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Wretman CJ, Zimmerman S, Sloane PD, Preisser JS. Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living. J Am Med Dir Assoc 2022; 23:1503-1504. [PMID: 35605682 PMCID: PMC10575547 DOI: 10.1016/j.jamda.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Carder P, Zimmerman S, Wretman CJ, Preisser JS, Dys S, Sloane PD. As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study. J Am Med Dir Assoc 2021; 23:1038-1044.e3. [PMID: 34919835 DOI: 10.1016/j.jamda.2021.11.009] [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: 05/25/2021] [Revised: 10/26/2021] [Accepted: 11/06/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS All AL residents and select staff in 250 AL communities in 7 states. METHODS Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7 days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics. RESULTS Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7 days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n = 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n = 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds. CONCLUSIONS AND IMPLICATIONS The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.
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Affiliation(s)
- Paula Carder
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA; School of Public Health, Oregon Health and Science University-Portland State University, Portland, OR, USA.
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah Dys
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA; School of Public Health, Oregon Health and Science University-Portland State University, Portland, OR, USA
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Yap TL, Alderden J, Kennerly SM, Horn SD, Rowe M, Sabol VK. To Turn or Not to Turn: Exploring Nurses' Decision-Making Processes Concerning Regular Turning of Nursing Home Residents. Gerontol Geriatr Med 2021; 7:23337214211046088. [PMID: 34631970 PMCID: PMC8493305 DOI: 10.1177/23337214211046088] [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: 06/09/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Nursing home (NH) residents are at high-risk for pressure injuries (PrIs), and those living with Alzheimer's Disease and Related Dementias (ADRD) are at even greater risk. Understanding how nursing staff approach repositioning remains critical. Methods: As part of an ongoing clinical trial, this mixed-method prospective, exploratory, descriptive study examined repositioning efforts for PrI prevention. An investigator-developed checklist guided researcher observations, and focus groups revealed staff perspective on resident behaviors and corresponding repositioning approaches. Focus group transcripts were analyzed using the constant comparative coding method. Results: Repositioning observations were conducted for 88 residents. Resident behaviors and nursing approaches were similar between the ADRD (n = 62, 70%) and non-ADRD (n = 26, 30%) groups. Thirty-six staff participated in one of six focus group sessions. A conceptual model was developed to depict the repositioning process. Staff revealed care is guided by clinical frameworks and guidelines, along with resident preferences and behaviors. Conclusions: Protocol-driven, standardized PrI prevention care may limit the capacity to honor repositioning preferences. Insights from the focus groups highlight the importance of being cognizant of competing factors that may interfere with successful repositioning. Approaches by staff may be protocol-driven or an integrated method of care.
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Affiliation(s)
- Tracey L Yap
- Duke University School of Nursing, Durham, NC, USA
| | - Jenny Alderden
- University of Utah College of Nursing, Salt Lake City, UT, USA
| | - Susan M Kennerly
- East Carolina University College of Nursing, Greenville, NC, USA
| | - Susan D Horn
- Consultant, 5823 Bowen Daniel Drive, Tampa, FL, USA
| | - Meredeth Rowe
- University of South Florida College of Nursing, Tampa, FL, USA
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Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool ©. A development and content validation study. Res Social Adm Pharm 2018; 15:691-700. [PMID: 30213525 DOI: 10.1016/j.sapharm.2018.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 08/23/2018] [Accepted: 08/29/2018] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Psychotropic medicines are often prescribed in nursing homes to manage behavioral and psychological symptoms of dementia despite marginal clinical effects alongside harmful adverse events. Organizational culture has been identified as a key factor that contributes to the high-level prescribing of psychotropic medicines in nursing homes. There are gaps in existing tools used to link organizational culture to the use of psychotropic medicines. The aim of this research was to develop and content validate a tool that evaluates organizational culture specific to the use of psychotropic medicines, named the Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. METHODS Schein's theory of organizational culture was used to guide the development and content validation of the PRACTICE tool©. The PRACTICE tool© was developed based on a comprehensive systematic review, qualitative research and generated by the research team. Content validity was assessed using the CVI (Content Validity Index). The content relevance and importance of the PRACTICE tool© items were rated by an expert panel with relevant knowledge and experience. Any modified or re-worded items were presented to the panel members in a subsequent survey for re-rating. RESULTS Across the two rounds, the PRACTICE tool© had 68 items that assessed all aspects of culture according to Schein's theory. Sixty-two items out of 68 (91%) met predefined cut-off values (≥0.78) for the I -CVI. The remaining six items (9%) did not fully meet the cut-off values but were deemed important to be included in the tool based on the systematic review, qualitative research and discussions with the research team. CONCLUSIONS The PRACTICE tool© is a step forward in validating an instrument that will help inform managers and policy makers to identify target areas for improvement to create a culture of appropriate psychotropic prescribing in nursing homes.
