Associated factors with antipsychotic use in long-term institutional care in eight European countries: Results from the RightTimePlaceCare study

Risk Factors for Delirium Superimposed on Dementia in Elderly Patients in Comprehensive Ward

OBJECTIVE

To investigate the incidence of delirium and its related risk factors in patients with senile dementia during hospitalization.

METHODS

A retrospective analysis of clinical data of 157 patients over 65 with cognitive impairment who were hospitalized in the comprehensive ward from October 2019 to February 2023 was conducted. Patients were assigned into delirium and non-delirium groups according to whether they exhibited delirium during hospitalization. General information about the patients and Visual Analogue Scale (VAS) score, blood C-reactive protein level, and blood superoxide dismutase (SOD) level were recorded. Univariate analysis was used to identify potential risk factors for delirium, and factors with statistical significance were subjected to multivariate logistic regression analysis. A prediction line chart for delirium in elderly dementia patients was constructed using R 4.03 software, and the model was validated.

RESULTS

Among the 157 patients with senile dementia, 42 patients exhibited delirium and 115 patients exhibited non-delirium. Multivariate logistic regression analysis showed that diabetes, cerebrovascular disease, VAS score ≥4 points, use of sedative drugs, and blood SOD <129 U/mL were independent risk factors for delirium during hospitalization in elderly dementia patients. A prediction nomogram was plotted based on the five risk factors, and receiver operating characteristic curve analysis presented an area under the curve of .875 (95% CI: .816-.934). The nomogram model was internally validated by the Bootstrap method, and the calibration curve showed good agreement between predicted and actual results. Hosmer-Lemeshow test demonstrated that the model had a good fit and high predictive ability.

CONCLUSION

Diabetes, cerebrovascular disease, VAS ≥4 points, use of sedative drugs, and blood SOD <129 U/mL were independent risk factors for delirium in patients with senile dementia during hospitalization. The nomogram model had good accuracy and clinical application value for predicting delirium in this study.

[Potentially Inappropriate Medication of Nursing Home Residents: An Analysis of Risk Factors Based on National Claims Data (AOK) for 2017]

AIM OF THE STUDY

The aim of this study was to assess risk factors for prescription of potentially inappropriate medication (PIM) to nursing home residents using the PRISCUS list in 2017.

METHODS

Using claims data (AOK) we analysed insured nursing home residents aged 65 or older in 2017. The PRISCUS list was used to identify PIMs. A multivariate logistic regression analysis was performed to analyse risk factors.

RESULTS

The study population in 2017 included 259 328 nursing home residents, out of them 25.5% received at least one potentially inappropriate medication (women: 25.6%/men: 24.9%). Female and younger aged nursing home residents had a higher risk for at least one PRISCUS prescription. Polypharmacy, an increasing number of attending physicians, and hospital stays were additional risk factors for a PRISCUS prescription. Furthermore, regional (Bundesland) variations contributed to differences in PRISCUS prescriptions.

CONCLUSION

The frequent PIM prescriptions in nursing home residents are a relevant topic regarding drug therapy safety. Regional differences, which cannot be explained by nursing home resident characteristics, show options for modifications and the need for further research.

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

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

Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors

BACKGROUND/AIMS

The aim was to explore the impact of sex on prevalence, patterns and trends in the prescription of psychotropics and analgesics in users of acetylcholinesterase inhibitors (AChEIs), before and after AChEI initiation, compared to the general population.

METHODS

A prospective study applying data from the Norwegian Prescription Database (NorPD) in the period 2004-2016. Prescription of antidepressants, antipsychotics, analgesics including opioids, benzodiazepines and z-hypnotics in persistent AChEI users was studied in a follow-up period from four years before to two years after AChEI initiation in men and women of four age groups: 37-64, 65-72, 73-80 and 81-88 years.

RESULTS

Use of antidepressants, antipsychotics and weaker analgesics increased in both sexes during the follow-up period in 11.764 persistent AChEI users. Women with pre-dementia and dementia stages of AD showed a prescription pattern with more use of psychotropics and opioids than men, except for antipsychotics.

