Longitudinal Study of Psychotropic Drug Use by Elderly Nursing Home Residents

Antidepressant prescribing patterns in the nursing home: second-generation issues revisited

INTRODUCTION

The object of this study was to provide an updated evaluation of the quality of antidepressant management and prescribing patterns in nursing homes in the context of organizational and resident factors.

DESIGN

Pearson correlation and chi-square analyses were conducted using information gathered from random nursing home charts.

SETTING

Nursing home facilities in and around the Louisville, KY, metropolitan area (n = 10).

PARTICIPANTS

Chart reviews were randomly chosen for 20% of long term care resident records in participating homes (n = 209).

MEASUREMENTS

Demographic information, documentation of depression diagnoses, and antidepressant prescribing patterns were evaluated using the Quality of Depression Management and Antidepressant Prescribing rating scale and information found in the Minimum Data Set 2.0.

RESULTS

Of the sample, 59.8% was prescribed antidepressants at the time of the chart review; 205 chart reviews indicated the absence or presence of a depression diagnosis. For those with documented depression diagnoses (n = 126), nearly one-quarter were not prescribed antidepressants. Of 79 chart reviews indicating no depression diagnosis, nearly a third were receiving an antidepressant. Documentation related to changes in dosing, the presence or absence of side effects, or reasons for continuation were suboptimal.

CONCLUSION

Discrepancy between antidepressant prescribing and the presence/absence of depression diagnoses continue to exist for nursing home residents. The quality of antidepressant documentation in nursing home charts continues to be inadequate. Future research should aim to explore possible solutions to these discrepancies and deficiencies in documentation.

The Association of Inappropriate Drug Use with Hospitalisation and Mortality

BACKGROUND AND OBJECTIVE

Inappropriate prescribing is an important and possibly preventable risk factor for adverse drug reactions (ADRs) in the elderly, and hospital-based studies have shown that a large proportion of admissions is a result of ADRs. However, little is known about how inappropriate drug use (IDU) affects the elderly at the population level. The aim of this study was to explore possible associations of IDU with acute hospitalisation and mortality in an elderly population during 3 years of follow-up.

PATIENTS AND METHODS

Data from a rural, population-based, longitudinal cohort study within the Kungsholmen Project, Sweden, were used. 785 participants, > or=75 years of age, had complete data on drug use and selected covariates collected during baseline investigation from 1995 to 1998, and were included in the study. Hospitalisation and mortality data during 3 years after inclusion were collected. IDU was assessed at baseline using consensus-based criteria applicable to available data (derived from Beers' criteria, Canadian criteria and clinical indicators of drug-related morbidity in older adults) with the addition of potentially dangerous drug duplication and additional potentially hazardous drug-drug interactions. IDU was defined as presence of at least one inappropriate drug regimen according to the study criteria. Logistic regression and proportional hazard models were used, respectively, to study the association of IDU with hospitalisation and mortality.

RESULTS

Drugs were used on a regular or 'as needed' basis by 91.6% of the study population, with a mean of 4.4 drugs per person. IDU was common, with a prevalence of 18.6% and was associated with increased risk of at least one acute hospitalisation in community-living elderly, after adjustment for age, sex, education, comorbidity, dependency in activities of daily living (ADL) and smoking. The odds ratio was 2.72 (95% CI 1.64, 4.51). No association with mortality was found, after adjustment for age, sex, housing, education, comorbidity, ADL-dependency, smoking and body mass index.

CONCLUSION

Polypharmacy and IDU are common among the elderly and IDU is associated with acute hospitalisation in community-living elderly. Although causality cannot be established with this study design, the results are consistent with the high prevalence of drug-related hospital admissions found in hospital-based studies. Our results indicate that it is desirable with current knowledge, to reduce IDU through information to physicians and careful prescribing.

Initiation and evaluation of a research-based fall prevention program

This study evaluated the effectiveness of research-based interventions in preventing falls. The interventions were based on research studies, experts' opinions, and a pilot study. Thirteen units (72%) had reduced fall rates. The fall rate two years before (O = 7.07; SD = 1.7) and two years after (O = 6.33; SD = 1.731) the intervention was significantly different at p < 0.003. Sixteen patients who fell were at risk (fall assessment score = 17.4 +/- 5.3) and had a history of falls. The most common site for falls was at the bedside. Most falls occurred during walking, climbing over the siderails, and accidentally rolling out of bed. Thus, a research-based fall prevention is effective in reducing falls.

