Factors associated with appropriate psychotropic drug prescription in nursing home patients with severe dementia

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use Among Assisted Living Residents

Objective To test the impact of the Function Focused Care Intervention on use of psychotropic medications and opioids over a 12-month period in assisted living residents. Setting The study included 794 residents from 85 general assisted living communities in the United States. The general assisted living communities that had at least 25 beds and 10 residents per community were enrolled. Results There was no significant difference in the treatment groups regarding medication use except for a decrease in opioid use at 4 months (P = 0.03). In the full sample there was a significant increase in use of benzodiazepines from baseline to 12 months (P = 0.04) and an increase in the use of antipsychotics between 4 and 12 months (P = 0.04). Conclusion Function-focused care does not increase the need for psychotropic medications or opioids and may help decrease the need for opioids. Further, we recommend the involvement of a pharmacy consultant to provide oversight and medication reviews for all residents in assisted living to consider deprescribing, if possible, for potentially unnecessary use of psychotropic medications or opioids.

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis

OBJECTIVES

Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia.

SETTING AND PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy.

RESULTS

Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07).

CONCLUSIONS

Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Can the PROPER intervention reduce psychotropic drug prescription in nursing home residents with dementia? Results of a cluster-randomized controlled trial

OBJECTIVES

To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms.

DESIGN

A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months.

SETTING

Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands.

PARTICIPANTS

Three hundred eighty nursing home residents with dementia.

INTERVENTION

The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation.

MEASUREMENTS

Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms.

RESULTS

The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months (p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months.

CONCLUSIONS

The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms.The study has been registered in The Netherlands Trial Register (NTR3569).

Current Psychotropic Medication Use and Contributing Factors Among Nursing Home Residents With Cognitive Impairment

This study described current use and predictors of psychotropics among residents with moderate to severe cognitive impairment. This was a secondary data analysis using baseline data from the first 341 residents in an ongoing trial. Predictive measures included age, gender, race, depressive symptoms, agitation, resistiveness to care, depression, cognition, pain, comorbidities, facility factors, and state. Overall 63% (n = 211) received at least one psychotropic medication, 16% (n = 52) an anti-seizure medication, 23% (n = 77) an anxiolytic, 30% (n = 99) an antidepressant, 2% (n = 8) a sedative hypnotic, 28% (n = 93) an antipsychotic medication, and 9% (n = 29) an opioid. Testing of models explained 9% to 15% of psychotropic medication use. There were high rates of psychotropic medication use and a limited association between demographic factors, behavioral symptoms, and psychotropic medication use. Continued research is needed to explore the impact of deprescribing, person-centered behavioral interventions, and beliefs of providers on psychotropic medication use.