Prescribing Trends and Associated Outcomes of Antiepileptic Drugs and Other Psychotropic Medications in US Nursing Homes: Proposal for a Mixed Methods Investigation

BACKGROUND

Pilot data suggest that off-label, unmonitored antiepileptic drug prescribing for behavioral and psychological symptoms of dementia is increasing, replacing other psychotropic medications targeted by purposeful reduction efforts. This trend accelerated during the COVID-19 pandemic. Although adverse outcomes related to this trend remain unknown, preliminary results hint that harms may be increasing and concentrated in vulnerable populations.

OBJECTIVE

Using a mixed methods approach including both a retrospective secondary data analysis and a national clinician survey, this study aims to describe appropriate and potentially inappropriate antiepileptic and other psychoactive drug prescribing in US nursing homes (NHs), characteristics and patient-oriented outcomes associated with this prescribing, and how these phenomena may be changing under the combined stressors of the COVID-19 pandemic and the pressure of reduction initiatives.

METHODS

To accomplish the objective, resident-level, mixed-effects regression models and interrupted time-series analyses will draw on cohort elements linked at an individual level from the Centers for Medicare and Medicaid Services' (CMS) Minimum Data Set, Medicare Part D, Medicare Provider Analysis and Review, and Outpatient and Public Use Files. Quarterly cohorts of NH residents (2009-2021) will incorporate individual-level data, including demographics; health status; disease variables; psychotropic medication claims; comprehensive NH health outcomes; hospital and emergency department adverse events; and NH details, including staffing resources and COVID-19 statistics. To help explain and validate findings, we will conduct a national qualitative survey of NH prescribers regarding their knowledge and beliefs surrounding changing approaches to dementia care and associated outcomes.

RESULTS

Funding was obtained in September 2022. Institutional review board exemption approval was obtained in January 2023. The CMS Data Use Agreement was submitted in May 2023 and signed in March 2024. Data access was obtained in June 2024. Cohort creation is anticipated by January 2025, with crosswalks finalized by July 2025. The first survey was fielded in October 2023 and published in July 2024. The second survey was fielded in March 2024. The results are in review as of July 2024. Iterative survey cycles will continue biannually until December 2026. Multidisciplinary dissemination of survey analysis results began in July 2023, and dissemination of secondary data findings is anticipated to begin January 2025. These processes are ongoing, with investigation to wrap up by June 2027.

CONCLUSIONS

This study will detail appropriate and inappropriate antiepileptic drug use and related outcomes in NHs and describe disparities in long-stay subpopulations treated or not treated with psychotropics. It will delineate the impact of the pandemic in combination with national policies on dementia management and outcomes. We believe this mixed methods approach, including processes that link multiple CMS data sets at an individual level and survey-relevant stakeholders, can be replicated and applied to evaluate a variety of patient-oriented questions in diverse clinical populations.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64446.

Lessons learned from CMS's National Partnership to Improve Dementia Care: a thematic synthesis of multiple stakeholder-engaged studies

BACKGROUND

Antipsychotic prescribing in United States nursing homes (NHs) has decreased since the Center for Medicare & Medicaid Service debuted the National Partnership to Improve Dementia Care in Nursing Homes (NP); however, reductions have stalled. To help explain persistent antipsychotic use despite the NP's reduction efforts, the perspectives of diverse NP stakeholders were qualitatively assessed. This study aimed to re-evaluate these individual perspectives in combined thematic synthesis to discover NP improvement opportunities undetectable in single stakeholder assessments.

METHODS

Thematic synthesis. Through immersive crystallisation, original source coding results were organised into related descriptive themes. Similarities and differences were identified, and descriptive themes were regrouped into new, increasingly abstract, analytical themes. This cycle continued until variances were resolved and analytic themes sufficiently described and explained all initial descriptive themes.

RESULTS

Three analytic themes emerged regarding NP improvement opportunities. The NP's positive impacts would be augmented by: (i) a deeper and expanded appreciation of stakeholder perspectives; (ii) more urgent and rapid adaptation to unintended adverse outcomes; and (iii) greater recognition of the contextual and environmental factors influencing decisions to prescribe or not prescribe antipsychotic medications. Stakeholder groups described: perspectives they perceived as inadequately considered by the NP; insufficient NP engagement with the stakeholders capable of creating evidenced, affordable, and available non-pharmacologic therapies for dementia symptoms; recognition that dementia interventions effective for a specific individual at a specific time in a specific community may not generalise; and diverse ongoing undesirable outcomes from NP policies that could be mitigated by NP modifications.