CONCLUSION

Female sex showed to have a significant influence on the prescriptions of psychotropics and analgesics in AD patients in a pre-dementia and dementia stage. The exception is for antipsychotics, that men used more than women. The prescription pattern showed a higher extent of polypharmacy of psychotropics and/or opioids in women than in men. The total prescription pattern of analgesics could indicate an undertreatment of pain in pre-dementia and dementia stages, most pronounced in men.

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals

BACKGROUND

It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support.

METHODS

This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale.

RESULTS

The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses.

CONCLUSIONS

It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

Care of older people with Cognitive Impairment or Dementia Hospitalized in Traumatology Units (CARExDEM): a quasi-experiment

BACKGROUND

In our context, as in other European countries, care of patients with cognitive disorders or dementia still represents a major challenge in hospital settings. Thus, there is a need to ensure quality and continuity of care, avoiding preventable readmissions, which involve an increase in public expenses. Healthcare professionals need to acquire the necessary knowledge and skills to care for hospitalized patients with cognitive disorders and dementia.

METHODS

A quasi-experimental design with repeated observations, taken at baseline, post-intervention, and at one and three months post-intervention, in people hospitalized with cognitive disorders or dementia. The study will be carried out in four general hospitals in Spain and will include 430 PwD and their caregivers. The intervention was previously developed using the Balance of Care methodology where nurses, physicians, social workers and informal caregivers identified the best practices for this specific care situation. We aim to personalize the intervention, as recommended in the literature. The study has an innovative approach that includes new technologies and previous scientific evidence. Valid, reliable instruments will be used to measure the intervention outcomes. Quality of care and comorbidity will be analyzed based on the use of restraints and psychotropic medication, pain control, falls, functional capacity and days of hospitalization. Continuity of care will be measured based on post-discharge emergency hospital visits, visits to specialists, cost, and inter-sectorial communication among healthcare professionals and informal caregivers. Statistical analysis will be performed to analyze the effect of the intervention on quality of care, comorbidity and continuity of care for patients with dementia.

DISCUSSION

Our aim is to helping healthcare professionals to improve the management of cognitive disorders or dementia care during hospitalization and the quality of care, comorbidity and continuity of care in patients with dementia and their informal caregivers. Moving towards dementia-friendly environments is vital to achieving the optimum care outcomes.

TRIAL REGISTRATION

Registered in Clinical Trials. ClinicalTrials.gov Identifier: NCT04048980 retrospectively registered on the 6th August 2019. https://clinicaltrials.gov/ Protocol Record HCB/2017/0499.

SPONSOR

Hospital Clinic Barcelona.

Determinants Of Antipsychotic Drugs Prescription Among Community-Living Older Adults With Dementia: A Population-Based Study Using Health Information Systems In The Lazio Region, Italy

Introduction

Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing.

Methods

This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016).

Results

We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57).

Conclusion

The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.

Change in sedative burden after dementia onset using difference-in-difference estimations

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.

[Medication safety for nursing home residents]

Due to demographic change, the number of elderly patients in need of long-term care is continuously increasing. Residents in nursing homes often suffer from various chronic diseases leading to the prescription of a plethora of drugs and a high risk for adverse drug reactions (ADR). Particularly, CNS-active drugs are critical in this context. Moreover, the medication process in nursing homes is complex with numerous interfaces and error sources. Therefore, medication safety for long-term care residents is regarded as a multiprofessional challenge.In Germany, several model projects have been conducted and initiated that aim at enhancing medication safety in nursing homes. The AMTS-AMPEL project is the largest intervention study so far dealing with medication safety in German long-term care facilities. After implementation of a complex multiprofessional intervention consisting of educative and structural measures, prevalence and incidence of preventable ADR could be significantly reduced. This and other projects suggest that medication safety in long-term care residents can be improved by targeted multiprofessional interventions.Although there is already evidence that interventions enhancing medication safety can improve medication appropriateness and solve drug-related problems, they still lack evidence of affecting clinical endpoints like hospitalization rate and mortality. Nevertheless, the model projects already enhance patient safety by increasing the awareness for risks in the medication process in long-term care facilities.

