The course of behavioral problems in elderly nursing home patients with dementia when treated with antipsychotics

Evidence-Informed Approach to De-Prescribing of Atypical Antipsychotics (AAP) in the Management of Behavioral Expressions (BE) in Advanced Neurocognitive Disorders (NCD): Results of a Retrospective Study

The LuBAIR™ Paradigm is a novel approach to ascribe meaning to behavioral expressions in advanced neurocognitive disorders when the reliability of a clinical assessment is limited. The meaning ascribed to each behavioral category was used to identify those which are likely to respond to the use of atypical antipsychotics, in their management. De-prescribing was attempted on patients who qualified to enter this retrospective study. De-prescribing was defined as successful if individuals were completely withdrawn from AAP and remained off them for 60 days, without the re-emergence of behaviors. The LuBAIR™ Inventory was filled on two occasions. The data collected on the second occasion, in the successful and failed de-prescribed groups, were compared in this retrospective study. MANOVA, Chi-Square paired t-test statistical analyses were used to detect the differences in the behavioral categories between the two cohorts. Cohen d was used to measure effect size. Patients who did not have Mis-Identification and Goal-Directed Expressions were more likely to successfully de-prescribe: X2 (1, N = 40) = 29.119 p < 0.0001 and X2 (1, N = 40) = 32.374, p < 0.0001, respectively. Alternatively, the same behavioral categories were more likely to be present in patients who failed de-prescribing: MANOVA and paired t-test (p < 0.0001). Atypical antipsychotics, in their role as an antipsychotic and mood stabilizer, may be used to manage Mis-Identification and Goal-Directed Expressions, respectively.

Event-Specific Emotional Expression of Persons Living With Dementia in Long-term Care: A 6 Months Follow-up Study

This longitudinal study aimed to explore the event-specific emotional expressions of persons living with dementia in long-term care during a 6-month period with repeated observations. Emotional expressions at three specific events (mealtime, personal care, and social activity) were videotaped at the beginning, month 3, and month 6. Thirty participants were enrolled, and nine observations were made for each participant. Mixed-effect models were used for statistical analysis. The type of care events, the person who provides care, and the facility type were associated with emotional expressions. Specifically, personal care, interaction with non-nursing providers, and facility type were associated with positive emotional expressions. Negative emotional expressions were related to personal care, interaction with family or volunteer, and facility type. This study provides a better understanding of event-specific emotional expressions and knowledge to support the development of emotion-oriented intervention programs to improve the psychological well-being of persons living with dementia.

Reasons for (not) discontinuing antipsychotics in dementia

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.

Prevalence of, and Resident and Facility Characteristics Associated With Antipsychotic Use in Assisted Living vs. Long-Term Care Facilities: A Cross-Sectional Analysis from Alberta, Canada

Background

Potentially inappropriate antipsychotic use in long-term care (LTC) facilities has been the focus of significant policy and clinical attention over the past 20 years. However, most initiatives aimed at reducing the use of these medications have overlooked assisted living (AL) settings.

Objective

We sought to compare the prevalence of antipsychotic use (including potentially inappropriate use) among older AL and LTC residents and to explore the resident and facility-level factors associated with use in these two populations.

Methods

We performed cross-sectional analyses of 1089 residents (mean age 85 years; 77% female) from 59 AL facilities and 1000 residents (mean age 85 years; 66% female) from 54 LTC facilities, in Alberta, Canada. Research nurses completed comprehensive resident assessments at baseline (2006–2007). Facility-level factors were assessed using standardized administrator interviews. Generalized linear models were used to estimate odds ratios for associations, accounting for clustering by facility.

Results

Over a quarter of residents in AL (26.4%) and LTC (31.8%) were using antipsychotics (p = 0.006). Prevalence of potentially inappropriate use was similar in AL and LTC (23.4 vs. 26.8%, p = 0.09). However, among users, the proportion of antipsychotic use deemed potentially inappropriate was significantly higher in AL than LTC (AL: 231/287 = 80.5%; LTC: 224/318 = 70.4%; p = 0.004). In both settings, comparable findings regarding associations between resident characteristics (including dementia, psychiatric disorders, frailty, behavioral symptoms, and antidepressant use) and antipsychotic use were observed. Few facility characteristics were associated with overall antipsychotic use, but having a pharmacist on staff (AL), or an affiliated physician (LTC) was associated with a lower likelihood of potentially inappropriate antipsychotic use.

Conclusion

Our findings illustrate the importance of including AL settings in clinical and policy initiatives aimed at reducing inappropriate antipsychotic use among older vulnerable residents.

