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Thunell JA, Joyce GF, Ferido PM, Chen Y, Guadamuz JS, Qato DM, Zissimopoulos JM. Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia. J Alzheimers Dis 2024; 99:513-523. [PMID: 38669535 DOI: 10.3233/jad-231266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Background Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD. Objective Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD. Methods We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use. Results Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants. Conclusions BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.
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Affiliation(s)
- Johanna A Thunell
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
| | - Geoffrey F Joyce
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Patricia M Ferido
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
| | - Yi Chen
- Rush Alzheimer's Disease Center, Chicago, IL, USA
| | - Jenny S Guadamuz
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Dima M Qato
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Julie M Zissimopoulos
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
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Mann NK, Mathes T, Sönnichsen A, Pieper D, Klager E, Moussa M, A. Thürmann P. Potentially Inadequate Medications in the Elderly: PRISCUS 2.0. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:3-10. [PMID: 36507719 PMCID: PMC10035347 DOI: 10.3238/arztebl.m2022.0377] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/12/2022] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The term potentially inadequate medication (PIM) is used to describe substances that may be unsuitable for use inthe elderly and should be avoided. The PRISCUS list, published in 2010, was the first catalog of PIM designed for the Germandrug market to become adopted in practice. While 24% of German patients aged ≥ 65 years were prescribed at least one PIMper year in 2009, the proportion in 2019 was only 14.5%. METHODS In a three-round Delphi process, experts from clinical practice and research evaluated whether selected substancesare PIM for the elderly. The participants were provided with dedicated literature including systematic reviews carried out for theparticular purposes of this project. RESULTS Fifty-nine persons took part in the Delphi process and, in addition, contributed comments and therapeutic alternatives.Altogether, 187 substances were classed as PIM. One hundred thirty-three of the substances now listed were not in the originalPRISCUS list: these include some oral antidiabetics, all of the selective COX-2 inhibitors, and moderately long acting benzodiazepinessuch as oxazepam. For some other substances, e.g., proton pump inhibitors (PPI), the advisability of treatment formore than 8 weeks was considered as potentially inappropriate, as was the use of ibuprofen in doses >1200 mg/day and formore than 1 week without PPI. Risperidone for more than 6 weeks is also PIM. CONCLUSION The new, greatly extended PRISCUS list must now be validated in epidemiological and prospective studies and itspracticability in routine daily use must be verified.
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Affiliation(s)
- Nina-Kristin Mann
- Chair of Clinical Pharmacology, Department of Medicine, Faculty of Health, University of Witten/Herdecke
| | - Tim Mathes
- Chair of Clinical Pharmacology, Department of Medicine, Faculty of Health, University of Witten/Herdecke
| | - Andreas Sönnichsen
- Chair of Clinical Pharmacology, Department of Medicine, Faculty of Health, University of Witten/Herdecke
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Department of Medicine, Faculty of Health, University of Witten/Herdecke
| | - Elisabeth Klager
- Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Austria
| | - Mahmoud Moussa
- Department of General and Family Medicine, Center for Public Health, Medical University of Vienna, Austria
| | - Petra A. Thürmann
- Chair of Clinical Pharmacology, Department of Medicine, Faculty of Health, University of Witten/Herdecke
- Philipp Klee Institute of Clinical Pharmacology, Helios University Hospital, Wuppertal
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Singer A, Kosowan L, Abrams EM, Katz A, Lix L, Leong K, Paige A. Implementing an audit and feedback cycle to improve adherence to the Choosing Wisely Canada recommendations: clustered randomized trail. BMC PRIMARY CARE 2022; 23:302. [PMID: 36435746 PMCID: PMC9701433 DOI: 10.1186/s12875-022-01912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Audit and Feedback (A&F), a strategy aimed at promoting modified practice through performance feedback, is a method to change provider behaviour and reduce unnecessary medical services. This study aims to assess the use of A&F to reduce antibiotic prescribing for viral infections and antipsychotic prescribing to patients with dementia. METHODS Clustered randomized trial of 239 primary care providers in Manitoba, Canada, participating in the Manitoba Primary Care Research Network. Forty-six practices were randomly assigned to one of three groups: control group, intervention 1 (recommendations summary), intervention 2 (recommendations summary and personalized feedback). We assessed prescribing rates prior to the intervention (2014/15), during and immediately after the intervention (2016/17) and following the intervention (2018/19). Physician characteristics were assessed. RESULTS Between 2014/15-2016/17, 91.6% of providers in intervention group 1 and 95.9% of providers in intervention group 2 reduced their antibiotic and antipsychotic prescribing rate by ≥ 1 compared to the control group (77.6%) (p-value 0.0073). This reduction was maintained into 2018/19 at 91.4%. On multivariate regression alternatively funded providers had 2.4 × higher odds of reducing their antibiotic prescribing rate compared to fee-for-service providers. In quantile regression of providers with a reduction in antibiotic prescribing, alternatively funded (e.g. salaried or locum) providers compared to fee-for-service providers were significant at the 80th quantile. CONCLUSIONS Both A&F and recommendation summaries sent to providers by a trusted source reduced unnecessary prescriptions. Our findings support further scale up of efforts to engage with primary care practices to improve care with A&F. TRIAL REGISTRATION ClinicalTrials.gov NCT05385445, retrospectively registered, 23/05/2022.
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Affiliation(s)
- Alexander Singer
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada.
| | - Leanne Kosowan
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Alan Katz
- Departments of Community Health Science & Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Centre for Health Policy, Winnipeg, MB, Canada
| | - Lisa Lix
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Katrina Leong
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
| | - Allison Paige
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave, Winnipeg, MB, R3E0W2, Canada
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Felstead C, Perkins L, Stott J, Hui EK, Spector A. A systematic literature review of group-based training interventions for informal carers: impact on the behavioural and psychological symptoms of dementia (BPSD). Aging Ment Health 2022:1-10. [PMID: 36369837 DOI: 10.1080/13607863.2022.2141193] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Caring for a relative with dementia can be extremely challenging especially when someone presents with behavioural and psychological symptoms of dementia (BPSD). The training provided to informal carers is varied and inconsistent. Group-based training programmes are often prescribed but their impact on care-recipient wellbeing and symptomology is yet to be well established. This review synthesises the literature on consensus, themes and effectiveness of informal-carer, group-based educational training programmes on BPSD symptoms. METHODS Ten papers were included of which very few considered BPSD outcomes as their primary aim of investigation. RESULTS Methodological and theoretical approaches across the empirical papers varied considerably. Generally, studies of higher quality and with some positive results on BPSD outcomes tended to incorporate teaching on structured problem-solving skills. Studies measuring for longer term changes also tended to conclude more beneficial outcomes. The length and duration of groups and the group-sizes appeared inconsequential to BPSD outcomes. CONCLUSION The empirical evidence is weak for carer group interventions in the management of BPSD. Practice reasons for this are discussed. Future studies designed to measure BPSD as a primary outcome would be a welcome addition to the literature.
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Affiliation(s)
- Cerne Felstead
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Luke Perkins
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Josh Stott
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Esther K Hui
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Aimee Spector
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Beaglehole B, Newton-Howes G, Porter R, Frampton C. Impact of diagnosis on outcomes for compulsory treatment orders in New Zealand. BJPsych Open 2022; 8:e145. [PMID: 35913107 PMCID: PMC9380042 DOI: 10.1192/bjo.2022.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Compulsory community treatment orders (CTOs) are controversial because they enforce psychiatric treatment of patients in the community. It is important to know which patients benefit from compulsory treatment to better inform CTO use. AIMS To examine the effect of a range of diagnoses on outcomes associated with CTOs to determine whether there are specific outcome signatures for CTOs according to diagnosis. METHOD New Zealand's Ministry of Health databases provided demographic, service use and medication-dispensing data for all individuals placed on a CTO between 2009 and 2018. We used a hierarchical approach to categorise individuals according to diagnosis. Admission rates, admission days per year, community care and medication dispensing were analysed according to diagnosis and CTO status. RESULTS In total, 14 726 patients were placed on a CTO over the 10-year period between 1 January 2009 and 31 December 2018. For psychotic disorders, CTOs were associated with reduced admission frequency and duration. However, the opposite occurred for dementia disorders, bipolar disorders, major depressive disorder and personality disorders. Higher rates of medications, including depot antipsychotic medications, were dispensed on CTOs for all diagnostic groups. CONCLUSIONS CTOs were associated with reduced admission frequency and admission days per year for patients with psychotic disorders, whereas the opposite occurred for other diagnostic groups. Rather than seeking to establish whether CTOs are effective, we suggest that there are specific outcome signatures associated with CTOs for different disorders and knowledge of these can improve understanding and clinical practice in this area.
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Affiliation(s)
- Ben Beaglehole
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Giles Newton-Howes
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | - Richard Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Chris Frampton
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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Han SH, Noh DH, Jo EJ, Kam KY. Effects of Apolipoprotein E ɛ4 and Risk Factors on Domains of Cognition in Mild Cognitive Impairment and Dementia. J Alzheimers Dis 2022; 87:1181-1188. [PMID: 35466935 DOI: 10.3233/jad-215075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The apolipoprotein E (APOE) gene is the most potent genetic risk factor for dementia. However, there are few studies on how the APOE gene affects cognitive domain functions. OBJECTIVE This study aimed to investigate the effects of risk factors for dementia on cognitive function in patients with mild cognitive impairment and Alzheimer's disease (AD). METHODS This study included subjects whose Clinical Dementia Rating scores ranged from 0.5 to 2 and who were older than 65 years. Risk factors for dementia included the APOE ɛ4 allele, age, education period, employment period, body mass index, and exercise. APOE genotyping was performed by polymerase chain reaction, and other factors were identified using medical charts or structured checklists. Cognitive function was measured using the Seoul Neuropsychological Screening Battery II. RESULTS General cognitive function did not show a significant difference according to APOE ɛ4 status. However, the score for delayed verbal memory was lower in the APOE ɛ4-carrier group than in the non-carrier group (p < 0.05). In addition, age, education period, employment period, and exercise were correlated with different cognitive function domains in the non-carrier group (p < 0.05); however, the carrier group was showed a significant correlation between age, body mass index, and cognitive domains. CONCLUSION Our findings suggest that APOE ɛ4 significantly decreases verbal memory in patients with AD. Moreover, the effects of risk factors on cognitive function were significantly different according to the APOE ɛ4 status.