Impact of a geriatric intervention conducted in nursing homes on inappropriate prescriptions of antipsychotics

PURPOSE

To study the effect of a quality assurance approach in a nursing home, with or without the intervention of a geriatrician, on the potentially inappropriate prescription of antipsychotics (PIPA) at 18 months; and to identify the factors associated with PIPA after 18 months of intervention (T18).

METHODS

We used data from a multicentre individually tailored controlled trial (IQUARE study). The study population comprised residents included in the IQUARE study with at least one potentially inappropriate prescription of antipsychotics at baseline (T0) who were still in nursing home at T18 (n = 636; nursing homes = 175). The control group received individual feedback from the quality assurance audit performed at baseline. The intervention group also had at least 5 collaborative work meetings with a geriatrician over an 18-month period. We used a multilevel logistic regression model.

RESULTS

The rates of inappropriate antipsychotic drug prescribing were 66.5% and 45.2% at T0 and T18, respectively. This decrease in the rate of PIPA is significant (p < 0.001). A significant decrease was found within each group: in the intervention arm (68.1% at T0 vs. 44.6% at T18; p < 0.001) and in the control arm (65.2% at T0 vs. 45.6% at T18; p < 0.001). Multivariate analysis did not highlight any statistically significant association between living in a nursing home having received an intervention and PIPA at T18.

CONCLUSIONS

Collaborative work meetings with a geriatrician does not provide significant added value to a global quality assurance approach towards PIPA. Individual feedback to each nursing home appears to have a substantial impact on decreasing PIPA.

[Effects of drug treatment on the surviral-time in patients with dementia]

AIM

The effect of polypharmacy on the surviral-time in patients with dementia has never been fully elucidated.

METHODS

A retrospective study was conducted in a hospital in Aichi, Japan, by reviewing the medical charts and autopsy reports. Patients were hospitalized and neuropathologically diagnosed with dementia. The data on medication was collected from the prescribed drugs taking right before the admission. Patients were divided into two groups according to the number of prescribed drugs: ≥ 5 drugs (polypharmacy) vs. ≤ 4 drugs (non-polypharmacy). "Drugs to be prescribed with special caution" were defined in accordance with the guidelines for medical treatment and its safety in the elderly (2015).

RESULTS

Seventy-six patients were eligible, and 39.5% of patients had polypharmacy. The Kaplan-Meier method showed that the polypharmacy group tended to have a shorter survival-time than the non-polypharmacy group (p=0.067). A Cox proportional hazard model showed that the polypharmacy group tended to have a higher risk for a reduced survival-time than the non-polypharmacy group, and this tendency was more prominent after adjusting for sex and age at admission (adjusted hazard ratio, 1.631; 95% confidence interval, 0.991-2.683; p=0.054). "Drugs to be prescribed with special caution", including hypnotic-sedative drugs, antianxiety drugs, antipsychotics, and benzodiazepines, were not found to be risk factors for a reduced survival-time.

CONCLUSIONS

The present study showed that polypharmacy in terminal patients with dementia tended to carry a risk for reducing their remaining lifespan. The results warrant further additional study.

Psychotropic drug prescription for nursing home residents with dementia: prevalence and associations with non-resident-related factors

OBJECTIVES

To determine psychotropic drug prescription rates in nursing home residents with dementia and to identify associations with the so far understudied psychosocial non-resident-related factors.

METHOD

A cross-sectional, observational, exploratory design as part of PROPER I (PRescription Optimization of Psychotropic drugs in Elderly nuRsing home patients with dementia). Participants were 559 nursing home residents with dementia, 25 physicians, and 112 nurses in the Netherlands. Psychotropic drug prescription, non-resident-related and known resident-related variables were measured to operationalize the themes of our previous qualitative analysis.

RESULTS

Fifty-six percent of residents were prescribed any psychotropic drug, 25% antipsychotics, 29% antidepressants, 15% anxiolytics, and 13% hypnotics, with large differences between the units. Multivariate multilevel regression analyses revealed that antipsychotic prescription was less likely with higher physicians' availability (odds ratio 0.96, 95% confidence interval 0.93-1.00) and that antidepressant prescription was more likely with higher satisfaction of nurses on resident contact (odds ratio 1.50, 95% confidence interval 1.00-2.25). Resident-related factors explained 6%-15% of the variance, resident- and non-resident-related factors together 8%-17%.