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Sawan M, Jeon YH, Chen TF. Relationship between Organizational Culture and the Use of Psychotropic Medicines in Nursing Homes: A Systematic Integrative Review. Drugs Aging 2018; 35:189-211. [DOI: 10.1007/s40266-018-0527-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Janus SIM, van Manen JG, Zuidema SU, Snijder C, Drossaert CHC, Ijzerman MJ. Reasons for (not) discontinuing antipsychotics in dementia. Psychogeriatrics 2018; 18:13-20. [PMID: 28745420 DOI: 10.1111/psyg.12280] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/07/2017] [Accepted: 04/30/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The gap between high antipsychotic prescription rates for patients with dementia and the guidelines' advice to prescribe cautiously indicates that barriers to discontinuation exist. This exploratory study used the theory of planned behaviour to give a first overview of the factors that influence physicians to discontinue antipsychotics in nursing home patients with dementia. METHODS Forty-one physicians in the Netherlands completed an online survey based on the theory of planned behaviour. RESULTS Half of the respondents agreed that antipsychotics have positive consequences for patients, such as calming effects. Physicians who indicated that they tend not to discontinue antipsychotics believe that antipsychotics are associated with positive consequences for nursing home staff. Physicians who tend to discontinue antipsychotics had a higher perceived behavioural control than those who indicated having a low intention. CONCLUSION To enhance discontinuation of antipsychotics, interventions should focus on both patient-related factors and staff-related factors. Prescribing decisions are influenced by staff-related factors that need to be addressed as well.
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Affiliation(s)
- Sarah I M Janus
- Department Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Jeannette G van Manen
- Department Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carina Snijder
- Department Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Constance H C Drossaert
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Maarten J Ijzerman
- Department Health Technology and Services Research, University of Twente, Enschede, The Netherlands
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Resident Vignettes for Assessing Care Quality in Nursing Homes. J Am Med Dir Assoc 2017; 19:405-410. [PMID: 29174560 DOI: 10.1016/j.jamda.2017.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/18/2017] [Accepted: 10/18/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Validated process measures that correlate with patient outcomes are needed for research and quality improvement. DESIGN Cross-sectional analysis within a cluster-randomized fall prevention study. SETTING Nursing homes in North Carolina (n = 16). PARTICIPANTS Nursing home staff (n = 541) and residents with 1 or more falls in 6 months (n = 597). MEASUREMENTS Fall-prevention process measures in 4 categories derived from Assessing Care of Vulnerable Elders quality indicators were measured in 2 ways: (1) chart abstraction; and (2) staff responses to clinical vignettes of hypothetical residents at risk for falls. Recurrent fall rates (falls/resident/year) were measured. The proportion of the total variation in falls rates explained by the scores for each method (chart abstraction or vignette) was calculated using multilevel adjusted models. RESULTS Chart and vignette measures of comorbidity management were moderately correlated (Pearson correlation coefficient 0.43), whereas other process measure categories had low or negative correlation between the 2 methods (psychoactive medication reduction 0.13, environmental modification -0.42, and exercise/rehabilitation -0.08). Measures of environmental modification and comorbidity management explained a moderate amount of the total variation in recurrent fall fates, vignettes (7%-10% variation explained) were superior to chart abstraction (2%-6% variation explained). Vignette responses from unlicensed staff (nurse aides and rehabilitation aides) explained more variance than registered nurses, licensed practical nurses, or other licensed staff in these categories. Process measures for psychoactive medication reduction and exercise/rehabilitation did not explain any of the variation in fall outcomes. Overall, vignette process measures explained 3.9% and chart abstraction measures explained 0% of the variation in fall outcomes. CONCLUSIONS Clinical vignettes completed by nursing home staff had greater association with resident recurrent fall rates than traditional chart abstraction process measures.
