the elderly who had psychiatric consultations between 2005 and 2007 was 31.8% (172/540). The main reasons for referral were forgetfulness (61%), depressive symptoms (37.7%), agitation and disruptive behavior (29.6%), and psychotic symptoms (27.9%). Of these patients, 46.5% were diagnosed with dementia, 20.9% with depression, 20.5% with behavioral and psychotic symptoms of dementia, and 18.6 % with primary psychotic disorders such as schizophrenia.

CONCLUSION

Homes for the elderly in Turkey are not adequate in terms of consultations for psychiatric problems. Integration of these institutions with hospitals and organizing routine consultation visits from the psychiatry units would enhance the mental health of the elderly. Supporting the staff, maintaining good cooperation between them, and organizing educational programs in the field of mental health of the elderly are also required.

[Primary care in homes for the elderly]

Dutch GP's (General Practitioners) take care of people living in homes for the elderly. The population of these homes is selected on the basis of poor functioning on ADL (activities of daily living). We expected to find a group of elderly people within these homes that need more complex primary care. We describe the characteristics of care for an institutionalized elderly population and compare these to the care provided to their independently living peers. The design of this study is a matched case-control study in a Dutch General Practice in the study period 1/1/1998 to 1/7/2004. Our main results show that the rate of cognitive problems is two times, the prevalence of depression even three times higher in older people living in a home for the elderly than in those who live independently. Locomotory problems are a frequent problem in homes for the elderly. Rates of chronic pulmonary problems, atherosclerosis-related diseases and urinary tract infection are higher, whereas no significant differences for CVA, diabetes and cancer were found. Institutionalized older patients use more different types of medication. GP's do not have more contacts with people living in a home for the elderly than with older people living independently. We conclude that people living in homes for the elderly have complex problems, and need special attention for their specific vulnerability. Differences in care are not primarily explained by chronic disease but by problems with mobility, confusion, depression and cognition.

Dementia-specific assisted living: clinical factors and psychotropic medication use

BACKGROUND

Assisted living (AL) is an increasingly popular long-term care alternative for older adults with dementia, making this setting an important focus for both clinical practice and research among psychiatric nurses.

OBJECTIVES

This article describes results from a pilot study focusing on residents' cognitive and emotional status as well as psychotropic drug use. Findings are compared to reports from larger studies in the literature.

STUDY DESIGN

A descriptive, correlational design was used to collect data from 17 residents in two dementia-specific AL facilities.

RESULTS

Thirty-one psychiatric diagnoses were identified for 17 participants. Anxiety and depression symptoms were endorsed by more than 50% of participants, and 88% were prescribed psychotropic medications.

CONCLUSIONS

AL residents may experience problems with cognition and emotional symptoms such as anxiety and depression, creating important roles for psychiatric nurses in staff education, promotion of nonpharmacologic interventions, and monitoring of psychotropic medication use in this growing population. J Am Psychiatr Nurses Assoc, 2008; 14(1), 39-49. DOI: 10.1177/1078390307310692.