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Affiliation(s)
- Seung-Hyup Han
- Department of Occupational Therapy, Masan University, Naeseo-eup, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, Republic of Korea
| | - Dong-Hee Noh
- Policy Team, Korea Workers' Compensation and Welfare Service Headquarters, Jung-gu, Ulsan, Republic of Korea
| | - Eun-Ju Jo
- Department of Occupational Therapy, Masan University, Naeseo-eup, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, Republic of Korea
| | - Kyung-Yoon Kam
- Department of Occupational Therapy, College of Healthcare Medical Science and Engineering, Inje University, Gimhae-si, Gyeongsangnam-do, Republic of Korea
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Psychotropic drug use among older people with major neurocognitive disorder: a cross-sectional study based on Swedish national registries. Eur J Clin Pharmacol 2021; 78:477-487. [PMID: 34738182 PMCID: PMC8818624 DOI: 10.1007/s00228-021-03241-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/21/2021] [Indexed: 10/27/2022]
Abstract
AIM Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD. METHODS This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007-2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression. RESULTS We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04-2.82). CONCLUSION Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people.
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Lee DCA, Robins LM, Bell JS, Srikanth V, Möhler R, Hill KD, Griffiths D, Haines TP. Prevalence and variability in use of physical and chemical restraints in residential aged care facilities: A systematic review and meta-analysis. Int J Nurs Stud 2020; 117:103856. [PMID: 33601305 DOI: 10.1016/j.ijnurstu.2020.103856] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Use of physical and chemical restraints are common in residential aged care facilities worldwide. Restraint use can pose harm to residents even causing deaths. OBJECTIVE To synthesize the prevalence and variability in physical and chemical restraint use, and examine factors that may contribute to this variability of prevalence rates. METHODS Six health science databases were searched from inception up to 21st January 2020. Quantitative studies investigating restraint use in residential aged care facilities that reported data from year 2000 onwards were included. Meta-analyses of binomial data using a random effect model were performed to pool proportions of physical or chemical restraints with 95% confidence intervals. Univariable meta-regression analyses were used to assess factors that may contribute to the variability in physical and chemical restraint prevalence. Multiple meta-regression analyses were performed where possible to construct models of factors contributing to these variations. RESULTS Eighty-five papers were included. The pooled proportion of physical and chemical restraint use in residential aged care facilities were 33% and 32% respectively. Bedrails (44%) and benzodiazepines (42%) were the most prevalent forms of physical and chemical restraint respectively. Studies from North America (lower prevalence) [coefficient (95% CI): -0.15 (-0.27, -0.03)], measurement approaches using direct observation (higher prevalence) [0.17 (0.02, 0.33)] and a combination of multiple measurement approaches (higher prevalence) [0.17 (0.05, 0.29)] explained 25.5% of variability in the prevalence of physical restraint. Multiple meta-regression analyses were not performed to identify factors that may explain the observed variability in chemical restraint prevalence due to the small number of studies with data available. CONCLUSION Variability in prevalence of physical restraint could be explained partly by different measurement approaches and geographical regions. Valid and reliable measurement approaches across different regions is required to understand cultural differences due to geographical region effects on the prevalence of physical restraint use.
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Affiliation(s)
- Den-Ching A Lee
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moorooduc Highway, Frankston, VIC 3199, Australia.
| | - Lauren M Robins
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moorooduc Highway, Frankston, VIC 3199, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Royal Parade, Parkville, VIC 3052, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston Hospital, Frankston, VIC 3199, Australia
| | - Ralph Möhler
- Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | - Keith D Hill
- School of Primary and Allied Health Care, Rehabilitation, Ageing and Independent Living (RAIL) research centre, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moorooduc Highway, Frankston, VIC 3199, Australia
| | - Debra Griffiths
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moorooduc Highway, Frankston, VIC 3199, Australia
| | - Terry P Haines
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Moorooduc Highway, Frankston, VIC 3199, Australia
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Wang S, Temkin-Greener H, Conwell Y, Cai S. Policy to Reduce Antipsychotic Use and Hospitalization of Nursing Home Residents With Dementia. J Am Med Dir Assoc 2020; 21:1617-1622.e3. [PMID: 32527648 DOI: 10.1016/j.jamda.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer's disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership. DESIGN Observational cross-sectional study. SETTING/PARTICIPANTS NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885). METHODS We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership). RESULTS We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use. CONCLUSIONS AND IMPLICATIONS Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.
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Affiliation(s)
- Sijiu Wang
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Liu YP, Chien WC, Chung CH, Chang HA, Kao YC, Tzeng NS. Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan. Front Pharmacol 2020; 11:30. [PMID: 32116707 PMCID: PMC7033580 DOI: 10.3389/fphar.2020.00030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/13/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/OBJECTIVE In previous reports, the usage of anticholinergic medications has been associated with an increased risk of dementia with prolonged usage or with a high Anticholinergic Cognitive Burden (ACB). This study aimed to investigate the association between anticholinergic medications and the risk of dementia using data from Taiwan's National Health Research Database (NHIRD). METHODS A total of 790,240 patients, with 197,560 patients receiving anticholinergic medications and 592,680 control patients (1:3) matched for sex, age, and index-year, were enrolled from the two million Longitudinal Health Insurance Dataset, a subdataset of the NHIRD, between 2000 and 2015. The time-dependent Cox regression analysis was used to explore the hazard ratio (HR) with a 95% confidence interval for the association between anticholinergics and the risk of dementia during the 15-year follow-up. The behavioral and psychological symptoms of dementia (BPSD) were recognized by the usage of psychotropics. The ACB ranged from zero to three, divided as score <1, 1-1.9, 2-2.9, 3-4.9,and ≧5. The sensitivity analysis was done by excluding the diagnoses of dementia in the first 2 or 4 years after anticholinergic usage. RESULTS In the anticholinergic usage cohort, the HR was 1.043 (95% CI = 0.958-1.212, p = 0.139) without a significant difference. The sensitivity analysis revealed no association between the usage of anticholinergics and the risk of dementia. Anticholinergic usage was not associated with BPSD. Male sex, patients of ages of 60-64 and ≧80, usage of antiparkinsonian medications, a history of Parkinson's disease, epilepsy, urinary incontinence, depression, bipolar disorder, and psychotic disorder were independent risk factors of dementia. Increased HRs for dementia were associated with an ACB ≥ 5 and an anticholinergic usage period ≥ 1,460 days. CONCLUSION In this study, the usage of anticholinergics was not associated with the risk of dementia or BPSD in a 15-year follow-up study. However, patients with the male sex, patients with ages of 65-79 and ≧80, patients with some comorbidities, high ACB scores, and long anticholinergic treatment duration were associated with the risk of dementia.
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Affiliation(s)
- Yia-Ping Liu
- Department of Psychiatry, Cheng Hsin General Hospital, Taipei, Taiwan
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Laboratory of Cognitive Neuroscience, Departments of Physiology and Biophysics, National Defense Medical Center, Taipei, Taiwan
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Graduate of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Chen Kao
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Nian-Sheng Tzeng
- Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
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Gafoor R, Charlton J, Ravindrarajah R, Gulliford MC. Importance of Frailty for Association of Antipsychotic Drug Use With Risk of Fracture: Cohort Study Using Electronic Health Records. J Am Med Dir Assoc 2019; 20:1495-1501.e1. [DOI: 10.1016/j.jamda.2019.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/09/2019] [Accepted: 05/11/2019] [Indexed: 12/01/2022]
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Hulshof TA, Zuidema SU, Gispen-de Wied CC, Luijendijk HJ. Run-in periods and clinical outcomes of antipsychotics in dementia: A meta-epidemiological study of placebo-controlled trials. Pharmacoepidemiol Drug Saf 2019; 29:125-133. [PMID: 31730266 PMCID: PMC7027584 DOI: 10.1002/pds.4903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 01/03/2023]
Abstract
Purpose Run‐in periods are used to identify placebo‐responders and washout. Our aim was to assess the association of run‐in periods with clinical outcomes of antipsychotics in dementia. Methods We searched randomized placebo‐controlled trials of conventional and atypical antipsychotics for neuropsychiatric symptoms (NPS) in dementia in electronic sources and references of selected articles. We extracted (a) the presence of a run‐in period, use of placebo/investigated drug during run‐in (versus washout only), and run‐in duration (1 week or more) and (b) the reduction in NPS, number of participants with somnolence, extrapyramidal symptoms (EPS), and deaths per treatment group. We pooled clinical outcomes comparing antipsychotic and placebo groups in trials with and without run‐in. Results We identified 35 trials. Twenty‐nine trials used run‐in. The pooled standardized mean difference in the reduction of NPS was −0.170 (95% CI, −0.227 to −0.112) in trials with run‐in and −0.142 (95% CI, −0.331 to 0.047) in trials without run‐in. The pooled odds ratio for somnolence was 2.8 (95% CI, 2.3‐3.5) in trials with run‐in and 3.5 (95% CI, 1.2‐10.7) in trials without run‐in; for EPS, these ORs were 1.8 (95% CI, 1.4‐2.2) and 2.0 (95% CI, 1.3‐3.1) respectively, and for mortality 1.4 (95% CI, 1.0‐2.0) and 1.6 (95% CI, 0.7‐3.4). The use of placebo/investigated drug during run‐in and run‐in duration did not affect the estimates in a consistent way. Conclusions The use of run‐in in trials might have led to overestimated efficacy and especially underestimated risks of side effects of antipsychotics compared with placebo for NPS in dementia.
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Affiliation(s)
- Tessa A Hulshof
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Hendrika J Luijendijk
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
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13
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Ohno Y, Kunisawa N, Shimizu S. Antipsychotic Treatment of Behavioral and Psychological Symptoms of Dementia (BPSD): Management of Extrapyramidal Side Effects. Front Pharmacol 2019; 10:1045. [PMID: 31607910 PMCID: PMC6758594 DOI: 10.3389/fphar.2019.01045] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/19/2019] [Indexed: 11/26/2022] Open
Abstract
Antipsychotic drugs are often used for the treatment of behavioral and psychological symptoms of dementia (BPSD), especially psychosis and behavioral disturbances (e.g., aggression and agitation). They are prescribed alone or in conjunction with anti-dementia (e.g., anti-Alzheimer’s disease drugs) and other psychotropic drugs (e.g., antidepressants). However, antipsychotic drugs frequently produce serious extrapyramidal side effects (EPS) including Parkinsonian symptoms (e.g., bradykinesia, akinesia, tremor, and muscle rigidity). Therefore, appropriate drug choice and combination strategy are important in the treatment of BPSD. Among anti-Alzheimer’s disease drugs, cholinesterase inhibitors (ChEIs, e.g., donepezil and galantamine) have a propensity to potentiate EPS associated with antipsychotic treatment in a synergistic manner. In contrast, the NMDA receptor antagonist memantine reduces antipsychotic-induced EPS. Antidepressant drugs, which inhibit 5-HT reuptake into the nerve terminals, also synergistically augment antipsychotic-induced EPS, while mirtazapine (α2, 5-HT2 and 5-HT3 antagonist) reduces the EPS induction. Importantly, previous studies showed that multiple 5-HT receptors play crucial roles in modulating EPS associated with antipsychotic treatment. Specifically, activation of 5-HT1A receptors or blockade of 5-HT2, 5-HT3 and 5-HT6 receptors can alleviate EPS induction both by antipsychotics alone and by combined antipsychotic treatments with ChEIs or 5-HT reuptake inhibitors. In this article, we review antipsychotic use in treating BPSD and discuss the favorable drug selection in terms of the management of antipsychotic-induced EPS.