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Walsh KA, Dennehy R, Sinnott C, Browne J, Byrne S, McSharry J, Coughlan E, Timmons S. Influences on Decision-Making Regarding Antipsychotic Prescribing in Nursing Home Residents With Dementia: A Systematic Review and Synthesis of Qualitative Evidence. J Am Med Dir Assoc 2017; 18:897.e1-897.e12. [DOI: 10.1016/j.jamda.2017.06.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 01/21/2023]
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Pharmacological and non-pharmacological treatment preferences of healthcare professionals and proxies for challenging behaviors in patients with dementia. Int Psychogeriatr 2017; 29:1377-1389. [PMID: 28416027 DOI: 10.1017/s1041610217000485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prescribing antipsychotics to patients with neuropsychiatric symptoms is a matter of concern. Physicians have to make treatment decisions for patients with dementia together with proxies and/or nurses. However, it is unknown whether physicians, nurses, and proxies' treatment preferences are aligned; hence this study. METHODS Sixteen treatment attributes were selected to elicit the preferences of physicians and nurses. Ten of these attributes were used for the proxies. Preferences were estimated using a case-1 Best-Worst-Scaling design; respondents are asked to select the best and worst attribute on being presented with a hypothetical patient with dementia demonstrating neuropsychiatric symptoms. The treatments offered are: antipsychotic treatment or non-pharmaceutical regimens. RESULTS The questionnaire was filled in by 41 physicians, 81 nurses, and 59 proxies. The non-pharmacological treatment option was chosen by 52% of the proxies and 71% of the physicians and nurses. The respondents who chose antipsychotics rated the aspects "fastest result" and "most effective" as important. Physicians ranked "experience with antipsychotics" as an important aspect for prescribing antipsychotics. Only the proxies rated the aspect "having a low negative effect on the patient" as important. The nurses and elderly care physicians who chose the non-pharmaceutical treatment ranked "appropriateness" and "of little burden to the patient" as important aspects. CONCLUSIONS While doctors and nurses prefer non-pharmacological interventions, proxies indicated a preference for pharmacological treatment because of the immediate effect. However, physicians follow treatment guidelines and nurses and proxies rely on the physician's recommendations. We suggest physicians should be sensitive to these differences.