Electronic supplementary material

The online version of this article (doi:10.1007/s40266-016-0411-0) contains supplementary material, which is available to authorized users.

Multidisciplinary, Nurse-Led Psychiatric Consultation in Nursing Homes: A Pilot Study in Clinical Practice

PURPOSE

To determine the effects of multidisciplinary, nurse-led psychiatric consultation on behavioral problems of nursing home residents. Residents often suffer from psychiatric symptoms, while staff psychiatric expertise varies.

DESIGN AND METHODS

A pre-post study was conducted in seven homes using the Neuropsychiatric Inventory Nursing Home version (NPI-NH).

FINDINGS

In 71 consultations during 18 months, 56-75% of residents suffered from agitation/aggression, depression, anxiety, and disinhibition. Post-intervention (n = 54), frequency, and severity of psychiatric symptoms were significantly and clinically meaningfully reduced. Also, staff suffered from less work stress.

PRACTICE IMPLICATIONS

Nurse-led psychiatric consultation is valuable to both nursing home residents and staff.

Relationship between care dependency and behavioral symptoms among elderly in-patients with Alzheimer's disease in Japan and the Netherlands

Objective:

This study investigates the influence of personal characteristics and health-related variables on the care dependency status among elderly in-patients with clinically diagnosed Alzheimer’s disease in two countries.

Methods:

A descriptive cross-cultural survey was administered to a convenience sample of 137 elderly in-patients. Patients were recruited from a hospital in Japan (N = 77) and from a nursing home in the Netherlands (N = 60).

Results:

In both countries, almost all participants are assessed on the severity level of care dependency in the range of “completely care dependent” (Japan: 35.1%; the Netherlands: 20.0%), or “to a great extent care dependent” (Japan: 24.7%; the Netherlands: 45.0%), to “partially care dependent” (Japan: 22.1%; the Netherlands: 21.7%).

Conclusion:

This study demonstrates that there is no interdependence between the severity level of care dependency and personal characteristics of patients with Alzheimer’s disease in both countries. Regarding the interplay of health-related variables on the severity level of care dependency, a difference was found between countries.

Dealing with behavioral and psychological symptoms of dementia: a general overview

Dealing with the behavioral and psychological symptoms of dementia (BPSD) is often complex. Given the controversy with regard to antipsychotics for behavioral problems in people with dementia, there has been a renewed emphasis on nonpharmacological interventions, with progress in the design of the relevant studies. Potential nonpharmacological interventions for BPSD are: cognitive training/stimulation, rehabilitative care, activities of daily living, music therapy, massage/touch, physical activity, education/training of professionals, and education and psychosocial support of informal caregivers. Use of antipsychotics in the management of BPSD is controversial due to limited efficacy and the risk of serious adverse effects, but credible alternatives remain scarce. The problem of chronic use of antipsychotics in nursing homes should be tackled. Discontinuation of antipsychotic medication in older individuals with BPSD appears to be feasible. Discontinuation efforts are needed to differentiate between patients for whom antipsychotics have no added value and patients for whom the benefits outweigh the risks.

Antipsychotic drug prescription rates among Dutch nursing homes: the influence of patient characteristics and the dementia special care unit

OBJECTIVES

To assess the differences in antipsychotic drug prescription rates in residents with dementia in dementia special care units (SCUs) of Dutch nursing homes, considering the differences in patient characteristics.

METHOD

As part of the Waalbed-II study, the data on antipsychotic drug use in 290 patients were collected and the Global Deterioration Scale (GDS) stage, type of dementia and behaviour (Cohen-Mansfield Agitation Inventory (CMAI)) were measured in 14 SCUs in nine nursing homes. A multilevel logistic regression model was used to assess the difference in antipsychotic drug prescription rates between dementia SCUs adjusted for age, gender, GDS stage, type of dementia and CMAI factor scores.

RESULTS

Two hundred and ninety residents met the inclusion criteria. Thirty-two per cent were prescribed an antipsychotic drug. Antipsychotic drugs were more often prescribed in patients with physically aggressive and non-aggressive behaviour and in patients with mixed dementia (vascular/Alzheimer's) than in patients with other types of dementia. Antipsychotic drug prescriptions significantly differed among the dementia SCUs. The odds of antipsychotic drug use for patients in the SCU with the highest prevalence of drug use were 2.76 (95% confidence interval (CI) 1.14-6.69) times as high as for the SCU with the lowest prevalence of drug use, taking the patient characteristics into account.