CONCLUSION

Prescription rates for antipsychotics are similar compared to other countries, and relatively low for antidepressants, anxiolytics, and hypnotics. Our findings indicate that improvement of prescribing could provisionally best be targeted at resident-related factors.

A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern

ABSTRACTBackground:Behavioral and psychological symptoms of dementia (BPSD) are a common problem in long-term care facilities (LTC). Clinical guidelines dictate that first-line treatments for BPSD are psychosocial and behavioral interventions; if these are unsuccessful, psychotropic medications may be trialed at low doses and their effects can be monitored.

METHODS

There have previously been no studies with nationally representative samples to investigate psychotropic administration in LTCs in Australia. This study determines the prevalence of psychotropic administration in a representative stratified random sample of 446 residents living with dementia from 53 Australian LTCs. Questionnaire and medical chart data in this study is drawn from a larger cross-sectional, mixed methods study on quality of life in Australian LTCs.

RESULTS

It was found that 257 (58%) residents were prescribed psychotropic medications including: antipsychotics (n = 160, 36%), benzodiazepines (n = 136, 31%), antidepressants (n = 117, 26%), and anti-dementia medications (n = 9, 2%). BPSD were found to be very common in the sample, with 82% (n = 364) of participants experiencing at least one BPSD. The most prevalent BPSD were depression (n = 286, 70%) and agitation (n = 299, 67%).

CONCLUSIONS

Although detailed background information was not collected on individual cases, the prevalence found is indicative of systematic industry-wide, over-prescription of psychotropic medications as a first-line treatment for BPSD. This study highlights a clear need for further research and interventions in this area.

Predictive factors for dementia and cognitive impairment among residents living in the veterans' retirement communities in Taiwan: Implications for cognitive health promotion activities

AIM

To identify potentially modifiable risk factors for cognitive decline among veterans' home residents in Taiwan METHODS: The present retrospective cohort study was part of the Veteran Affairs-Comprehensive Geriatric Assessment study that retrieved data of the comprehensive geriatric assessment for 946 residents living at four veterans' homes in Taiwan. The study participants were interviewed every 3-6 months from January 2012 and December 2014. Demographic characteristics,multimorbidity by Charlson's Comorbidities Index, physical function by the Barthel Index, cognition by the Mini-Mental State Examination (MMSE), depression by the five-item Geriatric Depression Scale and nutritional status by the Mini-Nutrition Assessment-Short Form were collected for analysis. A generalized estimating equation model was used after it was adjusted for age, educational level, five-item Geriatric Depression Scale, and problem of communication difficulty to identify potential modifiable risk factors for cognitive decline.

RESULTS

The mean age of the participants was 85.7 ± 5.2 years, with a mean follow-up period of 41 ± 21.6 weeks. The prevalence of cognitive impairment (defined by MMSE <24) was 65.6%, whereas 34% of the study participants were positive for depressive symptoms. Approximately one-fifth of the study participants were using psychotropic agents, which was higher among participants with cognitive impairment (23.6% vs 15.6%, P < 0.05) than those without. In the generalized estimating equation model, physical function, nutritional status, depressive symptoms, ex-drinker, multimorbidity and stool incontinence were positively correlated with MMSE score; whereas advanced age, low educational level (<6 years), presence of communication difficulty and use of psychotropic agents were inversely associated with the MMSE score.

CONCLUSIONS

Physical function and nutritional status were positively associated with the MMSE score, and use of psychotropic agents was negatively correlated with cognitive function. Further intervention study is required to improve the cognitive health of older adults living in the veterans' retirement communities. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 7-13.

Potentially inappropriate medication among people with dementia in eight European countries

Objectives

to evaluate the frequency of potentially inappropriate medication (PIM) prescription among older people with dementia (PwD) from eight countries participating in the European study 'RightTimePlaceCare', and to evaluate factors and adverse outcomes associated with PIM prescription.