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Affiliation(s)
| | - Elizabeth R.A. Beattie
- Professor of Aged and Dementia Care, Dementia Collaborative Research Centre: Consumers, Carers and Social Research, School of Nursing, Faculty of Health, Queensland University of Technology Brisbane, Queensland, Australia
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Rosen T, Lachs MS, Teresi J, Eimicke J, Van Haitsma K, Pillemer K. Staff-reported strategies for prevention and management of resident-to-resident elder mistreatment in long-term care facilities. J Elder Abuse Negl 2015; 28:1-13. [PMID: 25894206 PMCID: PMC4615545 DOI: 10.1080/08946566.2015.1029659] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Resident-to-resident elder mistreatment (R-REM) in nursing homes is frequent and leads to adverse outcomes. Nursing home staff responses may significantly mitigate R-REM's impact, but little is known about current practices. The objective was to identify common staff responses to R-REM. The authors interviewed 282 certified nursing assistants (CNAs) in five urban nursing homes on their responses during the previous 2 weeks to R-REM behaviors of residents under their care. Ninety-seven CNAs (34.4%) reported actions responding to R-REM incidents involving 182 residents (10.8%), describing 22 different responses. Most common were physically intervening/separating residents (51), talking calmly to settle residents down (50), no intervention (39), and verbally intervening to defuse the situation (38). Less common were notifying a nurse (13) or documenting in behavior log (4). Nursing home staff report many varied responses to R-REM, a common and dangerous occurrence. CNAs seldom documented behaviors or reported them to nurses.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, New York, NY, USA
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Mark S. Lachs
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jeanne Teresi
- Columbia University Stroud Center and New York State Psychiatric Institute, New York, NY, USA
- Research Division, Hebrew Home at Riverdale, 5901 Palisade Avenue, Bronx, NY, USA
| | - Joseph Eimicke
- Research Division, Hebrew Home at Riverdale, 5901 Palisade Avenue, Bronx, NY, USA
| | - Kimberly Van Haitsma
- Program for Person Centered Living Systems of Care, College of Nursing, The Pennsylvania State University, University Park, PA, USA
| | - Karl Pillemer
- Department of Human Development and Cornell Institute for Translational Research on Aging, 142 Martha Van Rensselaer Hall, Cornell University, Ithaca, NY, 14853 USA
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Brandt NJ, Pythtila J. Psychopharmacological medication use among older adults with dementia in nursing homes. J Gerontol Nurs 2013; 39:8-14. [PMID: 23616986 DOI: 10.3928/00989134-20130315-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Historically, the use of psychopharmacological medications, such as antipsychotic, antidepressant, and anxiolytic agents, have been scrutinized due to concerns with safety and efficacy especially in older adults with dementia. Over the past year, the Centers for Medicare & Medicaid Services launched a national initiative to improve the behavioral health of older adults residing in America's nursing homes with a focus on reducing the inappropriate use of these medications to inform the practitioner of the importance of not just evaluating antipsychotic agents but all medications that an older person with dementia may be prescribed. This is critical due to the increased vulnerability of this population to adverse effects coupled with varying degrees of efficacy. Online national resources are also provided.
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Affiliation(s)
- Nicole J Brandt
- University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
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Seitz DP, Gill SS, Herrmann N, Brisbin S, Rapoport MJ, Rines J, Wilson K, Le Clair K, Conn DK. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. Int Psychogeriatr 2013; 25:185-203. [PMID: 23083438 PMCID: PMC3544545 DOI: 10.1017/s1041610212001627] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 05/10/2012] [Accepted: 08/30/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medications are frequently prescribed for neuropsychiatric symptoms (NPS) associated with dementia, although information on the efficacy and safety of medications for NPS specifically in long-term care (LTC) settings is limited. The objective of this study was to provide a current review of the efficacy and safety of pharmacological treatments for NPS in LTC. METHODS We searched MEDLINE, EMBASE, PsychINFO, and the Cochrane Library for randomized controlled trials comparing medications with either placebo or other interventions in LTC. Study quality was described using the Cochrane collaboration risk of bias tool. The efficacy of medications was evaluated using NPS symptom rating scales. Safety was evaluated through rates of trial withdrawals, trial withdrawals due to adverse events, and mortality. RESULTS A total of 29 studies met inclusion criteria. The most common medications evaluated in studies were atypical antipsychotics (N = 15), typical antipsychotics (N = 7), anticonvulsants (N = 4), and cholinesterase inhibitors (N = 3). Statistically significant improvements in NPS were noted in some studies evaluating risperidone, olanzapine, and single studies of aripiprazole, carbamazepine, estrogen, cyproterone, propranolol, and prazosin. Study quality was difficult to rate in many cases due to incomplete reporting of details. Some studies reported higher rates of trial withdrawals, adverse events, and mortality associated with medications. CONCLUSIONS We conclude that there is limited evidence to support the use of some atypical antipsychotics and other medications for NPS in LTC populations. However, the generally modest efficacy and risks of adverse events highlight the need for the development of safe and effective pharmacological and non-pharmacological interventions for this population.
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Affiliation(s)
- Dallas P Seitz
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada.