CONCLUSION

Antipsychotic drug use in nursing home residents with dementia is not only predicted by the type of dementia and patient behaviour, but it is independently associated with the dementia SCU at which the patient resides. This result indicates that antipsychotic drugs are not only prescribed for their clinical indications (agitation/aggression) but are associated with environmental factors that may reflect a specific nursing home prescribing culture.

Variability between nursing homes in prevalence of antipsychotic use in patients with dementia

BACKGROUND

Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics.

METHODS

A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health.

RESULTS

In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with a high prevalence of APD use behavioral symptoms were present in 62% of their patients. In facilities with medium APD use behavioral problems remained frequent (57%), and in facilities with low prevalence of APD use 54% of the patients had behavioral symptoms. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities.

CONCLUSIONS

There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicates potential inappropriate prescribing because of differences in institutional prescribing culture.

Patients with Korsakoff syndrome in nursing homes: characteristics, comorbidity, and use of psychotropic drugs

BACKGROUND

Very limited literature exists on the care and course of patients with Korsakoff syndrome (KS) living in long-term care facilities (LTCFs). Even less literature can be found on the pharmacological treatment of behavioral symptoms of KS. The purpose of the present study was to describe baseline characteristics, comorbidity, and the use of psychotropic drugs in institutionalized patients with KS.

METHODS

In this cross-sectional descriptive study, 556 patients were included living in ten specialized care units in Dutch nursing homes. Data were collected by means of a retrospective chart review.

RESULTS

The majority of patients were men (75%) and single (78%) with a mean age on admission of 56.7 years (SD 8.9, range 29.8-85.3). Mean length of stay was 6.0 years (SD 5.4, range 0.2-33.3). Sixty-eight percent of patients suffered from at least one somatic disease and 66% from at least one extra psychiatric disorder. One or more psychotropic drugs were prescribed to 71% of patients with a great variation in prescription patterns between the different nursing homes.

CONCLUSION

Patients with KS depending on long-term care usually have comorbidity in more than one domain (somatic and psychiatric). The indications for prescribing psychotropic drugs are in many cases unclear and it seems probable that they are often given to manage challenging behavior. Longitudinal studies on the evidence for this prescription behavior and possible alternatives are recommended.

The effects of abrupt antipsychotic discontinuation in cognitively impaired older persons: a pilot study

BACKGROUND

Antipsychotic use for behavioural and psychological symptoms of dementia (BPSD) is controversial. Guidelines advise to reduce antipsychotics given the adverse effects and limited efficacy, to limit dose and treatment duration as well as to undertake discontinuation.

METHODS

A pilot study with 40 hospitalised geriatric cognitively impaired patients, in which the effects of abrupt antipsychotic discontinuation were investigated, using neuropsychiatric inventory (NPI) scores before and one month after discontinuation. Withdrawal symptoms were monitored thrice a day with a checklist during five consecutive days.

RESULTS

Participants (n = 40) had a mean age of 84 years (range 67-95) and 53% were male. The total mean baseline NPI score was 21 (SD 12) with predominantly behavioural rather than psychological disturbances. After abrupt discontinuation, mild withdrawal symptoms were observed in 72% of the patients, with frequencies of symptoms peaking on day 2 (53%) and day 3 (48%). After one month, 31 patients (85%) were still off antipsychotics and improved on the majority of NPI domains, with a total mean NPI score decreasing from 18 (SD 13) to 12 (SD 8, p = 0.003). In the relapse group, there was no deterioration associated with the abrupt discontinuation and subsequent resumption of therapy with a total mean NPI score decreasing from 31 (SD 12) at baseline to 27 (SD 8) at one-month follow-up (p = 0.345).

CONCLUSION

Abrupt antipsychotic discontinuation appears to be feasible in older individuals with BPSD. Systematically performed discontinuation efforts in clinical practice are needed to differentiate between patients where antipsychotics have no added value and patients where the benefits outweigh the risks.

Clinical pharmacology in old persons

The epidemiological transition, with a rapid increase in the proportion in the global population aged over 65 years from 11% in 2010 to 22% in 2050 and 32% in 2100, represents a challenge for public health. More and more old persons have multimorbidities and are treated with a large number of medicines. In advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. In addition, pharmacotherapy may be complicated by difficulties with obtaining drugs or adherence and persistence with drug regimens. Safe and effective pharmacotherapy remains one of the greatest challenges in geriatric medicine. In this paper, the main principles of geriatric pharmacology are presented.