Methods

survey of 2,004 PwD including a baseline assessment and follow-up after 3 months. Interviewers gathered data on age, sex, prescription of medication, cognitive status, functional status, comorbidity, setting and admission to hospital, fall-related injuries and mortality in the time between baseline and follow-up. The European Union(7)-PIM list was used to evaluate PIM prescription. Multivariate regression analysis was used to investigate factors and adverse outcomes associated with PIM prescription.

Results

overall, 60% of the participants had at least one PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most frequently prescribed were psycholeptics (26% of all PIM prescriptions) and 'drugs for acid-related disorders' (21%). PwD who were 80 years and older, lived in institutional long-term care settings, had higher comorbidity and were more functionally impaired were at higher risk of being prescribed two PIM or more. The prescription of two or more PIM was associated with higher chance of suffering from at least one fall-related injury and at least one episode of hospitalisation in the time between baseline and follow-up.

Conclusions

PIM use among PwD is frequent and is associated with institutional long-term care, age, advanced morbidity and functional impairment. It also appears to be associated with adverse outcomes. Special attention should be paid to psycholeptics and drugs for acid-related disorders.

Clinical Update on Nursing Home Medicine: 2016

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia - a review of the Swedish context

BACKGROUND

The aim of this study was to explore trends in treatment with antipsychotic medication in Swedish dementia care in nursing homes as reported in the most recent empirical studies on the topic, and to relate these trends to directives from the national authorities.

METHODS

The study included two scoping review studies based on searches of electronic databases as well as the Swedish directives in the field.

RESULTS

During the past decade, directives have been developed for antipsychotic medication in Sweden. These directives were generic at first, but have become increasingly specific and restrictive with time. The scoping review showed that treatment with antipsychotic drugs varied between 6% and 38%, and was higher in younger older persons and in those with moderate cognitive impairment and living in nursing homes for people with dementia. A decreasing trend in antipsychotic use has been seen over the last 15 years.

CONCLUSIONS

Directives from the authorities in Sweden may have had an impact on treatment with antipsychotic medication for people with dementia. Treatment with antipsychotic medication has decreased, while treatment with combinations of psychotropic medications is common. National directives may possibly be even more effective, if applied in combination with systematic follow-ups.

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

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

Antipsychotic prescribing for Alzheimer's disease and related disorders in specialized settings from 2010 to 2014 in France: a repeated cross-sectional study

BACKGROUND

Safety warnings from health authorities are currently intended to limit the use of antipsychotics (APs) in dementia-related conditions to treat neuropsychiatric symptoms, such as disturbing and/or delusional behaviors. The aim of this study is to investigate prevalence, correlates and trends of AP prescribing among people with dementia between 2010 and 2014 in the French population.

METHODS

AP prescribing and associated factors among individuals with AD, mixed dementia and vascular dementia in the French National Alzheimer Database between 2010 and 2014 were analyzed using multivariate generalized estimating equations models (n = 199,549).

RESULTS

In 2014, 7.7% of people with dementia were prescribed an AP. Compared with 2010 there was a 16% increase in AP use. Multivariate analysis showed a linear increase risk of prescription with an adjusted odds ratio (95% confidence interval) of 1.23 (1.17-1.30) in 2014 compared with 2010. Factors associated with AP prescribing were male gender, more severe cognitive decline and living in long-term care facilities. Older age and higher education were protective toward AP prescribing. The type of dementia did not have any influence on AP prescribing.

CONCLUSION

An increase in AP prescribing among individuals with dementia in French specialized settings over the last 5 years occurred despite safety warnings. This phenomenon suggests that alternative solutions for the management of behavioral and psychiatric symptoms in these populations are still urgently needed.

Cross-national comparison of medication use in Australian and Dutch nursing homes

Background

cross-national comparisons can be used to explore therapeutic areas and identify potential medication issues.

Methods

we used cross-sectional pharmacy supply data to explore medication use for nursing home residents in Australia (AU n = 26 homes, 1,560 residents) and the Netherlands (NL n = 6 homes, 2,037 residents). Binary logistic regression analysis was used to calculate the sex and aged adjusted odds ratios (OR) and associated 95% confidence intervals with a flexible Bonferroni-Holm procedure used to adjust for multiple hypothesis testing.