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Affiliation(s)
- Yukihiro Ohno
- Department of Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Naofumi Kunisawa
- Department of Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
| | - Saki Shimizu
- Department of Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
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14
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Vredeveld EJ, Hulshof TA, Zuidema SU, Luijendijk HJ. Subjective Versus Objective Outcomes of Antipsychotics for the Treatment of Neuropsychiatric Symptoms Associated with Dementia. CNS Drugs 2019; 33:933-942. [PMID: 31473979 PMCID: PMC6776492 DOI: 10.1007/s40263-019-00654-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Knowledge about treatment status can influence effects measured in trials when subjective scales are used. OBJECTIVE The aim of this study was to compare subjective outcomes with objective outcomes of conventional and atypical antipsychotics for neuropsychiatric symptoms (NPS) in dementia. METHODS We performed a meta-epidemiological study of 38 randomized, placebo-controlled trials. For effectiveness, we used change in NPS and response rate as subjective outcomes, while overall dropout and additional psychotropic use were used as objective outcomes. For side effects, extrapyramidal symptoms (EPS) and somnolence were used as subjective outcomes, while dropout due to adverse events, medication use for EPS, and participants falling were used as objective outcomes. RESULTS Conventional antipsychotics reduced NPS more than placebo (standardized mean difference [SMD] - 0.36, 95% confidence interval [CI] - 0.49 to - 0.23), as did atypical antipsychotics (SMD - 0.14, 95% CI - 0.19 to - 0.08). Response rates in the drug groups were also higher. Overall dropout did not differ between conventional antipsychotics and placebo (odds ratio [OR] 1.03, 95% CI 0.77-1.37) or atypical antipsychotics and placebo (OR 1.01, 95% CI 0.89-1.14). Furthermore, additional psychotropic use did not differ. The risk of EPS was higher for conventional (OR 2.93, 95% CI 2.04-4.22) and atypical antipsychotics (OR 1.52, 95% CI 1.23-1.88) versus placebo, as was the risk of somnolence and dropout due to adverse events, but medication use for EPS, as well as risk of falls, was not. CONCLUSIONS The effectiveness of antipsychotics for NPS in dementia based on subjective scales was not confirmed using objective outcomes, in contrast to the increased risk of side effects.
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Affiliation(s)
- Eline J Vredeveld
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlands
| | - Tessa A Hulshof
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlands
| | - Hendrika J Luijendijk
- Department of General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlands.
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15
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Assessing the Relative Contribution of Resident Versus Facility Characteristics Associated With Antipsychotic Medication Receipt Among Nursing Facility Residents. Med Care 2019; 57:822-829. [PMID: 31415339 DOI: 10.1097/mlr.0000000000001183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE In 2012 Centers for Medicare and Medicaid Services (CMS) launched a multifaceted initiative aimed at reducing the unnecessary use of antipsychotic medications in nursing facilities due to evidence these medications are associated with little or uncertain benefit and substantial risk. Yet, little is known about whether efforts to reduce antipsychotic medication should be focused on residents with targeted characteristics, or on nursing facility regulation (eg, staffing levels). Our objective was to identify the relative contribution of resident and facility characteristics to potentially inappropriate antipsychotic use. METHODS We examined 1,156,875 long stay residents in 14,699 US nursing facilities in 2014 and predicted resident antipsychotic use controlling sequentially for resident and facility characteristics and calculated the incremental variation explained. RESULTS We found significant variability in unadjusted rates of potentially inappropriate antipsychotic use among nursing facilities (mean=18.0%; interquartile range: 11.3%-23.7%; SD: 11.1). Regression results indicated that 93% of the explained variation in antipsychotic use was attributed to resident characteristics and 7% was attributed to facility-level factors. At the facility level, worker hours per resident day was not significantly associated with antipsychotic use. Simulations indicated that applying the effect sizes achieved by the best performing facilities to the existing case mix across all nursing facilities would result in no more than a 1 percentage point change in population-level antipsychotic use. CONCLUSIONS Efforts to reduce antipsychotic use may have greater impact by developing new clinical strategies to address specific diagnoses rather than regulations related to facility-level attributes.
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16
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Narayan SW, Pearson SA, Litchfield M, Le Couteur DG, Buckley N, McLachlan AJ, Zoega H. Anticholinergic medicines use among older adults before and after initiating dementia medicines. Br J Clin Pharmacol 2019; 85:1957-1963. [PMID: 31046175 PMCID: PMC6710547 DOI: 10.1111/bcp.13976] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/10/2019] [Accepted: 04/22/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS We investigated anticholinergic medicines use among older adults initiating dementia medicines. METHODS We used Pharmaceutical Benefits Scheme dispensing claims to identify patients who initiated donepezil, rivastigmine, galantamine or memantine between 1 January 2013 and 30 June 2017 (after a period of ≥180 days with no dispensing of these medicines) and remained on therapy for ≥180 days (n = 4393), and dispensed anticholinergic medicines in the 180 days before and after initiating dementia medicines. We further examined anticholinergic medicines prescribed by a prescriber other than the one initiating dementia medicines. RESULTS One-third of the study cohort (1439/4393) was exposed to anticholinergic medicines up to 180 days before or after initiating dementia medicines. Among patients exposed to anticholinergic medicines, 46% (659/1439) had the same medicine dispensed before and after initiating dementia medicines. The proportion of patients dispensed anticholinergic medicines increased by 2.5% (95% confidence interval [CI]: 1.3-3.7) after initiating dementia medicines. Antipsychotics use increased by 10.1% (95% CI: 7.6-12.7) after initiating dementia medicines; driven by increased risperidone use (7.3%, 95% CI: 5.3-9.3). Nearly half of patients dispensed anticholinergic medicines in the 180 days after (537/1133), were prescribed anticholinergic medicines by a prescriber other than the one initiating dementia medicines. CONCLUSION Use of anticholinergic medicines is common among patients initiating dementia medicines and this occurs against a backdrop of widespread campaigns to reduce irrational medicine combinations in this vulnerable population. Decisions about deprescribing medicines with questionable benefit among patients with dementia may be complicated by conflicting recommendations in prescribing guidelines.
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Affiliation(s)
- Sujita W Narayan
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.,Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Melisa Litchfield
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia
| | - David G Le Couteur
- Centre for Education and Research in Ageing, Concord Hospital, Sydney, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Nicholas Buckley
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Andrew J McLachlan
- Centre for Education and Research in Ageing, Concord Hospital, Sydney, Australia.,Sydney Pharmacy School, The University of Sydney, Sydney, Australia
| | - Helga Zoega
- Centre for Big Data Research in Health, University of New South Wales, Sydney, Australia.,Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Iceland
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17
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Lin CH, Lane HY. The Role of N-Methyl-D-Aspartate Receptor Neurotransmission and Precision Medicine in Behavioral and Psychological Symptoms of Dementia. Front Pharmacol 2019; 10:540. [PMID: 31191302 PMCID: PMC6539199 DOI: 10.3389/fphar.2019.00540] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 04/29/2019] [Indexed: 12/16/2022] Open
Abstract
While the world’s population is aging, the prevalence of dementia and the associated behavioral and psychological symptoms of dementia (BPSD) rises rapidly. BPSD are associated with worsening of cognitive function and poorer prognosis. No pharmacological treatment has been approved to be beneficial for BPSD to date. Dysfunction of the N-methyl-D-aspartate receptor (NMDAR)-related neurotransmission leads to cognitive impairment and behavioral changes, both of which are core symptoms of BPSD. Memantine, an NMDAR partial antagonist, is used to treat moderate to severe Alzheimer’s disease (AD). On the other hand, a D-amino acid oxidase inhibitor improved early-phase AD. Whether to enhance or to attenuate the NMDAR may depend on the phases of dementia. It will be valuable to develop biomarkers indicating the activity of NMDAR, particularly in BPSD. In addition, recent reports suggest that gender difference exists in the treatment of dementia. Selecting subpopulations of patients with BPSD who are prone to improvement with treatment would be important. We reviewed literatures regarding the treatment of BPSD, focusing on the NMDAR-related modulation and precision medicine. Future studies examining the NMDAR modulators with the aid of potential biomarkers to tailor the treatment for individualized patients with BPSD are warranted.
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Affiliation(s)
- Chieh-Hsin Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan.,Department of Psychology, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
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18
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Hulshof TA, Zuidema SU, van Meer PJ, Gispen‐de Wied CC, Luijendijk HJ. Baseline imbalances and clinical outcomes of atypical antipsychotics in dementia: A meta-epidemiological study of randomized trials. Int J Methods Psychiatr Res 2019; 28:e1757. [PMID: 30515916 PMCID: PMC6587552 DOI: 10.1002/mpr.1757] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/11/2018] [Accepted: 09/17/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To assess baseline imbalances in placebo-controlled trials of atypical antipsychotics in dementia, and their association with neuropsychiatric symptoms (NPS), extrapyramidal symptoms (EPS), and mortality. METHOD We searched for trials in multiple sources. Two reviewers extracted baseline characteristics and outcomes per treatment group. We calculated direction, range, pooled mean, and heterogeneity in the baseline differences, and used meta-regression for the relationship with the outcomes. RESULTS We identified 23 trials. Baseline type of dementia, cognitive impairment and NPS were poorly reported. The drug group had a higher mean age than the placebo group in nine trials and lower mean age in three trials (p = 0.073). The difference in percentage men between the drug and placebo group ranged from -9.7% to 4.4%. There were no statistically significant pooled baseline differences, but heterogeneity was present for age. Higher mean age at baseline in the drug versus placebo group was significantly associated with greater reduction in NPS, and higher percentage of non-White persons with lower risk of EPS. Imbalances were not significantly associated with risk of mortality. CONCLUSION Randomized trials of atypical antipsychotics in dementia showed baseline imbalances that were associated with higher efficacy and lower risk of EPS for atypical antipsychotics versus placebo.