Effectiveness of Physio Acoustic Sound (PAS) therapy in demented nursing home residents with nocturnal restlessness: study protocol for a randomized controlled trial

Background

Many older people with neuropsychiatric disorders such as Alzheimer's disease and frontotemporal dementia suffer from sleeping problems and often show nocturnal restlessness. Professionals and informal carers face considerable problems in solving these problems. Attempts to diminish these problems with medication in a safe and responsible manner have proven hardly effective or not effective at all. Therefore, nowadays the focus lies more on non-pharmacological solutions, for example by influencing environmental factors. There are indications that treatment with low-frequency acoustic vibrations, that is Physio Acoustic Sound (PAS) therapy, has a positive effect on sleeping problems. Therefore we study the effectiveness of PAS therapy in demented patients with nocturnal restlessness.

Methods

In a randomized clinical trial, 66 nursing home patients will be divided into two groups: an intervention group and a control group. For both groups nocturnal restlessness will be measured with actiwatches during a period of six weeks. In addition, a sleep diary will be filled in.

For the intervention group the baseline will be assessed, in the first two weeks, reflecting the existing situation regarding nocturnal restlessness. In the next two weeks, this group will sleep on a bed identical to their own, but with a mattress containing an in-built PAS device. As soon as the patient is lying in bed, the computer programme inducing the vibrations will be switched on for the duration of 30 min. In the last two weeks, the wash-out period, the measurements of the intervention group are continued, without the PAS intervention.

During the total study period, other relevant data of all the implied patients will be recorded systematically and continuously, for example patient characteristics (data from patient files), the type and seriousness of the dementia, occurrence of neuropsychiatric symptoms during the research period, and the occurrence of intermittent co-morbidity.

Discussion

If PAS therapy turns out to be effective, it can be of added value to the treatment of nocturnal restlessness in demented patients. Non-pharmacological PAS therapy is not only safe and patient-friendly, but it can also be widely used in a simple and relatively inexpensive way, both in institutions such as nursing homes and residential homes for the elderly, and at home. Ultimately, this may lead to a decrease in the frequent and still common use of psychotropic drugs. In addition, care needs of demented patients also may decrease as well as the number of preventable admissions to care institutions.

Trial registration

Netherlands Trial Register (NTR): NTR3242

Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers

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.

Course of neuropsychiatric symptoms in residents with dementia in nursing homes over 2-year period

OBJECTIVE

To determine the course of neuropsychiatric symptoms (NPSs) in nursing home residents with dementia and to determine their variability across diagnosis.

DESIGN

Prospective cohort study over 2 years.

SETTING

Fourteen dementia special care units in nine nursing homes in The Netherlands.

PARTICIPANTS

One hundred seventeen residents with dementia.

MEASUREMENTS

NPSs were measured using the Neuropsychiatric Inventory-Nursing Home version (NPI-NH).

RESULTS

The majority of residents had moderately severe to severe dementia. All but a few residents (97%) showed any NPS, and co-occurrence of NPSs was high. Agitation, irritability, and aberrant motor behavior were the most prevalent over the 2 years. Depression and anxiety as well as NPI total score decreased over time, whereas apathy tended to increase. Agitation and aberrant motor behavior were the most persistent symptoms. In asymptomatic residents, highest incidence rates were found for apathy, aggression/ agitation, irritability, and aberrant motor behavior. Anxiety and apathy were more prevalent in Alzheimer disease (AD) compared with vascular disease (VaD); vice versa, aggression and depression were more prevalent in VaD. Differences in change over time between AD and VaD were found for irritability and disinhibition.

CONCLUSION

This is the first study examining the 2-year course of NPSs in a large group of nursing home residents with dementia. Virtually all residents demonstrated and/or developed NPSs. Although affective symptoms decreased, apathy tended to increase. Agitated behaviors were particularly persistent. Our data may contribute to improve mental healthcare for demented nursing home residents.

Top cited papers in International Psychogeriatrics: 6b. Behavioral disorders and caregivers' reaction in Taiwanese patients with Alzheimer's disease

The behavioral and psychological symptoms of dementia (BPSD) are common and serious problems that affect the quality of life of the patients who experience such symptoms as well as their caregivers (Matsui et al., 2006). BPSD present a major challenge in the medical management of cognitively impaired patients. Our paper entitled “Behavioral disorders and caregivers’ reaction in Taiwanese patients with Alzheimer's disease” (hereafter referred to as the “paper”) (Fuh et al., 2001) has been cited widely, reflecting the importance of these clinical issues and the growing international interest in studies of BPSD.