Results

total use of antipsychotics (AU: 37.7%, NL: 40.3%; OR 0.91 (0.79-1.04, P = 0.16) and antibacterials (66.8% AU, 62.4% NL, OR 1.08 (0.93-1.24, P = 0.31) was similar, but choice of individual agents differed between the two countries. Differences were observed in the use of antithrombotics (46.7% AU, 64.7% NL, OR 0.48 (0.42-0.56, P > 0.01), ophthalmologicals (44.3% AU, 22.1% NL, OR 2.80 (2.42-3.24, P < 0.001), laxatives (77.1% AU, 65.8% NL, OR 1.65 (1.41-1.92, P < 0.001).

Conclusion

while the general prevalence of medication use in nursing home residents was similar across the two countries, distinct differences existed in the choice of agent among therapeutic groups. Comparing use between countries identified a number of potential medication related problem areas that need further exploration.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychotropic drug prescriptions in Western European nursing homes

BACKGROUND

Despite the numerous warnings of European and national drug agencies as well as clinical guidelines since the year 2004, psychotropic drugs are still frequently used in dementia. A systematic review comparing the use of psychotropic drugs in nursing homes from different European countries is lacking.

OBJECTIVE

The aim of this study was to examine prescription rates of psychotropic drug use in nursing home patients between different Western European countries since the first warnings were published.

METHODS

A literature review was performed and the various psychotropic prescribing rates in European nursing homes were investigated. The prescription rates of antipsychotic and antidepressants were pooled per country. Other classes of psychotropic drugs could not be pooled because of the limited number of studies found.

RESULTS

Thirty-seven studies on antipsychotic drug use and 27 studies on antidepressant drug use conducted in 12 different European countries. The antipsychotic use in nursing homes ranged from 12% to 59% and antidepressant use from 19% to 68%. The highest rates of antipsychotic drug prescription were found in Austria, Ireland, and Belgium while for antidepressants in Belgium, Sweden, and France.

CONCLUSIONS

Despite warnings about the side effects and recommendation to focus on non-pharmacological interventions, antipsychotics and antidepressants are commonly used drugs in nursing homes. The data suggest that Norway does best with regards having a low antipsychotic drug usage. Studies are needed to explain the differences between Norway and other European countries.

Antipsychotic drug use and associations with neuropsychiatric symptoms in persons with impaired cognition: a cross-sectional study

BACKGROUND

Neuropsychiatric symptoms (NPS) in cognitive disorders impair quality of life, increase caregiver stress, and may lead to earlier institutionalization and death. The objective of this study was to investigate the use of antipsychotics among persons with cognitive impairment in home care and residential care, and its associations with NPS and personal characteristics.

METHODS

Data were collected in the South Savo Hospital District area with 105 000 inhabitants, where 66 of 68 institutions providing long-term residential care and 20 of 21 municipal home care producers joined the study. Nurses recorded the current use of drugs, the activities of daily living (ADL), prevalence of diagnosed dementia, and assessed the cognitive status and the prevalence of recent NPS based on the item list of the Neuropsychiatric Inventory (NPI).

RESULTS

The study population was 1909 persons with cognitive impairment, and 1188 of them lived in residential care. Antipsychotics were used by 563 (29.5%) persons in the whole study population. In residential care 448 (37.7%) used antipsychotics and the corresponding figure in home care was 115 (15.9%). In the multivariate analysis, the antipsychotic use was associated with living in residential care, benzodiazepine use, and with NPS symptoms agitation/aggression (OR =1.70, 95% CI =1.16-2.48), disinhibition (OR =2.33, 95% CI =1.31-4.15), hallucinations (OR =2.77, 95% CI =1.69-4.55), and delusions (OR =1.71, 95% CI =1.01-2.91).

CONCLUSIONS

Antipsychotic use was common among persons with cognitive impairment. The results suggest that antipsychotics are commonly used to treat hyperactivity and psychotic symptoms, especially in residential care.