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Affiliation(s)
- Tessa A. Hulshof
- University Medical Center Groningen, Department of General Practice and Elderly Care MedicineUniversity of GroningenGroningenThe Netherlands
| | - Sytse U. Zuidema
- University Medical Center Groningen, Department of General Practice and Elderly Care MedicineUniversity of GroningenGroningenThe Netherlands
| | | | | | - Hendrika J. Luijendijk
- University Medical Center Groningen, Department of General Practice and Elderly Care MedicineUniversity of GroningenGroningenThe Netherlands
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19
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Nguyen TA, Pham T, Vu HTT, Nguyen TX, Vu TT, Nguyen BTT, Nguyen NQ, Nguyen BT, Nguyen BT, Nguyen TN, Phan SV, Nguyen AT, Pham TL, Dang HT, Kalisch-Ellett L, Gillam M, Pratt N, Qiang S, Wang H, Kanjanarach T, Hassali MAA, Babar ZUD, Razak AA, Chinwong D, Roughead EE. Use of Potentially Inappropriate Medications in People With Dementia in Vietnam and Its Associated Factors. Am J Alzheimers Dis Other Demen 2018; 33:423-432. [PMID: 29642720 PMCID: PMC10852524 DOI: 10.1177/1533317518768999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2024]
Abstract
This study examined the use of potentially inappropriate medicines that may affect cognition (PIMcog) in people with dementia and its associated factors. Medical records of all outpatients with dementia attending a tertiary hospital in Vietnam between January 1, 2015, and December 31, 2016, were examined. Medicine use was assessed against a list of PIMcog. Variables associated with having a PIMcog were assessed using a multiple logistic regression. Of the 128 patients, 41% used a PIMcog, 39.1% used cholinesterase inhibitors (CEIs) concomitantly with anticholinergics, and 18% used antipsychotics. The number of hospital visits (adjusted odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.02-1.16) and number of treating specialists (adjusted OR: 0.61; 95% CI: 0.45-0.83) were associated with PIMcog use. This study highlights a high-level use of medicines that can further impair cognition or reduce the effectiveness of CEIs in people with dementia. Efforts to improve quality use of medicines for this population are warranted.
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Affiliation(s)
- Tuan Anh Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Thang Pham
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | - Trinh Thi Vu
- National Geriatric Hospital of Vietnam, Hanoi, Vietnam
| | | | | | | | | | | | | | | | - Tuan Le Pham
- Hanoi Medical University and Ministry of Health of Vietnam, Hanoi, Vietnam
| | - Ha Thu Dang
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sun Qiang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | - Haipeng Wang
- Center for Health Management and Policy, School of Health Care Management, Shandong University, Jinan, China
| | | | | | | | - Asrenee Ab Razak
- Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Dujrudee Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, South Australia, Australia
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20
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Yu F, Rafizadeh R, Mabasa VH, Kang N. Risk Evaluation for Antipsychotic Agents Used in Elderly Inpatients (REPAIR). Can J Hosp Pharm 2018; 71:370-375. [PMID: 30626983 PMCID: PMC6306184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Antipsychotics have been approved for the treatment of certain psychiatric illnesses. However, these medications are also frequently used off label, and recent studies have suggested a concerning potential increase in the risk of death when used by elderly patients with dementia. Most of the available literature focusing on off-label use of antipsychotics comes from long-term care facilities; there is a lack of quantitative data for elderly patients in the acute care setting. This study was designed to examine this scenario and to identify potential quality improvement opportunities to minimize harm. OBJECTIVES The primary objectives were to determine the prevalence of hospital-initiated off-label use of antipsychotics for elderly inpatients and to determine the plan for these drugs upon discharge. The secondary objectives included identifying the most common diagnosis and the most common agent used. METHODS A retrospective cohort study was performed with a convenience sample. Patients included in the analysis were elderly adults (≥ 65 years) who had been admitted to either of 2 medical units at a community hospital between September 1 and November 8, 2014. Descriptive statistics were used to examine prevalence patterns for the off-label use of antipsychotics. RESULTS A total of 250 patients were included in the analysis. Forty-five patients (18%, 95% confidence interval [CI] 13.7%-23.2%) received a hospital-initiated antipsychotic for off-label use during the admission. For 27 (60%, 95% CI 45.5%-73.0%) of these 45 patients, the off-label therapy was discontinued upon discharge or death, and for 13 (29%, 95% CI 17.7%-43.4%), the agent was continued upon discharge without a plan in place. The most frequent diagnosis was delirium, and the agent most frequently used was haloperidol. CONCLUSIONS Off-label antipsychotic therapy was initiated for almost 1 in every 5 elderly patients receiving care in 2 medical units at a community hospital. These findings suggest a need to monitor and reassess the off-label use of these agents, especially at the time of discharge.
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Affiliation(s)
- Flora Yu
- BSc(Pharm), ACPR, is a Clinical Pharmacist with Vancouver General Hospital, Vancouver, British Columbia
| | - Reza Rafizadeh
- BSc(Pharm), ACPR, BCPP, is a Clinical Pharmacist in Mental Health and Substance Use with the Burnaby Centre for Mental Health & Addiction, Burnaby, British Columbia
| | - Vincent H Mabasa
- BSc(Pharm), ACPR, PharmD, is Clinical Coordinator with the Burnaby Hospital, Burnaby, British Columbia
| | - Nirmal Kang
- MBBS, FRCPC, is a Psychiatrist with the Burnaby Hospital, Burnaby, British Columbia
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21
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Singer A, Kosowan L, Katz A, Jolin-Dahel K, Appel K, Lix LM. Prescribing and testing by primary care providers to assess adherence to the Choosing Wisely Canada recommendations: a retrospective cohort study. CMAJ Open 2018; 6:E603-E610. [PMID: 30530720 PMCID: PMC6287976 DOI: 10.9778/cmajo.20180053] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Choosing Wisely Canada is an initiative to reduce overprescribing and overtesting. This study assessed adherence to 4 Choosing Wisely Canada recommendations for interventions commonly performed in primary care: (a) antibiotic prescriptions for infections that are probably viral in origin, (b) routine vitamin D tests in low-risk adults, (c) annual screening blood tests and (d) prescriptions of antipsychotic medication to treat symptoms of dementia. METHODS We conducted a retrospective cohort study of data from the electronic medical records of patients who had an encounter between 2014 and 2016 with a participating Manitoba Primary Care Research Network primary care provider in Manitoba, Canada. Patient encounter data were reviewed for prescribing and testing practices. Descriptive statistics and multivariable models assessed associations between patient and provider characteristics and rates of prescribing and testing. RESULTS Data for 164 195 patients from 230 providers were included in the study. Sixteen percent (n = 25 629) of patients had an encounter that involved potentially unnecessary diagnostic testing and treatment. A minority of providers contributed to above-average rates of prescribing and testing: 29% (n = 69) of providers prescribed antibiotics for a viral indication,11% (n = 24) prescribed an antipsychotic to a patient diagnosed with dementia, 9% (n = 24) ordered prostate-specific antigen tests and 14% (n = 34) ordered vitamin D tests at above-average rates, respectively. Patient and provider characteristics were associated with each of the prescribing and testing practices assessed. INTERPRETATION This study demonstrated that fewer than 30% of primary care providers contributed to interventions in direct contradiction to Choosing Wisely Canada recommendations. Improvement strategies specific to each prescription or testing recommendation should target specific providers to prevent patient harm and reduce unnecessary health care spending.
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Affiliation(s)
- Alexander Singer
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Leanne Kosowan
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man.
| | - Alan Katz
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Kheira Jolin-Dahel
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Karen Appel
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
| | - Lisa M Lix
- Departments of Family Medicine (Singer, Kosowan, Katz, Jolin-Dahel, Appel) and Community Health Sciences (Katz, Lix), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba; Manitoba Primary Care Research Network (Singer); Manitoba Centre for Health Policy (Katz), Winnipeg, Man.; Centre Medical Seine (Jolin-Dahel), Ste. Anne, Man.; Seven Oaks Hospital (Appel), Winnipeg, Man
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22
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Almutairi S, Masters K, Donyai P. The health professional experience of using antipsychotic medication for dementia in care homes: A study using grounded theory and focussing on inappropriate prescribing. J Psychiatr Ment Health Nurs 2018; 25:307-318. [PMID: 29719932 DOI: 10.1111/jpm.12464] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/14/2018] [Accepted: 04/25/2018] [Indexed: 01/23/2023]
Abstract
WHAT IS KNOWN ON THE SUBJECT People with dementia can experience symptoms that upset them and upset the people who care for them To cope, care homes sometimes use strong medicines called antipsychotics but these can make people with dementia become more ill We do not know just why doctors and nurses caring for people with dementia still use these strong medicines more than they need to WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Giving antipsychotics can make it easier to care for residents within busy care homes, so people tend to see and remember the benefits of antipsychotics The harm of antipsychotics is noticed less, meaning carers will use them again, in a "vicious circle" WHAT ARE THE IMPLICATIONS FOR PRACTICE: If these medicines worked before it does not make them the right choice again It might help to show carers very clearly the harms from using these medicines, to stress the dangers ABSTRACT: Introduction Treating the behavioural and psychological symptoms of dementia with antipsychotics can cause detrimental side-effects but their use in care homes remains problematic with the views of professionals not fully explored. AIM/QUESTION To develop an in-depth explanatory model about inappropriate prescribing of antipsychotics in dementia within care homes. METHODS Twenty-eight participants from eight different professional groups with a role in shaping treatment decisions in dementia care were recruited and interviewed. The audio-recorded interviews were transcribed and analyzed using constructivist grounded theory. RESULTS When patients with dementia present with behavioural and psychological symptoms, the prescribing of antipsychotics allows the multitude of work in a care home to be managed; the effectiveness of antipsychotics is more perceptible than their side-effects. This perceived usefulness strengthens beliefs that these medications ought to be prescribed again in future situations, generating a self-fulfilling prophecy. DISCUSSION Our findings may partly explain why the launch of the national dementia strategy in England has been found not to have reduced antipsychotic prescribing in care homes. IMPLICATIONS FOR PRACTICE Positive perceptions based on past experiences with antipsychotics should be challenged through future interventions that tackle inappropriate prescribing, for example using behaviour change techniques to better highlight adverse consequences of prescribing.
