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Chen AC, Epstein AM, Joynt Maddox KE, Grabowski DC, Orav EJ, Barnett ML. Impact of dementia special care units for short-stay nursing home patients. J Am Geriatr Soc 2024; 72:767-777. [PMID: 38041834 PMCID: PMC10947952 DOI: 10.1111/jgs.18708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients. METHODS We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool. RESULTS The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode. CONCLUSIONS Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.
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Affiliation(s)
- Amanda C Chen
- Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine and Center for Advancing Health Services, Policy and Economics Research, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Lapane KL, Dubé CE, Jesdale BM, Bova C. Social Connectedness among Long-Stay Nursing Home Residents with Alzheimer's and Dementia: Exploring Individual and Facility-Level Variation. Dement Geriatr Cogn Disord 2022; 51:249-261. [PMID: 35785759 PMCID: PMC9501789 DOI: 10.1159/000525343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/13/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION This study sought to explore individual and facility-level variation in social connectedness among long-stay nursing home residents with Alzheimer's or other dementias (ADRD). METHODS We identified 721,074 long-stay residents with ADRD using 2016 Minimum Data Set 3.0 data. Social connectedness was defined using the social connectedness index (SCI) (high: SCI = 5, lower: 0 < SCI ≤ 4). Adjusted odds ratios (aOR) provided estimates of the associations between resident-level and facility-level characteristics, and high SCI was derived from logistic models. RESULTS The SCI Cronbach's alpha was 0.69; 78.6% had high SCI scores. Men were less likely than women to have higher SCI scores (aOR = 0.97; 95% CI: 0.97-0.98). Increasing age was associated with higher SCI scores (e.g., aOR [85-94 vs. 40-64 years]: 1.07; 95% CI: 1.06-1.07). Those with moderate cognitive impairment (aOR: 0.87) and severe cognitive impairment (aOR: 0.85) had reduced odds of SCI = 5 relative to those with mild/intact cognitive function. Residents living in homes with special care dementia units and with higher percentage of residents with dementia had decreased odds of high social connectedness. DISCUSSION/CONCLUSION Understanding resident- and nursing home-level variation in social connectedness may be important for targeting interventions that reduce isolation among residents with ADRD.
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Affiliation(s)
- Kate L. Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA,*Kate L. Lapane,
| | - Catherine E. Dubé
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Bill M. Jesdale
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Carol Bova
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, Massachusetts, USA
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Orth J, Cagle JG. Nursing Home Alzheimer's Special Care Units: Geographic Location Matters. J Am Med Dir Assoc 2022; 23:150-155. [PMID: 34411539 PMCID: PMC8712367 DOI: 10.1016/j.jamda.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/10/2021] [Accepted: 07/18/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Limited data suggest nursing home (NH) Alzheimer's special care units (ASCUs) may improve care and outcomes among residents with dementia. Unfortunately, information describing NH characteristics related to presence of ASCUs is lacking, especially whether location and neighborhood resources influence their presence. We examined locations of NHs with ASCUs and assessed whether neighborhood socioeconomic deprivation, region, and levels of rurality were associated with NH ASCUs. DESIGN Cross-sectional. SETTING AND PARTICIPANTS Contiguous United States; we used 2017 LTCfocus and NH Compare data to identify free-standing NHs and obtain addresses (N = 13,207 NHs). METHODS NH ZIP+4 codes were linked to the Area Deprivation Index (ADI) (within-state ranking of neighborhood deprivation). The 9 census-defined regions of the United States and Rural Urban Continuum codes categorized location. Descriptive analyses and binary logistic regression models, adjusting for NH characteristics, examined associations between NH ASCUs and location. RESULTS Nearly 15% of NHs had ASCUs. In adjusted models, odds of NH ASCUs were 58% to 69% lower in Pacific, Middle Atlantic, and Southern regions compared with the East North Central region (P values <.001). Odds of NH ASCUs increased 25% to 47% as rurality increased relative to NHs in the most metropolitan areas (P < .01); however, odds of NH ASCUs decreased 63% in the most rural areas (P < .001). ADI was not significantly associated with NH ASCUs. For-profit NHs had 42% lower and chain-affiliated NHs 34% higher odds of ASCUs (P < .001). NHs with higher total staffing hours had 29% higher odds of ASCUs; odds of ASCUs were 46% lower in NHs with more RN staffing hours (P < .001). CONCLUSIONS AND IMPLICATIONS Using a robust sample, region, rurality, ownership, and nursing hours significantly predicted NH ASCUs whereas ADI did not. Geographically tailored interventions should be considered to promote use of NH-based ASCUs.