CONCLUSIONS

The NP has done much to advance dementia care in NHs. Notwithstanding, these results suggest the NP would only be improved through increasingly comprehensive inclusion of stakeholder perspectives, enhanced incorporation of individual contextual factors, and a more decisive mechanism for ongoing and continual adaptation.

Understanding Long-Stay Gabapentin Use Increases: A National Nursing Home Clinician Survey on Prescribing Intent

OBJECTIVES

Explore the indications for long-stay gabapentin use and elucidate the factors spurring the rapid increase in gabapentin prescribing in nursing homes (NHs).

METHODS

National cross-sectional survey of NH prescribers distributed anonymously using SurveyMonkey. Sampling for convenience was obtained through crowdsourcing, leveraging collaborations with NH clinician organizations. Developed by a multidisciplinary team, pilot data/existing literature informed survey content.

RESULTS

A total of 131 surveys completed. Participants: 71% white, 52% female, 71% physicians. Off-label gabapentin prescribing was ubiquitous. Nearly every clinician used gabapentin for neuropathic pain, most for any form of pain. Many clinicians also prescribe gabapentin to moderate psychiatric symptoms and behaviors. Clinicians' prescribing was influenced by opioid, antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative.

CONCLUSIONS

Off-label gabapentin increases are closely linked to opioid reduction efforts as more NH clinicians utilize gabapentin as an unmonitored opioid alternative. Our results highlight, however, the less recognized significance of long-stay prescribing for psychiatric symptoms and the similar contribution of psychotropic reduction initiatives, a phenomenon warranting further scrutiny.

CLINICAL IMPLICATIONS

Clinicians perceive gabapentin as safer than the drugs it is replacing. Whether this is true remains unclear; the individual- and population-level risks of increased gabapentin use are largely unknown.

Pharmacist-led telehealth deprescribing for people living with dementia and polypharmacy in primary care: A pilot study

BACKGROUND

People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed.

METHODS

A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS).

RESULTS

69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control.

CONCLUSION

Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD.

Healthcare professionals' experiences with the use of antipsychotics in dementia

Background

Antipsychotics are commonly administered to nursing home residents with dementia, despite the associated risk of severe adverse events.

Objective

This study aimed to explore healthcare professionals' experiences in caring for nursing home residents with dementia, with a focus on rationales behind the use of antipsychotics.

Method

Twelve semi-structured interviews with healthcare professionals' from Danish nursing homes were conducted and analyzed using the method Systematic Text Condensation.

Results

Nonpharmacological interventions were reported as the primary approach to care and the first-choice treatment for behavioral and psychological symptoms of dementia (BPSD). Use of antipsychotics was considered to serve as a last resort, reserved for residents with severe symptoms. However, most informants preferred a more limited use. The study identified four main barriers to reduce the use of antipsychotics: "Scarcity of resources", "Perceiving antipsychotic use to provide relieve", "Reluctance towards deprescribing" and "Limited access to medical counseling", and three potential enablers: "Updating knowledge and nonpharmacological competencies", "Management support and clear procedures" and "Regularity in interdisciplinary collaboration".

Conclusion

The treatment and care were reported as primarily following guidelines in BPSD. Several barriers were perceived to challenge the healthcare professionals' preference of limited use of antipsychotics. To further reduce the use, this study highlights the importance of understanding the adverse effects caused by limited resources, enhancing employee knowledge and competencies and ensuring regular interprofessional collaboration for assessing and reassessing the need to use antipsychotics.

Understanding Pandemic Increases in Long-Stay Psychotropic Prescribing for Dementia Symptoms: A Survey of Nursing Home Clinicians

Objective: To explore the perceptions of nursing home (NH) clinicians regarding factors underpinning known increases in psychotropic prescribing over the COVID-19 pandemic. Methods: Three iterative online surveys were fielded to Virginia NH prescribing clinicians (11/2021-6/2022) to assess their perspectives regarding factors driving pandemic increases in NH psychotropic use. Existing literature and emerging survey data informed survey content. Sampling was for convenience and achieved through crowdsourcing, leveraging collaborations with Virginia NH clinician professional organizations. Results: A total of 89 surveys were collected. Clinicians noted simultaneous surging of dementia symptoms with decreased availability of non-pharmacologic measures to remedy them, leading to increased prescribing of all psychotropics. Staff shortages and turnover, isolation from family and community, and personal protective equipment protocols were identified as key pandemic factors contributing to this mismatch. Conclusions: Virginia NH clinicians explicitly linked increased NH psychotropic prescribing to known pandemic phenomena, associations previously hypothesized, but not, to our knowledge, directly confirmed.