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Affiliation(s)
| | - Kate Masters
- R&D Department, Berkshire Healthcare NHS Foundation Trust, Bracknell, Bracknell Forest, UK
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Alldred DP, Petty DR, Bowie P, Zermansky AG, Raynor DK. Antipsychotic prescribing patterns in care homes and relationship with dementia. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.106.012880] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodTo determine the prescribing patterns for antipsychotics in care homes for the elderly, a cross-sectional study was carried out using data from the intervention group of a randomised controlled trial of medication review in care homes.ResultsOf 331 residents studied, 67 (20%) were prescribed an antipsychotic (70% atypical); 57 of these (85%) did not have a diagnosis of a psychotic disorder. The antipsychotic prescribing rate was 32% (46 out of 146) for those with dementia and 10% (17 out of 174) for those without dementia. A quarter (82 out of 331) had received a medication review by the general practitioner in the preceding 12 months.Clinical ImplicationsOne-fifth of residents were prescribed an antipsychotic with little evidence of review. Systems should ensure residents' treatment is reviewed regularly.
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Haw C, Yorston G, Stubbs J. Guidelines on antipsychotics for dementia: are we losing our minds? PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.107.017947] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodThe National Institute for Health and Clinical Excellence (NICE) and the Royal College of Psychiatrists have each issued guidance on the use of antipsychotics for behavioural and psychiatric symptoms of dementia (BPSD). We sent all old age psychiatrists an anonymous questionnaire asking for their opinions on these documents and for details of their use of antipsychotics for BPSD.ResultsThe response rate was 202 out of 648 (31.2%). the two documents, though similar in content provoked very different responses, with the College guidance being much more favourably received. All respondents prescribed antipsychotics for BPSD, most commonly quetiapine.Clinical ImplicationsWhen prescribing antipsychotics for behavioural and psychiatric symptoms of dementia, psychiatrists should take both NICE and College guidelines into account and use their clinical judgement.
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Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, Ballard C, Banerjee S, Burns A, Cohen-Mansfield J, Cooper C, Fox N, Gitlin LN, Howard R, Kales HC, Larson EB, Ritchie K, Rockwood K, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, Mukadam N. Dementia prevention, intervention, and care. Lancet 2017; 390:2673-2734. [PMID: 28735855 DOI: 10.1016/s0140-6736(17)31363-6] [Citation(s) in RCA: 3392] [Impact Index Per Article: 484.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/20/2017] [Accepted: 01/25/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Gill Livingston
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK.
| | | | - Vasiliki Orgeta
- Division of Psychiatry, University College London, London, UK
| | - Sergi G Costafreda
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Jonathan Huntley
- Division of Psychiatry, University College London, London, UK; Department of Old Age Psychiatry, King's College London, London, UK
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia; Academic Unit for Psychiatry of Old Age, University of Melbourne, Kew, VIC, Australia
| | | | - Sube Banerjee
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Alistair Burns
- Centre for Dementia Studies, University of Manchester, Manchester, UK
| | - Jiska Cohen-Mansfield
- Department of Health Promotion, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Heczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel; Minerva Center for Interdisciplinary Study of End of Life, Tel Aviv University, Tel Aviv, Israel
| | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Nick Fox
- Dementia Research Centre, University College London, Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Laura N Gitlin
- Center for Innovative Care in Aging, Johns Hopkins University, Baltimore, MD, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK; Camden and Islington NHS Foundation Trust, London, UK
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Karen Ritchie
- Inserm, Unit 1061, Neuropsychiatry: Epidemiological and Clinical Research, La Colombière Hospital, University of Montpellier, Montpellier, France; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kenneth Rockwood
- Centre for the Health Care of Elderly People, Geriatric Medicine Dalhousie University, Halifax, NS, Canada
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Quincy Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins University, Baltimore, MD, USA
| | - Lon S Schneider
- Department of Neurology and Department of Psychiatry and the Behavioural Sciences, Keck School of Medicine, Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Geir Selbæk
- Norwegian National Advisory Unit on Aging and Health, Vestfold Health Trust, Tønsberg, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Centre for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
| | - Linda Teri
- Department Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, WA, USA
| | - Naaheed Mukadam
- Division of Psychiatry, University College London, London, UK
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Abstract
This article reviews psychiatric considerations and common psychiatric emergencies in the elderly. The elderly are vulnerable to medication side-effects because of pharmacokinetic changes from aging, and require lower doses and slower titration. They are a high-risk group for suicide, with more serious intent, fewer warning signs, and more lethality. Prompt diagnosis and treatment of delirium in emergency settings is essential, given association with worse outcomes when undiagnosed. Pharmacologic options with demonstrable efficacy for agitation in dementia are limited to antipsychotics, which are, however, associated with an increased risk of mortality; behavioral interventions are universally recommended as first-line measures.
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Affiliation(s)
- Awais Aftab
- Department of Psychiatry, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10524 Euclid Avenue, 8th Floor, Cleveland, OH 44106, USA.
| | - Asim A Shah
- Psychiatric Residency Education, Menninger Department of Psychiatry, Baylor College of Medicine, 1977 Butler Boulevard, Houston, TX 77030, USA; Menninger Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive Suite 600, Houston, TX 77098, USA; Mood Disorder Research Program at BT, Neuropsychiatric Center, Ben Taub Hospital/HHS, Room 2.125, 1502 Taub Loop, Houston, TX 77030, USA; Community Behavioral Health Program, Psychotherapy Services, Neuropsychiatric Center, Ben Taub Hospital/HHS, Room 2.125, 1502 Taub Loop, Houston, TX 77030, USA
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Montalvo-Ortiz JL, Fisher DW, Rodriguez G, Fang D, Csernansky JG, Dong H. Histone deacetylase inhibitors reverse age-related increases in side effects of haloperidol in mice. Psychopharmacology (Berl) 2017; 234:2385-2398. [PMID: 28421257 PMCID: PMC5538925 DOI: 10.1007/s00213-017-4629-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/04/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Older patients can be especially susceptible to antipsychotic-induced side effects, and the pharmacodynamic mechanism underlying this phenomenon remains unclear. We hypothesized that age-related epigenetic alterations lead to decreased expression and functionality of the dopamine D2 receptor (D2R), contributing to this susceptibility. METHODS In this study, we treated young (2-3 months old) and aged (22-24 months old) C57BL/6 mice with the D2R antagonist haloperidol (HAL) once a day for 14 days to evaluate HAL-induced motor side effects. In addition, we pretreated separate groups of young and aged mice with histone deacetylase (HDAC) inhibitors valproic acid (VPA) or entinostat (MS-275) and then administered HAL. RESULTS Our results show that the motor side effects of HAL are exaggerated in aged mice as compared to young mice and that HDAC inhibitors are able to reverse the severity of these deficits. HAL-induced motor deficits in aged mice are associated with an age- and drug-dependent decrease in striatal D2R protein levels and functionality. Further, histone acetylation was reduced while histone tri-methylation was increased at specific lysine residues of H3 and H4 within the Drd2 promoter in the striatum of aged mice. HDAC inhibitors, particularly VPA, restored striatal D2R protein levels and functionality and reversed age- and drug-related histone modifications at the Drd2 promoter. CONCLUSIONS These results suggest that epigenetic changes at the striatal Drd2 promoter drive age-related increases in antipsychotic side effect susceptibility, and HDAC inhibitors may be an effective adjunct treatment strategy to reduce side effects in aged populations.
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Affiliation(s)
- Janitza L. Montalvo-Ortiz
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Daniel W. Fisher
- Department of Neurology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Guadalupe Rodriguez
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Deyu Fang
- Department of Pathology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - John G. Csernansky
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Chicago, IL 60611, USA
| | - Hongxin Dong
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Ward 7-103, Chicago, IL, 60611, USA.
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Dennis M, Shine L, John A, Marchant A, McGregor J, Lyons RA, Brophy S. Risk of Adverse Outcomes for Older People with Dementia Prescribed Antipsychotic Medication: A Population Based e-Cohort Study. Neurol Ther 2017; 6:57-77. [PMID: 28054240 PMCID: PMC5447553 DOI: 10.1007/s40120-016-0060-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Over recent years there has been growing evidence of increased risk of mortality associated with antipsychotic use in older people with dementia. Although this concern combined with limited evidence of efficacy has informed guidelines restricting antipsychotic prescription in this population, the use of antipsycotics remains common. Many published studies only report short-term outcomes, are restricted to examining mortality and stroke risk or have other limitations. The aim of this study was to assess adverse outcomes associated with the use of antipsychotics in older people living with dementia in Wales (UK). METHODS This was a retrospective study of a population-based dementia cohort using the Welsh Secure Anonymised Information Linkage databank. The prior event rate ratio (PERR) was used to estimate the influence of exposure to antipsychotic medication on acute cardiac events, venous thromboembolism, stroke and hip fracture, and adjusted Cox proportional hazard models were used to compare all-cause mortality. RESULTS A total of 10,339 people aged ≥65 years were identified with newly diagnosed dementia. After excluding those who did not meet the inclusion criteria, 9674 people remained in the main cohort of whom 3735 were exposed to antipsychotic medication. An increased risk of a venous thromboembolic episode [PERR 1.95, 95% confidence interval (CI) 1.83-2.0], stroke (PERR 1.41, 95% CI 1.4-1.46) and hip fracture (PERR 1.62, 95% CI 1.59-1.65) was associated with antipsychotic use. However, there was no long-term increased mortality in people exposed to antipsychotics (adjusted hazard ratio 1.06, 95% CI 0.99-1.13). CONCLUSIONS The increase in adverse medical events supports guidelines restricting antipsychotic use in this population.
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Affiliation(s)
- Michael Dennis
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK.
| | - Laura Shine
- Cwm Taf Health Board, Port Talbot, Wales, UK
| | - Ann John
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Amanda Marchant
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Joanna McGregor
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Ronan A Lyons
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
| | - Sinead Brophy
- Farr Institute of Health Informatics Research, Swansea University Medical School, Swansea, Wales, UK
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van der Linde RM, Dening T, Stephan BCM, Prina AM, Evans E, Brayne C. Longitudinal course of behavioural and psychological symptoms of dementia: systematic review. Br J Psychiatry 2016; 209:366-377. [PMID: 27491532 PMCID: PMC5100633 DOI: 10.1192/bjp.bp.114.148403] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 02/27/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions. AIMS To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset. METHOD A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined. RESULTS The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence. CONCLUSIONS Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.