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Physicians' practice and familiarity with treatment for agitation associated with dementia in Israeli nursing homes. Int Psychogeriatr 2013; 25:236-44. [PMID: 23174135 DOI: 10.1017/s104161021200172x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To clarify physicians' actual practice in treating agitation in the nursing home and to elucidate the relationship between background factors, familiarity with interventions, and practice. METHODS A survey of actual practice for agitation in persons with dementia was administered to 67 physicians aged 31-70+ working in nursing homes in Israel. Questionnaires were administered by personal interview, self-completed, or a combination of the two. RESULTS Psychotropic medications are prescribed by 92.5% of physicians for treating agitation, most notably, Haloperidol (39%). Non-pharmacological treatment was also reported to be common, though to a lesser extent, with environmental change being the most prevalent non-pharmacological intervention. Generally, physicians showed low familiarity levels with non-pharmacological interventions, with higher levels noted for physicians with a specialty in geriatrics compared to those who were non-specialized. Physicians who were non-Israeli and younger also reported higher familiarity levels compared to their respective counterparts (i.e. Israeli and older) but this difference did not reach significance. CONCLUSION The findings indicate that, despite current guidelines, psychotropic medications are the treatment of choice among nursing home physicians in Israel. While rates of use of non-pharmacological interventions are substantial, their in-practice application may be hindered by lack of familiarity as well as system barriers. The results have implications for system and education changes.
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Efficacy and Feasibility of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia in Long Term Care: A Systematic Review. J Am Med Dir Assoc 2012; 13:503-506.e2. [DOI: 10.1016/j.jamda.2011.12.059] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 11/04/2011] [Accepted: 12/21/2011] [Indexed: 11/24/2022]
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Cohen-Mansfield J, Thein K, Marx MS, Dakheel-Ali M. What are the barriers to performing nonpharmacological interventions for behavioral symptoms in the nursing home? J Am Med Dir Assoc 2012; 13:400-5. [PMID: 21872537 PMCID: PMC3262905 DOI: 10.1016/j.jamda.2011.07.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 07/07/2011] [Accepted: 07/07/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms. DESIGN A descriptive study of barriers to intervention delivery in a controlled trial. SETTINGS The study was conducted in six nursing homes in Maryland. PARTICIPANTS Participants were 89 agitated nursing home residents with dementia. INTERVENTION Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined. MEASUREMENTS Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect. RESULTS Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment. CONCLUSION Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.
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Affiliation(s)
- Jiska Cohen-Mansfield
- Research Institute on Aging of Charles E. Smith Life Communities, Rockville, MD 20852, USA.
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Abstract
BACKGROUND The goal of this study is to determine patterns of psychotropic drug use (PDU), the association with neuropsychiatric symptoms (NPS), and the variability across dementia types in nursing home residents with dementia. In addition, PDU was analyzed across multiple indications. METHODS This was a prospective cohort study over a two-year period from 2006 to 2008, which involved 14 dementia special care units in nine nursing homes. A total of 117 residents with dementia participated in the study, of whom 35% had Alzheimer's dementia (AD) and 11% vascular dementia (VaD). PDU was classified according to anatomical therapeutic chemical-classification as either "present" or "absent". RESULTS The majority of residents had moderately severe to severe dementia. At all successive assessments, almost two-thirds of residents received any psychotropic drug (PD) and almost one-third continued to receive any PD. Of all PDs, antipsychotics (APs) were prescribed most frequently. Fewer residents started with antidepressants, but continued to receive antidepressants at higher percentages. Anxiolytics showed an intermittent course, but a subgroup of 9% showed two-year continuation. Once started on PDs at baseline, residents continued to use PDs at high percentages: three-quarters continued to receive APs for at least six months. Half of residents received at least one PD; one-fifth received at least two PDs simultaneously. Residents with AD received more hypnotics and antidementia drugs; residents with VaD received more antipsychotics, antidepressants, anxiolytics and anticonvulsants. CONCLUSIONS PDs have different utilization patterns, but overall, consistently high continuation rates were found. These results warrant scrutiny of continuous PDU.