BPSDiary study protocol: a multi-center randomized controlled trial to compare the efficacy of a BPSD diary vs. standard care in reducing caregiver's burden

Behavioral and Psychological Symptoms of Dementia (BPSD) are a heterogeneous set of psychological and behavioral abnormalities seen in persons with dementia (PwD), significantly impacting their quality of life and that of their caregivers. Current assessment tools, such as the Neuropsychiatric Inventory (NPI), are limited by recall bias and lack of direct observation. This study aims to overcome this limitation by making caregiver reports more objective through the use of a novel instrument, referred to as the BPSDiary. This randomized controlled trial will involve 300 caregiver-PwD dyads. The objective is to evaluate whether the use of the BPSDiary could significantly reduce caregiver burden, assessed using the Zarit Burden Interview (ZBI), compared to usual care. The study will include adult PwD, caregivers living with or close to the patient, and BPSD related to the HIDA (hyperactivity, impulsivity, irritability, disinhibition, aggression, agitation) domain. Caregivers randomized to the intervention arm will use the BPSDiary to record specific BPSD, including insomnia, agitation/anxiety, aggression, purposeless motor behavior, and delusions/hallucinations, registering time of onset, severity, and potential triggers. The primary outcome will be the change in ZBI scores at 3 months, with secondary outcomes including changes in NPI scores, olanzapine equivalents, NPI-distress scores related to specific BPSD domains, and caregiver and physician satisfaction. The study will be conducted in 9 Italian centers, representing diverse geographic and sociocultural contexts. While potential limitations include the relatively short observation period and the focus on specific BPSD disturbances, the BPSDiary could provide physicians with objective data to tailor appropriate non-pharmacological and pharmacological interventions. Additionally, it may empower caregivers by encouraging reflection on BPSD triggers, with the potential to improve the quality of life for both PwD and their caregivers.

Trial registry

NCT05977855.

A systematic review of quantitative studies exploring staff views on antipsychotic use in residents with dementia in care homes

BACKGROUND

Despite significant warnings of adverse effects, antipsychotics continue to be prescribed for managing the behavioural and psychological symptoms of dementia (BPSD) in care homes. Information provided by staff working within care homes is a factor that can influence prescribing decisions in residents with BPSD.

AIM

The review aimed to capture care home staff views towards antipsychotics for residents with BPSD and separately analyse tools utilized in the studies, mapping them onto the theory of planned behaviour (TPB).

METHOD

A comprehensive literature search published in ten databases was conducted between May and July 2020 and updated in July 2021. Studies published in full with no date restriction were included and quality assessed using CROSS checklist. A thematic framework approach was applied to extract data and study tools which were then mapped onto the TPB.

RESULTS

Fourteen studies (2059 participants) were included. Findings identified four overarching themes: attitudes toward antipsychotics (e.g. antipsychotics as an appropriate strategy and effectiveness); barriers to deprescribing (e.g. lower staff education, lack of resources and time, poor medication reviews); measures implemented (e.g. nonpharmacological interventions, medication reviews); and perceived needs of staff (e.g. need for training, financial or clinical support). Identified tools addressed seven but not all components of TPB namely, behavioural, normative and control beliefs, attitude, perceived behavioural control, intention and behaviour.

CONCLUSION

The positive attitudes toward antipsychotics, the identified barriers to deprescribing and the existing tools not addressing all components of the TPB provide the impetus for further research.

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Importance

Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.

Objective

To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.

Design, Setting, and Participants

In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.

Exposure

Incident dementia diagnosis.

Main Outcomes and Measures

The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.

Results

The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).

Conclusions and Relevance

In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

Person-Centred, Culturally Appropriate Music Intervention to Improve Psychological Wellbeing of Residents with Advanced Dementia Living in Australian Rural Residential Aged Care Homes

This quasi-experimental, nonrandomized intervention study reports the effect of person-centred, culturally appropriate music on psychological wellbeing of residents with advanced dementia in five rural residential aged care homes in Australia. Seventy-four residents attended in person-centred music sessions and culturally appropriate group sessions. Interest, response, initiation, involvement, enjoyment, and general reactions of the residents were assessed using the Music in Dementia Assessment Scale (MiDAS), and interviews and focus groups were conducted with aged care staff and musicians. The overall effect of person-centred sessions at two-time points were: during the intervention-351.2 (SD 93.5); and two-hours post intervention-315.1 (SD 98.5). The residents presented a moderate to high level of interest, response, initiation, involvement, and enjoyment during the session and at post-intervention. However, the MiDAS sub-categories' mean scores differed between the time-points: interest (t₅₉ = 2.8, p = 0.001); response (t₅₉ = 2.9, p = 0.005); initiation (t₅₉ = 2.4, p = 0.019); and involvement (t₅₉ = 2.8, p = 0.007), indicating a significant decline in the effect of person-centred music over time. Interestingly, during the period of time, most of the residents were observed with no exhibitions of agitation (87.5%), low in mood (87.5%), and anxiousness (70.3%), and with a presentation of relaxation (75.5%), attentiveness (56.5%), and smiling (56.9%). Themes from qualitative data collected regarding culturally appropriate group music sessions were behavioural change, meaningful interaction, being initiative, increased participation, and contentment. The findings suggest that the integration of music into care plans may reduce the residents' agitation and improve their emotional wellbeing in rural aged care homes.