Benzodiazepine use among elderly patients presenting at the emergency room

This study evaluated the prevalence of benzodiazepine intake by elderly patients presenting at the emergency room of a university hospital. Of 388 patients, 42.5% used one or more benzodiazepine (BZD) drugs in the week prior to admission. There were significantly more women among the BZD users (P < 0.05). Mean duration of intake was long (62 months), but daily dosage was adjusted to age. Of the BZD using patients, 27% took a BZD with long elimination half life. No relationship was found between the BZD intake and the occurrence of falls. Fallers were significantly older (P = 0.019) and were more often women (P = 0.046).

Alcohol and drug misuse in the nursing home

The misuse of alcohol or drugs is a common and frequently neglected problem among nursing home residents. The misuse of prescription medications is particularly prevalent, but tobacco, alcohol, and illicit drugs are all subject of misuse by nursing home residents. This article reviews the epidemiologic and clinical aspects of substance misuse in nursing homes, including alcohol, illicit drugs, tobacco, and pyscho-active medications. Regulations regarding the prescription of psycho-active drugs in nursing homes is also discussed.

The use of medicines with anticholinergic effects in older people: a population study in an urban area of Sweden

OBJECTIVE

To investigate the use of medicines with anticholinergic properties among older people in an urban population in Sweden.

DESIGN

A cross-sectional survey.

SETTING

Ordinary homes, sheltered accommodations, nursing homes, and geriatric departments.

PARTICIPANTS

All residents aged 75 and older in a district of Stockholm, Sweden.

MEASUREMENTS

Structured interviews with older persons, their relatives and/or health care personnel; prescription forms; medical records.

RESULTS

The overall use of medicines with anticholinergic effects was comparatively low. Doses of these medicines were also generally low. Concurrent use of several such medicines was uncommon. The most prevalent therapeutic/pharmacological group was neuroleptics. In contrast, antidepressants were used by few older people. The prevalence of medicines with anticholinergic effects was highest at institutions, where neuroleptics were frequent and use of low-potency neuroleptics was not uncommon.

CONCLUSION

Our results indicate that the risk of anticholinergic side effects may be quite low in the present population as a whole. However, there may be grounds for revising the therapy in institutions, where the use of neuroleptics was shown to be high and low-potency neuroleptics, known to have a higher incidence of anticholinergic side effects, were not avoided.

The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes

OBJECTIVES

The purpose of this study was to examine prevalence rates of psychotropic drug use by elderly nursing home residents 3 years before and 1 year after implementation of the 1987 Omnibus Budget Reconciliation Act drug regulations throughout the United States on October 1, 1990.

METHODS

A cohort study was conducted of elderly nursing home residents, for each of 4 study years (approximately 33,000 residents per year), of all nursing homes (n = 372) in Minnesota certified by Medicare and Medicaid. Data included (1) health status assessment and psychotropic drug use; (2) nursing home and care characteristics; and (3) county geographic and population characteristics.

RESULTS

Annual rates of antipsychotic drug use declined by one third over the 4-year period (23%, 22%, 19%, and 15% from 3 years before enforcement of the regulations to 1 year afterward). All differences were statistically significant. Antianxiety use rates were 11%, 12%, 12%, and 12%, respectively, and antidepressant use rates were 14%, 15%, 16%, 16%, respectively, for the 4 years. The latter two classes of drugs were not affected directly by the regulations.

CONCLUSIONS

Declines in the rates of antipsychotic drug use appear to be associated with anticipation of the regulations the year before and as the result of the regulations the year after the October 1990 implementation. A hypothesized medication shift to benzodiazepine drugs was not observed.

Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents

OBJECTIVE

To determine the impact of OBRA 87 on antipsychotic prescribing in a 485-bed nursing home.

DESIGN

Twelve-month retrospective cohort review of medical charts, medication administration records, and computerized pharmacy records.

MEASUREMENTS

The percent of residents by diagnostic group and antipsychotic use.

MAIN RESULTS

An attempt was made to stop or lower the dose of antipsychotic in 75% of the 107 residents studied. Antipsychotics were stopped in 45% of residents with a dementia-only diagnosis and 25% of residents with a psychiatric diagnosis (P < 0.05). Residents with documented symptoms appropriate for the use of antipsychotic, per OBRA 87, were significantly less likely to have their antipsychotic stopped. Twenty percent of residents whose antipsychotic was either stopped or its dose lowered had the agent restarted or its dose increased.

CONCLUSION

OBRA 87 had a significant impact on antipsychotic use in this facility.