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Enmarker I, Olsen R, Hellzen O. Management of person with dementia with aggressive and violent behaviour: a systematic literature review. Int J Older People Nurs 2011; 6:153-62. [PMID: 21539720 DOI: 10.1111/j.1748-3743.2010.00235.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Studies indicate that physical and pharmacological restraints are still often in the frontline of aggression management in a large number of nursing homes. In the present literature review the aim was to describe, from a nursing perspective, aggressive and violent behaviour in people with dementia living in nursing home units and to find alternative approaches to the management of dementia related aggression as a substitute to physical and chemical restraints. METHODS A systematic literature review in three phases, including a content analysis of 21 articles published between 1999 and August 2009 has been conducted. RESULTS The results could be summarised in two themes: 'origins that may trigger violence' and 'activities that decrease the amount of violent behaviour'. Together, the themes showed that violence was a phenomenon that could be described as being connected to a premorbid personality and often related to the residents' personal care. It was found that if the origin of violent actions was the residents' pain, it was possible to minimise it through nursing activities. This review also indicated that an organisation in special care units for residents who exhibit aggressive and violent behaviour led to the lesser use of mechanical restraints, but also an increased use of non-mechanical techniques. CONCLUSION The optimal management of aggressive and violent actions from residents with dementia living in nursing homes was a person-centred approach to the resident. Qualitative studies focusing on violence were sparsely found, and this underlines the importance of further research in this area to elucidate how violence and aggressiveness is experienced and understood by both staff and patients. RELEVANCE TO CLINICAL PRACTICE To communicate with people with dementia provides a challenge for nurses and other health caregivers. To satisfy the needs of good nursing care, an important aspect is therefore to get knowledge and understanding about aggressive and violent behaviour and its management.
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Affiliation(s)
- Ingela Enmarker
- Faculty of Health Science, Nord-Trondelag University College, Namsos, Norway.
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Abstract
With the advent of the graying of the baby boomers, there is an urgent need to enhance care in the nursing home. This article focuses on the areas where high-quality care can improve outcomes.
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Affiliation(s)
- Debbie Tolson
- Scottish Centre for Evidence Based Care of Older People, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 OBA, UK
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Cornegé-Blokland E, Kleijer BC, Hertogh CMPM, van Marum RJ. Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers. J Am Med Dir Assoc 2010; 13:80.e1-6. [PMID: 21450216 DOI: 10.1016/j.jamda.2010.10.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Despite serious safety concerns, prescription rates of antipsychotics for the treatment of the behavioral and psychological symptoms of dementia remain high, especially in nursing homes. This high prevalence of antipsychotic use cannot be explained by the modest success rate reported in the literature. In this study, we aim at clarifying the reasons for prescribing an antipsychotic drug in behavioral and psychological symptoms of dementia and look at the role of nurses and family caregivers in the decision-making process that precedes the prescription of an antipsychotic drug. DESIGN Questionnaire used in a one-on-one interview with elderly care physicians, nurses, and family caregivers. SETTING We conducted a survey in 23 nursing homes in the Netherlands. METHOD On each dementia ward, the physician selected 1 or 2 patients who started antipsychotics most recently. An interviewer then held a structured questionnaire with the physician, the nurse, and the first relative of the patient. The first part of the interview consisted of questions about the general ideas of the physicians and the second part consisted of case-related questions to physicians, nurses, and family caregivers. RESULTS Physicians, nurses, and family caregivers generally consider the possible benefits of antipsychotics to outweigh the risk of side effects. The main reasons to start therapy are agitation and aggression. Physicians felt pressured by nurses to prescribe in 17% of cases. Physicians felt supported by the guideline of the Dutch Association of Elderly Care Physicians. The estimated average success rate in the discussed cases (the patient is expected to improve on the target behavior) among physicians was 50%, nurses reported 53%, and relatives 55%. The most frequently expected adverse reactions were increased fall risk, sedation, and parkinsonism. Nurses expected cognitive decline. The family felt insufficiently informed about the side effects in 44% of the cases. CONCLUSION The interviewed nursing home physicians and nurses expect almost half of their patients with dementia and behavioral disturbances to benefit from antipsychotic therapy. Serious side effects were expected to occur only sporadically. These expectations may contribute to the high rate of antipsychotic use among these patients.