The relationship between daily stressors, social support, depression and anxiety among dementia family caregivers: a micro-longitudinal study

Objectives: This study aimed to examine the relationships between daily stress, social support, and the mental health of dementia family caregivers.Methods: A national sample of family caregivers (N = 165) completed daily diary surveys over 21 days (n = 2,841). Mixed-level models were used to examine the daily odds of experiencing depression and anxiety-related symptoms when risk factors, such as the stress of managing behavioral symptoms of dementia (BSDs) exhibited by the person living with dementia, and protective factors, such as social support, were reported on a given day.Results: Dementia caregivers were more likely to report depression and anxiety-related symptoms when BSDs were present and perceived as more bothersome than usual. Specific BSDs, including restless behaviors and intense emotions, were also found to increase the daily odds of experiencing depression and anxiety symptoms. The daily odds of depression symptoms decreased on days when caregivers reported receiving instrumental support, while the daily odds of anxiety symptoms increased on days when caregivers reported receiving emotional support.Conclusions: The daily odds of experiencing depression and anxietyvary based on the presence of specific BSDs and social support. These findings support the need for targeted interventions to improve the day-to-day well-being of dementia family caregivers.

The longitudinal patterns of psychotropic drug prescriptions for subpopulations of community-dwelling older people with dementia: electronic health records based retrospective study

BACKGROUND

Studies focusing on patterns of psychotropic drug prescriptions (PDPs) for subpopulations of community-dwelling older people with dementia are lacking.

OBJECTIVE

The aim of this study was to identify the longitudinal patterns of PDPs in subpopulations.

METHODS

This retrospective study used electronic health records from general practitioners (GPs) in the Netherlands. People (N = 1278) firstly diagnosed with dementia between 2013 and 2015, aged 65 years or older, were selected and categorized into four subpopulations: community-dwelling (CD) group throughout follow-up, ultimately admitted to nursing homes (NH) group, ultimately died (DIE) group, and ultimately deregistered for unclear reasons (DeR) group. Generalised estimating equations were used to estimate the patterns of psychotropic drug prescriptions, after the diagnosis of dementia for a five-year follow-up, and 0-3 months before institutionalisation or death.

RESULTS

Over the five-year follow-up, antipsychotic prescriptions increased steadily in CD (OR = 1.07 [1.04-1.10]), NH (OR = 1.10 [1.04-1.15]), and DIE (OR = 1.05 [1.02-1.08]) groups. Similarly, prescriptions of antidepressants also showed upward trends in CD (OR = 1.04 [1.02-1.06]), NH (OR = 1.10 [1.02-1.18]), and DIE (OR = 1.04 [1.00-1.08]) groups. The other psychotropic drugs did not show clear changes over time in most of the subpopulations. In the three months before institutionalisation, antipsychotic prescriptions increased (OR = 2.12 [1.26-3.57]) in the NH group compared to prior periods. Likewise, before death, prescriptions of antipsychotics (OR = 1.74 [1.28-2.38]) and hypnotics and sedatives (OR = 2.11 [1.54-2.90]) increased in the DIE group, while anti-dementia drug prescriptions decreased (OR = 0.42 [0.26-0.69]).

CONCLUSIONS

After community-dwelling older people are diagnosed with dementia, all subpopulations' prescriptions of antipsychotics and antidepressants increase continuously during the follow-up. While we cannot judge whether these prescriptions are appropriate, GPs might consider a more reluctant use of psychotropic drugs and use alternative psychosocial interventions. Additionally, antipsychotic prescriptions rise considerably shortly before institutionalisation or death, which might reflect that older people experience more neuropsychiatric symptoms during this period.