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Affiliation(s)
- Rianne M. van der Linde
- Correspondence: R. van der Linde, Department of Public Health and Primary Care, Herchel Smith Building, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
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Henni S, Damier FD, Sonnic A, Feinard G, Veyrac G, Pujol JF, de Decker L, Berrut G, Piessard S. NEURODEM: assessment of the iatrogenic alert indicator for nursing home patients with Alzheimer's or Alzheimer-like disease. Aging Clin Exp Res 2016; 28:1015-21. [PMID: 26639669 DOI: 10.1007/s40520-015-0502-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/13/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neuroleptics are known to induce Parkinsonism, tardive dyskinesia and their long-term use was associated with increased risk of hip fractures and impaired cognitive function and even death. METHODS The primary objective of Neurodem study was to determine the IAI of patients with Alzheimer's disease in French NH. RESULTS 1022 patients were enrolled. The IAI was 24.8 %. Multivariate logistic analysis showed that having a severe form of dementia, resident without MMS evaluation the last 12 months and having a prescription for an anxiolytic drug were associated with a higher risk of having a prescription for an antipsychotic drug. CONCLUSION The results from our study show that the percentage of patients receiving an antipsychotic drug (24.8 %) was higher than the national average (18 %). Effective educational activities about appropriate use of antipsychotic drugs in patients with Alzheimer's disease are needed.
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Affiliation(s)
- Samir Henni
- University Hospital Center of Angers, 4 Rue Larrey, 49100, Angers, France.
- AGREE, 8 Brairon, 44690, Château Thebaud, France.
| | | | - Anne Sonnic
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pôle de Gérontologie Clinique, CHU Nantes, Hôpital Bellier, 41 Rue Curie, 44046, Nantes Cedex 1, France
| | - Gwennaelle Feinard
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pharmacie Hôpital Sèvre ET Loire, 44120, Vertou, France
| | - Gwennäelle Veyrac
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pôle de Gérontologie Clinique, CHU Nantes, Hôpital Bellier, 41 Rue Curie, 44046, Nantes Cedex 1, France
- Clinical Pharmacology Department, Institute of Biology, University Hospital, Nantes, France
| | - Jean-Francois Pujol
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- , 27 Les Essarts Nursing Home, Rue Des Hirondelles, 85140, Les Essarts, France
| | - Laure de Decker
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pôle de Gérontologie Clinique, CHU Nantes, Hôpital Bellier, 41 Rue Curie, 44046, Nantes Cedex 1, France
| | - Gilles Berrut
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pôle de Gérontologie Clinique, CHU Nantes, Hôpital Bellier, 41 Rue Curie, 44046, Nantes Cedex 1, France
| | - Sylvie Piessard
- AGREE, 8 Brairon, 44690, Château Thebaud, France
- Pharmacie Hôpital Sèvre ET Loire, 44120, Vertou, France
- Faculté de Pharmacie, Université de Nantes, 9, Rue Bias BP53508, 44035, Nantes Cedex 1, France
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Mansbach WE, Mace RA, Clark KM, Firth IM, Breeden JK. Predicting Off-Label Antipsychotic Medication Use in a Randomly Selected Nursing Home Sample Based on Resident and Facility Characteristics. Res Gerontol Nurs 2016; 9:257-266. [PMID: 27665755 DOI: 10.3928/19404921-20160920-03] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/08/2016] [Indexed: 11/20/2022]
Abstract
Reducing off-label antipsychotic medication use for behavioral and psychological symptoms of dementia (BPSD) in nursing home residents has been a centerpiece of government regulation, but without insight into utilization differences based on resident and facility characteristics. To examine whether resident and facility characteristics can predict off-label antipsychotic medication treatment for BPSD, residents prescribed antipsychotic medication (N = 216) from 17 Maryland nursing facilities were randomly selected. Based on physician diagnoses, 59.7% of participants were taking off-label antipsychotic medications for BPSD. Hierarchical logistic regression results suggest that dementia level (indicated by Brief Cognitive Assessment Tool scores) and age, but not facility characteristics, significantly predict greater likelihood of using off-label antipsychotic medications for BPSD. Having moderate-severe dementia was associated with more than a four-fold increase in off-label antipsychotic medication use for BPSD. Off-label use of antipsychotic medications for BPSD remains high, especially for older nursing home residents with more severe dementia, indicating that more targeted reduction approaches are needed. [Res Gerontol Nurs. 2016; 9(6):257-266.].
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Atypical antipsychotics and effects on feeding: from mice to men. Psychopharmacology (Berl) 2016; 233:2629-53. [PMID: 27251130 DOI: 10.1007/s00213-016-4324-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 05/15/2016] [Indexed: 12/22/2022]
Abstract
RATIONALE So-called atypical antipsychotics (AAPs) are associated with varying levels of weight gain and associated metabolic disturbances, which in patients with serious mental illness (SMI) have been linked to non-compliance and poor functional outcomes. Mechanisms underlying AAP-induced metabolic abnormalities are only partially understood. Antipsychotic-induced weight gain may occur as a result of increases in food intake and/or changes in feeding. OBJECTIVE In this review, we examine the available human and preclinical literature addressing AAP-related changes in feeding behavior, to determine whether changes in appetite and perturbations in regulation of food intake could be contributing factors to antipsychotic-induced weight gain. RESULTS In general, human studies point to disruption by AAPs of feeding behaviors and food consumption. In rodents, increases in cumulative food intake are mainly observed in females; however, changes in feeding microstructure or motivational aspects of food intake appear to occur independent of sex. CONCLUSIONS The findings from this review indicate that the varying levels of AAP-related weight gain reflect changes in both appetite and feeding behaviors, which differ by type of AAP. However, inconsistencies exist among the studies (both human and rodent) that may reflect considerable differences in study design and methodology. Future studies examining underlying mechanisms of antipsychotic-induced weight gain are recommended in order to develop strategies addressing the serious metabolic side effect of AAPs.
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The effect of memantine on sleep architecture and psychiatric symptoms in patients with Alzheimer's disease. Acta Neuropsychiatr 2016; 28:157-64. [PMID: 26572055 DOI: 10.1017/neu.2015.61] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Behavioural and psychological symptoms of dementia (BPSD) are commonly present in patients with Alzheimer's disease (AD). Disturbed sleep quality is also observed in AD patients. However, the effects of memantine on sleep architecture have not been investigated. The purpose of this study was to investigate the effects of memantine on polysomnography (PSG) variables and BPSD. METHODS In total, 12 patients with AD (mean age: 79.0±4.1 years old) were enrolled in this study. The following tests were performed: the Neuropsychiatric Inventory for the assessment of BPSD, the Mini-Mental State Examination (MMSE) for cognitive function, and PSG for evaluation of sleep architecture. After baseline examinations, patients were treated with memantine according to a standard prescription protocol. After being treated with 20 mg/day of memantine for 4 weeks, examinations were carried out again. RESULTS All subjects completed the trial. The mean MMSE and NPI scores were 22.6±3.4 and 13.8±12.9, respectively. Treatment with memantine significantly decreased the NPI score (5.8±4.3, p<0.01). There were significant decreases in the scores of subscales for anxiety (p=0.04) and irritability/lability (p=0.04). PSG demonstrated a longer total sleep time (TST) (p<0.01), increases in sleep efficiency (p<0.01) and time spent in stage II (% TST, p=0.02), and decreases in nocturnal awakening (p<0.01), the periodic limb movement index (p<0.01), and time spent in stage I (% TST, p=0.02). CONCLUSION Memantine was effective for reducing fragmented sleep and improving BPSD, and was well tolerated.
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Shaw C, McCormack B, Hughes CM. Prescribing of Psychoactive Drugs for Older People in Nursing Homes: An Analysis of Treatment Culture. Drugs Real World Outcomes 2016; 3:121-130. [PMID: 27747811 PMCID: PMC4819472 DOI: 10.1007/s40801-016-0066-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is increasing interest in how culture may affect the quality of healthcare services, and previous research has shown that 'treatment culture'-of which there are three categories (resident centred, ambiguous and traditional)-in a nursing home may influence prescribing of psychoactive medications. OBJECTIVE The objective of this study was to explore and understand treatment culture in prescribing of psychoactive medications for older people with dementia in nursing homes. METHOD Six nursing homes-two from each treatment culture category-participated in this study. Qualitative data were collected through semi-structured interviews with nursing home staff and general practitioners (GPs), which sought to determine participants' views on prescribing and administration of psychoactive medication, and their understanding of treatment culture and its potential influence on prescribing of psychoactive drugs. Following verbatim transcription, the data were analysed and themes were identified, facilitated by NVivo® and discussion within the research team. RESULTS Interviews took place with five managers, seven nurses, 13 care assistants and two GPs. Four themes emerged: the characteristics of the setting, the characteristics of the individual, relationships and decision making. The characteristics of the setting were exemplified by views of the setting, daily routines and staff training. The characteristics of the individual were demonstrated by views on the personhood of residents and staff attitudes. Relationships varied between staff within and outside the home. These relationships appeared to influence decision making about prescribing of medications. The data analysis found that each home exhibited traits that were indicative of its respective assigned treatment culture. CONCLUSION Nursing home treatment culture appeared to be influenced by four main themes. Modification of these factors may lead to a shift in culture towards a more flexible, resident-centred culture and a reduction in prescribing and use of psychoactive medication.
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Affiliation(s)
- Catherine Shaw
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
| | - Brendan McCormack
- School of Health Sciences, Queen Margaret University, Musselburgh, Scotland, UK
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
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Pasqualetti G, Tognini S, Calsolaro V, Polini A, Monzani F. Potential drug-drug interactions in Alzheimer patients with behavioral symptoms. Clin Interv Aging 2015; 10:1457-66. [PMID: 26392756 PMCID: PMC4573195 DOI: 10.2147/cia.s87466] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The use of multi drug regimens among the elderly population has increased tremendously over the last decade although the benefits of medications are always accompanied by potential harm, even when prescribed at recommended doses. The elderly populations are particularly at an increased risk of adverse drug reactions considering comorbidity, poly-therapy, physiological changes affecting the pharmacokinetics and pharmacodynamics of many drugs and, in some cases, poor compliance due to cognitive impairment and/or depression. In this setting, drug–drug interaction may represent a serious and even life-threatening clinical condition. Moreover, the inability to distinguish drug-induced symptoms from a definitive medical diagnosis often results in addition of yet another drug to treat the symptoms, which in turn increases drug–drug interactions. Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, are the most widely prescribed agents for Alzheimer’s disease (AD) patients. Behavioral and psychological symptoms of dementia, including psychotic symptoms and behavioral disorders, represent noncognitive disturbances frequently observed in AD patients. Antipsychotic drugs are at high risk of adverse events, even at modest doses, and may interfere with the progression of cognitive impairment and interact with several drugs including anti-arrhythmics and acetylcholinesterase inhibitors. Other medications often used in AD patients are represented by anxiolytic, like benzodiazepine, or antidepressant agents. These agents also might interfere with other concomitant drugs through both pharmacokinetic and pharmacodynamic mechanisms. In this review we focus on the most frequent drug–drug interactions, potentially harmful, in AD patients with behavioral symptoms considering both physiological and pathological changes in AD patients, and potential pharmacodynamic/pharmacokinetic drug interaction mechanisms.