People with dementia in nursing home research: a methodological review of the definition and identification of the study population

Background

There are various definitions and diagnostic criteria for dementia, leading to discrepancies in case ascertainment in both clinical practice and research. We reviewed the different definitions, approaches and measurements used to operationalize dementia in health care studies in German nursing homes with the aim of discussing the implications of different approaches.

Methods

We conducted a systematic search of the MEDLINE and CINAHL databases to identify pre-2016 studies conducted in German nursing homes that focused on residents with dementia or cognitive impairment. In- or exclusion of studies were consented by all authors; data extraction was independently carried out by 2 authors (RP, SJ). The studies’ sampling methods were compared with respect to their inclusion criteria, assessment tools and methods used to identify the study population.

Results

We summarized case ascertainment methods from 64 studies. Study participants were identified based on a diagnosis that was evaluated during the study, or a recorded medical dementia diagnosis, or a recorded medical diagnosis either with additional cognitive screenings or using screening tests exclusively. The descriptions of the diagnostics that were applied to assess a diagnosis of dementia were not fully transparent in most of the studies with respect to either a clear reference definition of dementia or applied diagnostic criteria. If reported, various neuropsychological tests were used, mostly without a clear rationale for their selection.

Conclusion

Pragmatic considerations often determine the sampling strategy; they also may explain the variances we detected in the different studies. Variations in sampling methods impede the comparability of study results. There is a need to consent case ascertainment strategies in dementia studies in health service research in nursing homes. These strategies should consider resource constraints and ethical issues that are related to the vulnerable population of nursing home residents. Additionally, reporting about dementia studies in nursing homes need to be improved. If a diagnosis cannot be evaluated based on either ICD or DSM criteria, the study population may not be reported as having dementia. If a diagnosis is evaluated based on ICD or DSM criteria within the study, there is a need for more transparency of the diagnostic process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0249-7) contains supplementary material, which is available to authorized users.

The impact of facility characteristics on the use of antipsychotic medications in nursing homes: a cross-sectional study

Background

Antipsychotic medications (APMs) are commonly prescribed in nursing homes (NHs) and their excessive use raises concerns about the quality of care. They are often seen as “chemical restraints”, and were shown to increase morbidity and mortality risks in NH residents. The objective of this study was to investigate the variability in prevalence in APM use in a sample of Israeli NHs and to examine the effect of facility characteristics on the use of APMs.

Methods

A retrospective cross-sectional study was conducted in 2011 using data which were collected in a sample of NHs in the Tel Aviv district during the annual certification process. Prevalence of APMs was determined on the basis of all residents using antipsychotics on a regular basis. The association between facility characteristics and APM use was assessed by multivariate analysis.

Results

Forty-four NHs providing care for 2372 residents were investigated. The prevalence of APM use varied between facilities from 14.8 to 70.6 %, with an overall prevalence of 37.3 %. Multiple linear regression analysis revealed that greater use of APMs was associated with for-profit facilities, facilities in which most of the residents were self-pay, the presence of a “mentally frail” unit, a medical director non-specialized in geriatrics, shortage of social workers and occupational therapists, presence of unsafe/non-fitting equipment or self-aids (e.g., unsafe bath/toilet seats, unsuitable height of tables) and shortage of recreational activities.

Conclusions

A wide variation in APM use was recorded in NHs in the Tel Aviv district. This variation was associated with facility characteristics that undermine quality of care. Application of APM use as a measure of quality in NHs and publicizing their utilization may decrease their overall use.

Antipsychotic Use in a Diverse Population With Dementia: A Retrospective Review of the National Alzheimer's Coordinating Center Database

A cross-sectional analysis examined medication records in the National Alzheimer's Coordinating Center Database for community-dwelling patients with dementia who visited an Alzheimer's Disease Center between 2008 and 2014. Hispanic participants had a 1.62-fold greater use of antipsychotic medications, which was largely accounted for by a higher prevalence of neuropsychiatric symptoms and more severe dementia compared with non-Hispanic whites. These results are consistent with reports of later transition to nursing home care among Hispanic participants. Further studies are needed to clarify ethnic differences in how families and physicians address dementia progression and neuropsychiatric symptoms in community-dwelling patients with dementia.