Nursing Home Residents' Relocation to Another Facility: an Exploratory Study of Family Caregiver Experiences

Over time, family caregivers for older adults may face care transitions for their loved ones. The move from home to residential care facility is a much-studied transition. Yet we know little of family caregiver experiences when their loved ones move from one facility to another. We interviewed family caregivers of nursing home residents and inquired about caregiver experiences in prior facilities and factors that prompted moving to another facility. Our analysis identified three themes: 1) A precursor of moving to another facility was caregivers' assessment of poor fit between their family member and the facility; 2) Executing a move was demanding for the caregiver in instrumental and emotional ways; 3) Once in the new facility, caregivers adapted their caregiving to the capacity of the new facility and fostered resident-facility fit (not interfering with good care and supplementing facility care). Findings suggest that family caregivers continually assess and respond to emerging problems with resident-facility fit, which sometimes escalate and necessitate a move to another facility. Nursing home social workers are well-positioned to help families address emerging care problems, so they do not escalate. Doing so can promote care continuity, which benefits both the resident and the family caregiver.

Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey

BACKGROUND

It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications.

METHODS

A cross-sectional survey was conducted from March-April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities.

RESULTS

Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02-2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05-2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39-1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48-0.91]).

CONCLUSIONS

Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.

Community, Social, and Facility Factors and Long-stay Antipsychotic Use

OBJECTIVES

Compare Virginia nursing homes in the top- and bottom-quintiles of antipsychotic use for variation in community, social, and facility factors.

METHODS

2018 CMS data ascertained Virginia nursing homes in the top and bottom quintiles for antipsychotic use. The Virginia Health Department provided social determinant of health (SDOH) statistics for each facility's county/city while claims identified facility demographics. Chi square and independent two-sample t-tests compared quintiles for regional, social, and demographic differences.

RESULTS

Quintiles averaged 3000 residents and 56 facilities. Facilities with the lowest rates of antipsychotic use were more likely to be privately owned and had fewer African-American and minority residents and more white residents. All 18 SDOH statistics were superior for the communities of facilities with the lowest antipsychotic rates. Nine of these differences were statistically significant, including the aggregated "Health Opportunity Index."

CONCLUSIONS

The antipsychotic prevalence rate for facilities in the top-quintile of antipsychotic use is fivefold the bottom-quintile's rate. Antipsychotic prescribing in nursing homes is associated with regional, demographic, and social factors not addressed by existing antipsychotic reduction measures, with vulnerable populations at greatest risk.

CLINICAL IMPLICATIONS

The efficacy of measures aimed at curbing long-stay antipsychotic prescribing could be improved by addressing SDOH including economic opportunities.

Should antipsychotics be used for the management of agitation and psychosis in dementia?

Agitation and psychosis are two common distressing symptoms of dementia. The results of this issue's Cochrane Corner review suggest that, if a pharmacological approach is required, the use of risperidone and other atypical antipsychotics for the purpose of managing these symptoms seems questionable. Furthermore, typical antipsychotics, haloperidol in particular, might have a greater impact on agitation and psychosis than already recognised. This commentary critically appraises the evidence on the efficacy of typical and atypical antipsychotics for agitation and psychosis in dementia.

Nonpharmacological Interventions for Management of Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities by Direct Caregivers: A Systematic Review

Behavioral and psychological symptoms of dementia (BPSD) are a worldwide problem. Estimates indicate approximately 96% of persons with dementia (PWD) exhibit BPSD that are directly associated with long-term care (LTC) placement and approximately one half of these persons experience symptoms classified as severe. BPSD are associated with lost days of work, high turnover, and poor job satisfaction for direct caregivers. Nonpharmacological interventions (NPIs) are effective for management of BPSD when used properly. NPIs are more likely to be used by direct caregivers who are knowledgeable about and have confidence in BPSD effectiveness. Various training techniques promote development of this self-efficacy. The current systematic review synthesizes evidence concerning the use of NPIs for management of BPSD by direct caregivers in LTC settings. Gaps in the literature include evaluation of positive impact of NPIs on PWD and behavior precedent factors. This review emphasizes the need for development and provision of quality NPI education for direct caregivers in LTC settings. [Journal of Gerontological Nursing, 48(7), 18-23.].

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia

OBJECTIVES

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.

DESIGN

A mixed-methods study was performed.

SETTING AND PARTICIPANTS

During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.

METHODS

Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.

RESULTS

Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Attitudes toward deprescribing among older adults with dementia in the United States

BACKGROUND

People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD.

METHODS

This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking.

RESULTS

The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04).

CONCLUSIONS

A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review

Background

psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.

Methods

a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.

Results

overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.