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Affiliation(s)
- Giuseppe Pasqualetti
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sara Tognini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valeria Calsolaro
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio Polini
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Fabio Monzani
- Geriatrics Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Griffin JM, Meis LA, Greer N, MacDonald R, Jensen A, Rutks I, Carlyle M, Wilt TJ. Effectiveness of Caregiver Interventions on Patient Outcomes in Adults With Dementia or Alzheimer's Disease: A Systematic Review. Gerontol Geriatr Med 2015; 1:2333721415595789. [PMID: 28138460 PMCID: PMC5129450 DOI: 10.1177/2333721415595789] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: We conducted a systematic review to evaluate whether caregiver-involved interventions improve patient outcomes among adults with dementia or Alzheimer's disease. Method: We identified and summarized data from randomized controlled trials enrolling adults with dementia or Alzheimer's disease by searching MEDLINE, PsycINFO, and other sources. Patient outcomes included global quality of life, physical and cognitive functioning, depression/anxiety, symptom control and management, and health care utilization. Results: We identified 31 trials; 20 compared a caregiver intervention with usual care or usual care with promise of intervention at completion of study period. Fifteen compared one caregiver intervention with another individual or caregiver intervention (active control). Compared with usual care or active controls, caregiver-involved interventions had low to insufficient strength of evidence and did not consistently improve patient outcomes. Discussion: Evidence is insufficient to endorse use of most caregiver interventions to improve outcomes for patients with dementia or Alzheimer's disease.
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Affiliation(s)
- Joan M Griffin
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA; Mayo Clinic, Rochester, MN, USA
| | - Laura A Meis
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA; University of Minnesota, Minneapolis, USA
| | - Nancy Greer
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA
| | - Agnes Jensen
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA
| | - Indulis Rutks
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA
| | - Maureen Carlyle
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Center for Chronic Disease Outcomes Research, MN USA; University of Minnesota, Minneapolis, USA; Minneapolis VA Medical Center Section of General Medicine, MN, USA
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Wastesson JW, Ringbäck Weitoft G, Johnell K. Educational disparities in antipsychotic drug use among older people with and without dementia in Sweden. Acta Psychiatr Scand 2015; 132:20-8. [PMID: 25532774 DOI: 10.1111/acps.12378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Antipsychotic drugs are commonly used to treat behavioural and psychological symptoms of dementia. The aim was to investigate if socioeconomic position was associated with antipsychotic drug treatment among older adults with and without dementia. METHOD By record linkage of the Swedish Prescribed Drug Register, Patient Register, and Educational Register, we obtained information on antipsychotics, dementia status, and educational level for 641,566 persons aged 75-89 year old in Sweden 2005. RESULTS Among persons diagnosed with dementia (n = 32 092), 21% used antipsychotics compared with 4% in the total sample (n = 641,566). Lower education was associated with a higher probability of antipsychotic use in the total sample (adjusted odds ratio [OR] low vs. high education: 1.56; 95% confidence interval [CI]: 1.48-1.64). In the dementia subpopulation, lower education was also associated with a higher likelihood of use of antipsychotics (adjusted OR(low vs. high) 1.43; 95% CI: 1.28-1.59). CONCLUSION People with dementia were five times more likely to use antipsychotic drugs than the general population of older adults. Also, lower education was associated with a higher use of antipsychotics, both in the general population and in the subgroup of persons with dementia. This finding highlights the importance of investigating healthcare inequalities also among cognitively impaired older adults.
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Affiliation(s)
- J W Wastesson
- Aging Research Center, Karolinska Institutet, Stockholm University, Stockholm, Sweden
| | | | - K Johnell
- Aging Research Center, Karolinska Institutet, Stockholm University, Stockholm, Sweden
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Chang KJ, Hong CH, Lee Y, Lee KS, Roh HW, Back JH, Jung YK, Lim KY, Noh JS, Kim HC, Choi SH, Kim SY, Na DL, Seo SW, Lee S, Son SJ. Effect of Psychotropic Drugs on Development of Diabetes Mellitus in Patients With Alzheimer's Disease. Medicine (Baltimore) 2015; 94:e919. [PMID: 26061313 PMCID: PMC4616477 DOI: 10.1097/md.0000000000000919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We aimed to examine risk of diabetes mellitus (DM) among older adults with Alzheimer's disease receiving 3 types of psychotropic drugs, that is, antipsychotics, antidepressants, and sedative anxiolytics. We retrospectively analyzed data from a hospital-based Clinical Research Center for Dementia of South Korea (CREDOS) study conducted between January 1, 2008 and December 31, 2012. Participants (n = 3042) with Alzheimer's disease were aged 65 or older and had no preexisting history of DM. Development of DM was identified using claims for initiating at least 1 prescription of antidiabetic medications or a diagnosis of DM during the follow-up period. Cox proportional hazards regression was used to demonstrate the Hazard ratio of DM in use of each psychotropic drug. Among the 3042 participants, 426 patients (14.0%) developed DM, representing an incidence rate of 5.2/100 person-years during an average 2.9 years of follow-up period. Among the 3 types of psychotropic drugs, antipsychotic users had a significantly higher risk of DM (hazard ratio = 1.74, 95% confidence interval = 1.10, 2.76) than nonusers, after adjusting covariates. Antidepressants and sedative anxiolytics did not achieve statistical significance. These results suggested that the diabetes risk was elevated in Alzheimer patients on antipsychotic treatment. Therefore, patients with Alzheimer's disease receiving antipsychotic treatment should be carefully monitored for the development of DM.
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Affiliation(s)
- Ki Jung Chang
- From the Department of Psychiatry, Ajou University School of Medicine (KJC, CHH, HWR, YKJ, ZKYL, JSN, SJS); Institute on Aging, Ajou University Medical Center (CHH, YL); Department of Preventive Medicine and Public Health, Ajou University School of Medicine, Suwon (YL); Department of Psychiatry, CHA University School of Medicine, CHA Hospital, Bundang (KSL); Health Insurance Policy Research Institute (JHB); Department of Psychiatry, National Medical Center, Seoul (HCK); Department of Neurology, Inha University College of Medicine, Incheon (SHC); Memory Impairment Center, Ajou University Hospital, Suwon (CHH); Department of Psychiatry, Asan Medical Center (SYK); Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine (DLN, SWS); and Department of Medicare Administration, Backseok Arts University, Seoul, South Korea (SL)
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Abstract
Primary care providers (PCPs) are frequently responsible for the pharmacologic management of mood disorders, and the PCP is often an important member of the clinical team in the management of bipolar disorder and schizophrenia. Not only is a good understanding of psychopharmacology important for the effective treatment of psychiatric disease, it is also necessary for patient safety. Clinicians should understand the side effects and the medication interactions associated with psychotropic medications. This article reviews mechanisms of action, indications, dosing, side effects, medication interactions, and general management considerations for common medications used to treat psychiatric conditions encountered in the primary care setting.
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Affiliation(s)
- L Renata Thronson
- Division of General Internal Medicine, Department of Medicine, Adult Medicine Clinic, Harborview Medical Center, University of Washington School of Medicine, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Genevieve L Pagalilauan
- Department of Medicine, Division of General Internal Medicine, Roosevelt General Internal Medicine Clinic, University of Washington Medical Center, 4245 Roosevelt Way North East, Seattle, WA 98105
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Marvanova M. Antipsychotic use in elderly patients with dementia: Efficacy and safety concerns. Ment Health Clin 2014. [DOI: 10.9740/mhc.n204371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Behavioral and psychiatric symptoms of dementia (BPSD) refer to a heterogeneous group of symptoms that represent non-cognitive complications of Alzheimer's disease (AD) and other dementias. Currently, there are no FDA-approved antipsychotic medications for management of BPSD in the United States. Second generation antipsychotics (SGAs) should only be used for appropriate and justified BPSD targets including distressing and severe physical aggression and/or disturbing hallucinations or delusions that pose a risk of harm to self or others after non-pharmacologic interventions have failed. At best, SGAs provide only modest effects and are associated with increased risk for mortality and cerebrovascular complications in addition to other agent-specific side effects. Current evidence and recommendations support use of risperidone, aripiprazole or olanzapine for Alzheimer's disease (AD) and vascular dementia (VaD), and use of quetiapine or clozapine for Lewy body dementia (LBD) and Parkinson's disease dementia (PDD). Any SGA should be initiated at low dosages with slow titration; and the lowest effective dose should be used as a maintenance dose only for a short period of time. Patients should be monitored for clinical response and adverse effects and should be periodically evaluated for continued need for medication. Appropriate use of SGAs for management of BPSD is critical to increase safety for our growing elderly population with dementia.
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Affiliation(s)
- Marketa Marvanova
- 1 Associate Professor, Pharmacy Practice, Chicago State University College of Pharmacy, Adjunct Associate Professor of Neurology, Northwestern University Feinberg School of Medicine, Department of Neurology, Clinical Pharmacy Specialist, Neurology, Rush University Medical Center, Chicago, IL
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Konetzka RT, Brauner DJ, Shega J, Werner RM. The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment. J Am Geriatr Soc 2014; 62:454-61. [PMID: 24617991 DOI: 10.1111/jgs.12711] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment. DESIGN Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs. SETTING Medicare- and Medicaid-certified NHs in the United States. PARTICIPANTS Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states. INTERVENTION Public reporting of physical restraint use rates. MEASUREMENTS Use of physical restraints and antipsychotic medications. RESULTS Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints. CONCLUSION This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.
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Affiliation(s)
- R Tamara Konetzka
- Department of Health Studies, University of Chicago, Chicago, Illinois
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Moretti R, Torre P, Antonello RM, Pizzolato G. Atypical neuroleptics as a treatment of agitation and anxiety in Alzheimer’s disease: risks or benefits. Expert Rev Neurother 2014; 6:705-10. [PMID: 16734518 DOI: 10.1586/14737175.6.5.705] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Behavioral problems produce excess disability that can be potentially devastating in cognitively impaired patients. These behavioral symptoms can be a major cause of stress, anxiety and concern for caregivers. While psychotropic drugs are frequently used to control these symptoms, they have the potential for significant side effects, which include sedation, disinhibition, depression, falls, incontinence, parkinsonism and akathisias. On examination of the consequences of adverse events, somnolence, as well as postural instability and postural hypotension, have been noted. All patients with Alzheimer's disease (AD) and other progressive dementias will advance through stages of moderate-to-severe AD unless effective treatments suspend transition from mild deterioration to dementia, or competitive mortality truncates survival. Treatment trials suggest that these patients respond to both disease-modifying (such as inhibitors of cholinesterase and butirrylcholinesterase) and symptomatic (such as neuroleptics) agents. Relatively few studies have been conducted in this patient population, and more information regarding the type of behavioral disturbances exhibited, how best to measure them in this disabled population and their optimum treatment are urgently needed.