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Affiliation(s)
- Jessica Orth
- University of Maryland School of Social Work, Baltimore, MD, USA.
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
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Palm R, Fahsold A, Roes M, Holle B. Context, mechanisms and outcomes of dementia special care units: An initial programme theory based on realist methodology. PLoS One 2021; 16:e0259496. [PMID: 34784375 PMCID: PMC8594822 DOI: 10.1371/journal.pone.0259496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 10/20/2021] [Indexed: 11/19/2022] Open
Abstract
Background Dementia special care units represent a widely implemented care model in nursing homes. Their benefits must be thoroughly evaluated given the risk of exclusion and stigma. The aim of this study is to present an initial programme theory that follows the principles of realist methodology. The theory development was guided by the question of the mechanisms at play in the context of dementia special care units to produce or influence outcomes of interest in people with dementia. Methods The initial programme theory is based on qualitative interviews with dementia special care stakeholders in Germany and a realist review of complex interventions in dementia special care units. The interviews were analysed using content analysis techniques. For the realist review, a systematic literature search was conducted in four scientific databases; studies were appraised for quality and relevance. All data were analysed independently by two researchers. A realist informed logic model was developed, and context-mechanism-outcome (CMO) configurations were described. Results We reviewed 16 empirical studies and interviewed 16 stakeholders. In the interviews, contextual factors at the system, organisation and individual levels that influence the provision of care in dementia special care units were discussed. The interviewees described the following four interventions typical of dementia special care units: adaptation to the environment, family and public involvement, provision of activities and behaviour management. With exception of family and public involvement, these interventions were the focus of the reviewed studies. The outcomes of interest of stakeholders include responsive behaviour and quality of life, which were also investigated in the empirical studies. By combining data from interviews and a realist review, we framed three CMO configurations relevant to environment, activity, and behaviour management. Discussion As important contextual factors of dementia special care units, we discuss the transparency of policies to regulate dementia care, segregation and admission policies, purposeful recruitment and education of staff and a good fit between residents and their environment.
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Affiliation(s)
- Rebecca Palm
- Faculty of Health, Witten/Herdecke University, School of Nursing Science, Witten, Germany
- * E-mail:
| | - Anne Fahsold
- Faculty of Health, Witten/Herdecke University, School of Nursing Science, Witten, Germany
- German Center for Neurodegenerative Diseases, Witten, Germany
| | - Martina Roes
- Faculty of Health, Witten/Herdecke University, School of Nursing Science, Witten, Germany
- German Center for Neurodegenerative Diseases, Witten, Germany
| | - Bernhard Holle
- Faculty of Health, Witten/Herdecke University, School of Nursing Science, Witten, Germany
- German Center for Neurodegenerative Diseases, Witten, Germany
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Xu H, Intrator O, Culakova E, Bowblis JR. Changing landscape of nursing homes serving residents with dementia and mental illnesses. Health Serv Res 2021; 57:505-514. [PMID: 34747498 DOI: 10.1111/1475-6773.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/29/2021] [Accepted: 10/29/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g., dementia) and mental health conditions. This study aims to: (1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; (2) examine NH staffing related to the clusters; and (3) investigate the association of staffing and NH quality (measured by the number of deficiencies and deficiency scores) in each cluster. DATA SOURCES 2009-2017 Certification and Survey Provider Enhanced Reporting (CASPER) were merged with LTCFocUS.org data on NHs in the United States. STUDY DESIGN Unsupervised machine learning algorithm (K-means) clustered NHs based on percent residents with dementia, depression, and serious mental illness (SMI, e.g., schizophrenia, anxiety). Panel fixed-effects regressions on deficiency outcomes with staffing-cluster interactions were conducted to examine the effects of staffing on deficiency outcomes in each cluster. DATA EXTRACTION METHODS We identified 110,463 NH-year observations from 14,671 unique NHs using CASPER data. PRINCIPAL FINDINGS Three clusters were identified: low dementia and mental illnesses (Postacute Cluster); high dementia and depression, but low SMI (Long-stay Cluster); and high dementia and mental illnesses (Cognitive-mental Cluster). From 2009 to 2017, the number of Postacute Cluster NHs increased from 3074 to 5719, while the number of Long-stay Cluster NHs decreased from 6745 to 3058. NHs in Long-stay/Cognitive-mental Clusters reported slightly lower nursing staff hours in 2017. Regressions suggested the effect of increasing staffing on reducing deficiencies is statistically similar across NH clusters. For example, 1 hour increase in registered nurse hours per resident day was associated with -0.67 (standard error [SE] = 0.11), -0.88 (SE = 0.12), and -0.97 (SE = 0.15) deficiencies in Postacute Cluster, Long-stay Cluster, and Cognitive-mental Cluster, respectively. CONCLUSIONS Unsupervised machine learning detected a changing landscape of NH serving residents with dementia and mental illnesses, which requires assuring staffing levels and trainings are suited to residents' needs.