Conclusion

psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Understanding the Effects of Music Care on the Lived Experience of Isolation and Loneliness in Long-Term Care: A Qualitative Study

This qualitative study aims to understand the lived experience of residents and other stakeholders during the implementation of a comprehensive music program in long-term care. It was conducted using a subset of 15 long-term care homes from the Room 217 Foundation Music Care Partners (MCP) “Grow” study in Ontario, Canada. The MCP program’s approach to music delivery uses therapeutic music practices such as “music care” to improve the care experience for caregivers and residents in long-term care homes. Thirty-two participants were interviewed, including staff, volunteers, and residents. Data were transcribed and analyzed using a modified grounded theory approach based on emergent themes. In total, seven themes arose from the data: limited resources, distinct experiences, life enrichment, dynamic relationships, program flexibility, potential continuity, and enhanced socialization. This study provides insight on barriers, enablers, and outcomes of the MCP program and on key considerations for implementing a novel interdisciplinary music program in a healthcare setting.

The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review

BACKGROUND

Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia.

METHODS

In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes.

RESULTS

We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances.

CONCLUSION

Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.

Unreported Antipsychotic Use Increasing in Nursing Homes: The Impact of Quality-Measure Exclusions on the Percentage of Long-Stay Residents Who Got an Antipsychotic Medication Quality-Measure

OBJECTIVE

Excluded from reporting to CMS's Percentage of long-stay residents who got an antipsychotic medication quality-measure are antipsychotics prescribed to nursing home patients with schizophrenia, Tourette's, or Huntington's. Over the 4 years following its 2012 debut, the quality-measure calculated a 27% reduction in inappropriate antipsychotic use but also an 18.3% increase in exclusion claims. This study evaluated the impact of these exclusions on the measure's findings.

METHODS

Claims data for the years 2011-2016 retrospectively identified the prevalence of schizophrenia, Tourette's, and Huntington's in quarterly cohorts of Virginia long-stay residents prescribed antipsychotics. Annualized diagnoses in 2011 were compared with subsequent years using simple logistic regression.

RESULTS

In 2016, 29% of the antipsychotics prescribed in Virginia nursing homes were to residents with diagnoses of schizophrenia, Tourette's, and Huntington's, a significant 32% increase from 2011.

CONCLUSION

Almost 30% of the antipsychotics employed in Virginia nursing homes are excluded from CMS's long-stay antipsychotic quality-measure.

Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults

IMPORTANCE

How clinicians communicate about deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, may be associated with the extent to which older adults are willing to do it.

OBJECTIVE

To examine older adults' preferences regarding different rationales a clinician may use to explain why a patient should stop an unnecessary or potentially harmful medication.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study was conducted from March 25 to April 19, 2020, among a nationally representative, probability-based online survey panel (KnowledgePanel). KnowledgePanel members aged 65 years and older were recruited by random digit dialing and address-based sampling. Data were analyzed from May 4 to July 8, 2020.

EXPOSURES

The survey presented 2 vignettes involving hypothetical older adults. One described a statin being used for primary prevention by a person with functional impairment and polypharmacy. The second described a sedative-hypnotic, such as zolpidem, being used for insomnia by a person with good functional status.

MAIN OUTCOMES AND MEASURES

After each vignette, participants expressed preferences using a best-worst scaling method for 7 different phrases a clinician may use to explain why they should reduce or stop the medication. Conditional logistic regression was used to quantify respondents' relative preferences.

RESULTS

A total of 1193 KnowledgePanel members were invited, and 835 respondents (70.0%) completed the survey. The mean (SD) age was 73 (6) years, 414 (49.6%) were women, and 671 (80.4%) self-identified as White individuals. A total of 496 respondents (59.8%) had ever used a statin, and 124 respondents (14.9%) had ever used a sedative-hypnotic. For both medications, the most preferred phrase to explain deprescribing focused on the risk of side effects. For statins, this phrase was 5.8-fold (95% CI, 5.3-6.3) more preferred than the least preferred option, which focused on the effort (treatment burden) involved in taking the medicine. For sedative-hypnotics, the phrase about side effects was 8.6-fold (95% CI, 7.9-9.5) more preferred over the least preferred option, "This medicine is unlikely to help you function better."

CONCLUSIONS AND RELEVANCE

These findings suggest that among older adults, the most preferred rationale for deprescribing both preventive and symptom-relief medicines focused on the risk of side effects. These results could be used to inform clinical practice and improve effective communications around deprescribing in older adults.

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.

Designing a Primary Care-Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

BACKGROUND

Patients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.

OBJECTIVES

To elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.

DESIGN

Qualitative approach based on semi-structured interviews with patients, caregivers, and physicians.