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Affiliation(s)
- Rita Moretti
- Università di Trieste, Dipartimento di Medicina Clinica e Neurologia, UCO di Neurologia dell'Università degli Studi di Trieste, Ospedale di Cattinara, 34149 Trieste, Italy.
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Alessi-Severini S, Dahl M, Schultz J, Metge C, Raymond C. Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases. PeerJ 2013; 1:e168. [PMID: 24109553 PMCID: PMC3792174 DOI: 10.7717/peerj.168] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 08/31/2013] [Indexed: 11/21/2022] Open
Abstract
Background. Psychotropic medications, in particular second-generation antipsychotics (SGAs) and benzodiazepines, have been associated with harm in elderly populations. Health agencies around the world have issued warnings about the risks of prescribing such medications to frail individuals affected by dementia and current guidelines recommend their use only in cases where the benefits clearly outweigh the risks. This study documents the use of psychotropic medications in the entire elderly population of a Canadian province in the context of current clinical guidelines for the treatment of behavioural disturbances. Methods. Prevalent and incident utilization of antipsychotics, benzodiazepines and related medications (zopiclone and zaleplon) were determined in the population of Manitobans over age 65 in the time period 1997/98 to 2008/09 fiscal years. Comparisons between patients living in the community and those living in personal care (nursing) homes (PCH) were conducted. Influence of sociodemographic characteristics on prescribing was assessed by generalized estimating equations. Non-optimal use was defined as the prescribing of high dose of antipsychotic medications and the use of combination therapy of a benzodiazepine (or zopiclone/zaleplon) with an antipsychotic. A decrease in intensity of use over time and lower proportions of patients treated with antipsychotics at high dose or in combination with benzodiazepines (or zopiclone/zaleplon) was considered a trend toward better prescribing. Multiple regression analysis determined predictors of non-optimal use in the elderly population. Results. A 20-fold greater prevalent utilization of SGAs was observed in PCH-dwelling elderly persons compared to those living in the community. In 2008/09, 27% of PCH-dwelling individuals received a prescription for an SGA. Patient characteristics, such as younger age, male gender, diagnoses of dementia (or use of an acetylcholinesterase inhibitor) or psychosis in the year prior the prescription, were predictors of non-optimal prescribing (e.g., high dose antipsychotics). During the period 2002/3 and 2007/8, amongst new users of SGAs, 10.2% received high doses. Those receiving high dose antipsychotics did not show high levels of polypharmacy. Conclusions. Despite encouraging trends, the use of psychotropic medications remains high in elderly individuals, especially in residents of nursing homes. Clinicians caring for such patients need to carefully assess risks and benefits.
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Psychotropic prescribing in the oldest old attending a geriatric psychiatry service: a retrospective, cross-sectional study. Ir J Psychol Med 2013; 30:187-196. [PMID: 30189496 DOI: 10.1017/ipm.2013.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy. METHODS Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria. RESULTS A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0-5) psychotropics and 4.99 (S.D. 2.7, range 0-11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = -1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9-17.4)], anxiolytic [OR 13.5 (95% CI 1.7-110.4)] and antipsychotic [OR 3.4 (95% CI 1.1-10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%). CONCLUSIONS Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.
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Huang YJ, Lin CH, Lane HY, Tsai GE. NMDA Neurotransmission Dysfunction in Behavioral and Psychological Symptoms of Alzheimer's Disease. Curr Neuropharmacol 2013; 10:272-85. [PMID: 23450042 PMCID: PMC3468881 DOI: 10.2174/157015912803217288] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 06/04/2012] [Accepted: 07/09/2012] [Indexed: 01/06/2023] Open
Abstract
Dementia has become an all-important disease because the population is aging rapidly and the cost of health care associated with dementia is ever increasing. In addition to cognitive function impairment, associated behavioral and psychological symptoms of dementia (BPSD) worsen patient’s quality of life and increase caregiver’s burden. Alzheimer’s disease is the most common type of dementia and both behavioral disturbance and cognitive impairment of Alzheimer’s disease are thought to be associated with the N-methyl-D-aspartate (NMDA) dysfunction as increasing evidence of dysfunctional glutamatergic neurotransmission had been reported in behavioral changes and cognitive decline in Alzheimer’s disease. We review the literature regarding dementia (especially Alzheimer’s disease), BPSD and relevant findings on glutamatergic and NMDA neurotransmission, including the effects of memantine, a NMDA receptor antagonist, and NMDA-enhancing agents, such as D-serine and D-cycloserine. Literatures suggest that behavioral disturbance and cognitive impairment of Alzheimer’s disease may be associated with excitatory neurotoxic effects which result in impairment of neuronal plasticity and degenerative processes. Memantine shows benefits in improving cognition, function, agitation/aggression and delusion in Alzheimer’s disease. On the other hand, some NMDA modulators which enhance NMDA function through the co-agonist binding site can also improve cognitive function and psychotic symptoms. We propose that modulating NMDA neurotransmission is effective in treating behavioral and psychological symptoms of Alzheimer’s disease. Prospective study using NMDA enhancers in patients with Alzheimer’s disease and associated behavioral disturbance is needed to verify this hypothesis.
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Affiliation(s)
- Yu-Jhen Huang
- Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan ; Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
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Physicians' practice and familiarity with treatment for agitation associated with dementia in Israeli nursing homes. Int Psychogeriatr 2013; 25:236-44. [PMID: 23174135 DOI: 10.1017/s104161021200172x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To clarify physicians' actual practice in treating agitation in the nursing home and to elucidate the relationship between background factors, familiarity with interventions, and practice. METHODS A survey of actual practice for agitation in persons with dementia was administered to 67 physicians aged 31-70+ working in nursing homes in Israel. Questionnaires were administered by personal interview, self-completed, or a combination of the two. RESULTS Psychotropic medications are prescribed by 92.5% of physicians for treating agitation, most notably, Haloperidol (39%). Non-pharmacological treatment was also reported to be common, though to a lesser extent, with environmental change being the most prevalent non-pharmacological intervention. Generally, physicians showed low familiarity levels with non-pharmacological interventions, with higher levels noted for physicians with a specialty in geriatrics compared to those who were non-specialized. Physicians who were non-Israeli and younger also reported higher familiarity levels compared to their respective counterparts (i.e. Israeli and older) but this difference did not reach significance. CONCLUSION The findings indicate that, despite current guidelines, psychotropic medications are the treatment of choice among nursing home physicians in Israel. While rates of use of non-pharmacological interventions are substantial, their in-practice application may be hindered by lack of familiarity as well as system barriers. The results have implications for system and education changes.
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Abstract
BACKGROUND Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Affairs (VA) nursing homes [ie, Community Living Centers (CLCs)], we assessed the prevalence and risk factors for antipsychotic use in older residents of VA CLCs. METHODS This cross-sectional study included 3692 Veterans age 65 or older who were admitted between January 2004 and June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (eg, schizophrenia, dementia with psychosis). We used multivariable logistic regression and generalized estimating equations to identify factors independently associated with antipsychotic receipt. RESULTS Overall, 948/3692(25.7%) residents received an antipsychotic, of which 59.3% had an evidence-based indication for use. Residents with aggressive behavior [odds ratio (OR)=2.74, 95% confidence interval (CI), 2.04-3.67] and polypharmacy (9+ drugs; OR=1.84, 95% CI, 1.41-2.40) were more likely to receive antipsychotics, as were users of antidepressants (OR=1.37, 95% CI, 1.14-1.66), anxiolytic/hypnotics (OR=2.30, 95% CI, 1.64-3.23), or drugs for dementia (OR=1.52, 95% CI, 1.21-1.92). Those residing in Alzheimer/dementia special care units were also more likely to receive an antipsychotic (OR=1.66, 95% CI, 1.26-2.21). Veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR=1.10, 95% CI, 0.82-1.47). CONCLUSIONS Antipsychotic use is common among VA nursing home residents aged 65 and older, including those without a documented evidence-based indication for use. Further quality improvement efforts are needed to reduce potentially inappropriate antipsychotic prescribing.
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Ismail Z, Emeremni CA, Houck PR, Mazumdar S, Rosen J, Rajji TK, Pollock BG, Mulsant BH. A comparison of the E-BEHAVE-AD, NBRS, and NPI in quantifying clinical improvement in the treatment of agitation and psychosis associated with dementia. Am J Geriatr Psychiatry 2013; 21:78-87. [PMID: 23290205 PMCID: PMC3499650 DOI: 10.1016/j.jagp.2012.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 04/20/2011] [Accepted: 06/06/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of this study is to compare the Empirical Behavioral Rating Scale (E-BEHAVE-AD), Neurobehavioral Rating Scale (NBRS), and Neuropsychiatric Interview (NPI) in detecting behavioral disturbance and psychotic symptoms in dementia and characterizing changes in response to treatment. DESIGN Eighty-seven subjects in the randomized controlled trial "Continuation Pharmacotherapy for Agitation of Dementia" were included in this analysis. We compared the detection in, and changes of, both agitation and psychosis, using these three instruments. A receiver operating characteristic analysis was performed to compare the performance of the three instruments in detecting global improvement. RESULTS The instruments were equally likely to detect agitation. The NBRS was most likely to detect psychosis. Although the NPI best detected improvement in agitation, the instruments were equal for detecting improvement in psychosis. In the receiver operating characteristic analysis for overall clinical improvement in response to treatment, there were no differences in the areas under the correlated curves for the three instruments, but they demonstrated different sensitivity and specificity at different cutoff points for target symptom reduction. The E-BEHAVE-AD performed best at a cut point of 30% target symptom reduction and the NBRS and NPI both performed best at 50%. CONCLUSION The E-BEHAVE-AD, NBRS, and NPI were more similar than different in characterizing symptoms but differed in detecting response to treatment. Differences in sensitivity and specificity may lead clinicians to prefer a specific instrument, depending on their goal and the expected magnitude of response to any specific intervention.
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Affiliation(s)
- Zahinoor Ismail
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto Ontario, Canada
- Department of Psychiatry, University of Calgary, Calgary Alberta, Canada
| | - Chetachi A Emeremni
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Patricia R. Houck
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Sati Mazumdar
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Jules Rosen
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Tarek K. Rajji
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto Ontario, Canada
| | - Bruce G. Pollock
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto Ontario, Canada
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Benoit H. Mulsant
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto Ontario, Canada
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, USA
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