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Affiliation(s)
- Huiwen Xu
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas, USA.,Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA
| | - Orna Intrator
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.,Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VA Medical Center, Canandaigua, New York, USA
| | - Eva Culakova
- Department of Surgery, Cancer Control, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, Ohio, USA.,Scripps Gerontology Center, Miami University, Oxford, Ohio, USA
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van der Steen JT, Westzaan A, Hanemaayer K, Muhamad M, de Waal MWM, Achterberg WP. Probable Pain on the Pain Assessment in Impaired Cognition (PAIC15) Instrument: Assessing Sensitivity and Specificity of Cut-Offs against Three Standards. Brain Sci 2021; 11:brainsci11070869. [PMID: 34210018 PMCID: PMC8301856 DOI: 10.3390/brainsci11070869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/16/2021] [Accepted: 06/26/2021] [Indexed: 11/25/2022] Open
Abstract
Observational pain scales can help to identify pain in persons with dementia who may have difficulty expressing pain verbally. The Pain Assessment in Impaired Cognition-15 (PAIC15) covers 15 items that indicate pain, but it is unclear how probable pain is, for each summed score (range 0–45). We aimed to determine sensitivity and specificity of cut-offs for probable pain on the PAIC15 against three standards: (1) self-report when able, (2) the established Pain Assessment in Advanced Dementia (PAINAD) cut-off of 2, and (3) observer’s overall estimate based on a series of systematic observations. We used data of 238 nursing home residents with dementia who were observed by their physician in training or nursing staff in the context of an evidence-based medicine (EBM) training study, with re-assessment after 2 months in 137 residents. The area under the ROC curve was excellent against the PAINAD cut-off (≥0.8) but acceptable or less than acceptable for the other two standards. Across standards and criteria for optimal sensitivity and specificity, PAIC15 scores of 3 and higher represent possible pain for screening in practice, with sensitivity and specificity against self-report in the 0.5 to 0.7 range. While sensitivity for screening in practice may be too low, a cut-off of 4 is reasonable to indicate probable pain in research.
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Affiliation(s)
- Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Department of Primary and Community Care, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Correspondence:
| | - Andrew Westzaan
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Aafje Thuiszorg, Huizen en Zorghotels, Pietersdijk 60, 3079 TD Rotterdam, The Netherlands
| | - Kimberley Hanemaayer
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Franciscus Vlietland Hospital, Vlietlandplein 2, 3118 JH Schiedam, The Netherlands
| | - Muhamad Muhamad
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
- Stichting Voor Regionale Zorgverlening (Nursing Home), Prins Clauslaan 1, 4691 ZA Tholen, The Netherlands
| | - Margot W. M. de Waal
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands; (A.W.); (K.H.); (M.M.); (M.W.M.d.W.); (W.P.A.)
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Orth J, Li Y, Simning A, Zimmerman S, Temkin-Greener H. End-of-Life Care among Nursing Home Residents with Dementia Varies by Nursing Home and Market Characteristics. J Am Med Dir Assoc 2021; 22:320-328.e4. [PMID: 32736989 PMCID: PMC7855379 DOI: 10.1016/j.jamda.2020.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes vary by NH/market characteristics for this population is unknown but essential information for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL care/outcomes among decedents with ADRD and identify associations with NH/market characteristics. DESIGN Cross-sectional. OUTCOMES Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations (PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence of Alzheimer's units, and market competition. SETTING AND PARTICIPANTS Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435; 14,618 NHs) in NHs or hospitals shortly after NH discharge. METHODS National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses and multivariable logistic regressions. RESULTS As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased (17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH market competition was associated with higher likelihood of hospice use, and lower likelihood of in-hospital deaths among decedents with moderate ADRD. CONCLUSIONS AND IMPLICATIONS Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications to state Medicaid NH payments may promote better EOL care/outcomes for this population. Future research to understand NH care practices associated with presence of Alzheimer's units is warranted to identify mechanisms possibly promoting higher-quality EOL care.