PARTICIPANTS

Patients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.

APPROACH

We used constant comparison to identify and compare themes between patients, caregivers, and physicians.

KEY RESULTS

We conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers' expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.

CONCLUSIONS

Culturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.

Primary caregivers experience of anti-psychotic medication: A qualitative study

BACKGROUND

Management of schizophrenia is now shifted to the community setting and family caregivers are the primary caregivers. Managing medications is a complex responsibility of family caregivers caring for patients with mental illness. Medication compliance contributes to improve health outcomes and reduced hospitalization for the care service users; however, little is known about attitudes and perception of family caregivers.

AIMS AND OBJECTIVES

To explore family caregivers experience towards antipsychotic medications.

METHODS

A purposeful sampling of 21 family caregivers was included in the study. Semi-structured interview was employed to collect data from the participants between May and October 2015. Thematic analysis approach was used to identify the common pattern in the data.

RESULTS

Four main themes emerged from the study: insight into illness (poor understanding of illness), treatment factor (thinking about medication, poor guidance for medication compliance), resources and support (availability of medication and cost of medication), health care provider factors (communication gap and poor assessment with follow-up, social dysfunction (social isolation, disruption in life routine) of the primary caregivers.

CONCLUSIONS

Responsibility for providing care for patients with mental illness are taken place in the community setting and cared by family caregivers. More information resources are required for this role, which requires specific medication management skills and knowledge.

Dementia as Fixed or Malleable: Development and Validation of the Dementia Mindset Scale

Background and Objectives

Care professionals differ in how they experience and respond to dementia caregiving. To explain such differences, we developed a new measure: the Dementia Mindset Scale. This scale captures the extent to which care professionals view dementia as stable and fixed (akin to the biomedical perspective) or as flexible and malleable (akin to the person-centered approach).

Research Design and Methods

We conducted four studies to develop the scale. We tested items for comprehensibility, assessed the scale's factorial structure and psychometric properties, and investigated its predictive validity for care professionals' well-being.

Results

A new scale with a two-factor structure-distinguishing a malleable dementia mindset from a fixed dementia mindset-was developed. Results showed good convergent and divergent validity. Moreover, the dementia mindsets predicted aspects of job-related well-being in care professionals.

Discussion and Implications

The scale allows for the assessment of individual differences in how care professionals see dementia. This insight can be used to improve interventions aimed at enhancing care professionals' well-being and quality of care.

The Association Between Antipsychotic Drug Use and Rehabilitation Outcome in Post-Acute Hip Fractured Patients: A Retrospective Cohort Study

Antipsychotic (AP) use may lead to numerous side effects which may affect rehabilitation outcomes. A retrospective cohort study was carried out on 448 hip fractured patients admitted to a post-acute geriatric rehabilitation center. Functional improvement was measured by the Functional Independence Measure (FIM), motor FIM (mFIM), and mFIM effectiveness. A multiple linear regression model and regression analysis was used to evaluate the level of association between AP use and achievement of favorable functional gain. AP users exhibited lower functional ability on admission and at discharge, achieved a significantly lower functional gain and required longer rehabilitation time compared with nonusers. AP use by post-acute hip fractured patients negatively affects their chances of achieving favorable rehabilitation outcome after adjustment for confounders.

How Clinicians Discuss Medications During Primary Care Encounters Among Older Adults with Cognitive Impairment

BACKGROUND

People with cognitive impairment experience high rates of polypharmacy and potentially inappropriate medication use. How clinicians communicate about medications may affect to what extent patients and family companions understand and participate in decisions about medication use.

OBJECTIVE

To characterize how primary care clinicians discuss medications during encounters with older adults with cognitive impairment and their companions.

DESIGN

Qualitative content analysis of audio-recorded clinical encounters from SAME Page, a randomized controlled trial to examine the effects of a patient-family agenda setting checklist on primary care visit communication among patients with cognitive impairment. Visits occurred between August 2016 and August 2017.

PARTICIPANTS

Patients were 65 or older, had > 1 incorrect answer on a cognitive screener, and attended visits with a relative or unpaid companion. Clinicians were physicians, nurse practitioners, or physician assistants at participating practices.

APPROACH

The encounters were transcribed verbatim. We used qualitative content analysis to identify major themes.

KEY RESULTS

Patients were on average 79.9 years of age. The average MMSE score was 21.6. About half of clinicians reported practicing for 15 or more years (n = 8). We identified three major themes. First, we found numerous instances in which primary care clinicians introduced patients and companions to key principles of optimal prescribing and deprescribing. Second, clinicians used a variety of approaches to foster shared decision-making about medication use. Third, several challenges prevented clinicians from working together with patients and companions to optimize prescribing and deprescribing.