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Morley JE. Anorexia, weight loss, and frailty. J Am Med Dir Assoc 2010; 11:225-8. [PMID: 20439039 DOI: 10.1016/j.jamda.2010.02.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 02/03/2010] [Indexed: 10/19/2022]
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Testad I, Auer S, Mittelman M, Ballard C, Fossey J, Donabauer Y, Aarsland D. Nursing home structure and association with agitation and use of psychotropic drugs in nursing home residents in three countries: Norway, Austria and England. Int J Geriatr Psychiatry 2010; 25:725-31. [PMID: 19823985 DOI: 10.1002/gps.2414] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Understanding the underlying mechanisms and risk factors leading to agitation is crucial to reduce the severity of agitation and increase quality of life. International comparative studies offer special advantages in elucidating environmental risk factors by providing a wider diversity of environmental exposures such as nursing home structures, health care systems and genetic diversity. METHODS Baseline data for three different intervention studies in Austria (n = 38), England (n = 302) and Norway (n = 163) were combined posthoc. Patients were grouped according to their dementia severity using the global deterioration scale (GDS), functional assessment staging (FAST) and clinical dementia rating (CDR) scales. For the measurement of agitation, the Cohen-Mansfield Agitation Inventory (CMAI) was used. Data analysis was performed using one-way ANOVA, multivariate and linear regression analysis. RESULTS CMAI scores were available for 503 subjects with dementia. There were significant differences between the nursing home residents in the three countries regarding age, gender and dementia severity (all p values < 0.001). In the multivariate analyses, the level of agitation differed with higher mean scores in the Austrian (mean (SD) score 51.9(21.8)) compared to UK (43.3(16.1)) and Norwegian (41.6(13.2)) nursing homes (p = 0.002). Similarly, the use of psychotropic drugs differed significantly, with a higher proportion of neuroleptics in UK (48%, p < 0.001) and Austrian (52.6%; p = 0.001) compared to Norwegian (19%) nursing homes. CONCLUSION We found differences in agitation and antipsychotic drug use which are likely related to structural and cultural differences in nursing homes in three European countries. These findings suggest that structural changes can improve quality of care and quality of life for nursing home residents.
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Affiliation(s)
- I Testad
- Psychiatric Clinic, Stavanger University Hospital, Stavanger, Norway.
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Aman E, Thomas DR. Supervised Exercise to Reduce Agitation in Severely Cognitively Impaired Persons. J Am Med Dir Assoc 2009; 10:271-6. [DOI: 10.1016/j.jamda.2008.12.053] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 12/17/2008] [Indexed: 11/29/2022]
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Abstract
Delirium is a common, serious medical and often life-threatening condition in elderly in-patients. Delirium can develop primarily or secondarily related to other medical conditions and lead to hospital admission. The pathogenesis is still not fully known and is usually addressed as multifactorial. Alterations in neurotransmitters have a key role in this process. The incidence varies by setting up to 90%. Delirium is associated with increased short- and long-term mortality, iatrogenic complications, functional decline, and future development of cognitive impairment or dementia. Delirium is also associated with longer hospital stays, higher hospital and total health system costs, and an increasing rate of nursing home admissions. A structured diagnostic and therapeutic process is recommended. Delirium should become a quality indicator for hospital medicine; however, many research questions still exist.
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Physicians' Perceptions of Their Role in Treating Dementia-related Behavior Problems in the Nursing Home: Actual Practice and the Ideal. J Am Med Dir Assoc 2008; 9:552-7. [DOI: 10.1016/j.jamda.2008.02.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 02/12/2008] [Accepted: 02/15/2008] [Indexed: 11/19/2022]
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