CONCLUSIONS

This study offers insight into key language clinicians can use to initiate discussions about optimizing prescribing, as well as barriers they face in doing so. Examples identified in these transcripts should be tested with patients and caregivers to examine how such communications are received and interpreted. Future research should develop and test interventions that seek to overcome obstacles to optimizing prescribing for older adults with cognitive impairment.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.

Clinicians' Perspectives on Barriers and Enablers of Optimal Prescribing in Patients with Dementia and Coexisting Conditions

PURPOSE

Patients with dementia experience high rates of polypharmacy, potentially inappropriate medication use, and adverse drug events. There is little guidance for clinicians on how to optimize prescribing for this population. Our objective was to investigate clinician-perceived barriers to and facilitators of optimizing prescribing for people with dementia.

METHODS

Qualitative study involving semistructured interviews of primary care and specialist clinicians in urban, suburban, and rural settings. Transcripts were analyzed using qualitative content analysis.

RESULTS

Interviews were conducted with 12 primary care and 9 specialist clinicians, with a mean (SD) age of 47 (9) and mean (SD) of 14 (10) years in practice. Clinicians cited decisions regarding the following drug classes as particularly challenging: oral anticoagulants, antidiabetic agents, statins, bladder antimuscarinics, and antipsychotics. Perceived enablers of optimizing prescribing included access to interdisciplinary services and guidelines for nondementia illnesses (eg, diabetes) addressing the care of people with dementia. Barriers included the lack of data on efficacy and safety of most medications in people with dementia, difficulty assessing medication effects in an individual patient, and the perception that stopping medications is seen as "giving up." Clinicians used a variety of strategies to discuss risks and benefits of medications with patients and caregivers.

CONCLUSIONS

Clinicians identified numerous barriers to and some facilitators of optimizing prescribing in people with dementia. More data are needed on the benefits and harms of stopping medications in this population. Research should also test different approaches for supporting informed decision making about medications by people with dementia and caregivers.

Increased Reporting of Exclusionary Diagnoses Inflate Apparent Reductions in Long-Stay Antipsychotic Prescribing

OBJECTIVE

Over the two years following the 2012 introduction of CMS's National Partnership, combined rates of schizophrenia, Tourette's, and Huntington's in US long-stay residents increased 12%. We evaluated trends in reporting of these diagnoses for the subgroup of long-stay residents on antipsychotics.

METHODS

Retrospective analysis of Virginia Medicaid claims identified annual utilization rates of psychiatric diagnoses for long-stay seniors on antipsychotics. Chi-square analysis compared rates for the year before March, 2012 with the same 12-month period 1 year later. A 5-year pre-existing baseline rate was also obtained.

RESULTS

Diagnosis rates for 2011 were unchanged from baseline. Comparing 2011 with 2013, diagnoses rates for schizophrenia, Tourette's, and Huntington's combined increased 40% (p < .0001), primarily because schizophrenia reporting nearly doubled (p < .0001).

CONCLUSIONS

For long-stay seniors on antipsychotics, reporting of schizophrenia, Tourette's, and Huntington's began increasing in 2012 and at almost triple the rate CMS described for the general long-stay population. The increased reporting of these diagnoses described by CMS since 2012 appears to be new and concentrated in residents on antipsychotics Clinical Implications: Since antipsychotics prescribed for schizophrenia, Tourette's, and Huntington's are excluded from quality-measure auditing, apparent reductions in inappropriate long-stay antipsychotic use since the National Partnership may be exaggerated.

Ongoing Medical Management to Maximize Health and Well-being for Persons Living With Dementia

Background and Objectives

Persons living with dementia have complex care needs including memory loss that should be taken into account by providers and family caregivers involved with their care. The prevalence of comorbid conditions in people with dementia is high and, thus, how primary care, community providers and family caregivers provide best practice care, person-centered care is important.

Research Design and Methods

Care providers should understand the ongoing medical management needs of persons living with dementia in order to maximize their quality of life, proactively plan for their anticipated needs, and be as well prepared as possible for health crises that may occur.

Results

This article provides eight practice recommendations intended to promote understanding and support of the role of nonphysician care providers in educating family caregivers about ongoing medical management to improve the wellbeing of persons living with dementia.

Discussion and Implications

Key among these are recommendations to use nonpharmacological interventions to manage behavioral and psychological symptoms of dementia as the first line of treatment and recommendations on how to best support the use and discontinuation of pharmacological interventions as necessary.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.