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Affiliation(s)
- Jessica Orth
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research and The Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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8
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Orth J, Li Y, Simning A, Temkin-Greener H. Severe Behavioral Health Manifestations in Nursing Homes: Associations with Service Availability? J Am Geriatr Soc 2020; 68:2643-2649. [PMID: 33460044 PMCID: PMC8269953 DOI: 10.1111/jgs.16772] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/10/2020] [Accepted: 07/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES Despite high prevalence of behavioral health (BH) manifestations among nursing home (NH) residents, availability of BH services in this care setting is often inadequate. Our objective was to examine associations between availability of BH services and the presence of severe depression, suicidal ideation (SI), and severe aggressive behaviors (ABs) among NH residents. DESIGN Cross-sectional. SETTING/PARTICIPANTS This study used 2017 survey data about BH service availability obtained from 1,051 NHs. The Minimum Data Set (MDS) was used to identify long-stay residents in these facilities (N = 101,238) and the prevalence of BH manifestations. Descriptive statistics and multivariable logistic regressions were used. MEASUREMENTS We constructed measures of three severe BH manifestations based on the MDS: presence of depression, SI, and ABs. Three independent measures of service availability based on survey items asked about degrees of inadequate (1) staff BH education, (2) coordination/collaboration between facility/community providers, and (3) facility infrastructure (ie, ability to make referrals/transport residents to services). RESULTS Odds of severe depression were 21% higher (odds ratio [OR] = 1.21; P < .001) when NHs reported inadequate BH staff education. Residents with SI had 13% higher odds (OR = 1.13; P = .027) of living in NHs that reported inadequate coordination between facility and community providers. Severe ABs were 10% more likely among residents in NHs reporting inadequate facility infrastructure (OR = 1.10; P = .002) and 7% more likely in facilities with self-reported inadequate coordination between facility/community providers (OR = 1.07; P = .019). Several facility-level factors (eg, staffing, training, turnover) were also statistically significantly associated with these severe BH manifestations. CONCLUSION Residents in NHs reporting inadequate BH services were more likely to experience adverse severe BH manifestations even after controlling for individual and facility-level risk factors. Higher nurse staffing and more staff psychiatric training were associated with lower prevalence of severe BH manifestations. Policy changes and modifications to Medicaid NH reimbursements may be warranted to better incentivize NHs to improve provision of BH services.
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Affiliation(s)
- Jessica Orth
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Adam Simning
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY
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9
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Kok JS, Oude Voshaar RC, Scherder EJA. Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study. Aging Ment Health 2020; 24:689-696. [PMID: 30835505 DOI: 10.1080/13607863.2019.1584784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.
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Affiliation(s)
- Jeroen S Kok
- Lentis
- Dignis, Mental Health Care Institute, Zuidlaren, The Netherlands
| | - Richard C Oude Voshaar
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik J A Scherder
- Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands
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10
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Joyce NR, McGuire TG, Bartels SJ, Mitchell SL, Grabowski DC. The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis. Health Serv Res 2018; 53:3657-3679. [PMID: 29736944 DOI: 10.1111/1475-6773.12867] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia. DATA SOURCES/STUDY SETTING National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database. STUDY DESIGN We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument. DATA COLLECTION/EXTRACTION METHODS Minimum dataset assessments performed at NH admission and every quarter thereafter. PRINCIPAL FINDINGS Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality. CONCLUSIONS Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.
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Affiliation(s)
- Nina R Joyce
- Department of Health Services Policy and Practice, Brown School of Public Health, Brown University School of Public Health, Providence, RI.,Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Stephen J Bartels
- Department of Psychiatry, Community and Family Medicine, The Dartmouth Institute, Hanover, NH.,Dartmouth Centers for Health and Aging, Geisel School of Medicine at Dartmouth, Hanover, NH.,New Hampshire-Dartmouth Psychiatric Research Center, Hanover, NH
| | - Susan L Mitchell
- Hebrew Senior Life Institute for Aging Research, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Blackburn J, Zheng Q, Grabowski DC, Hirth R, Intrator O, Stevenson DG, Banaszak-Holl J. Nursing Home Chain Affiliation and Its Impact on Specialty Service Designation for Alzheimer Disease. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018787992. [PMID: 30047810 PMCID: PMC6077895 DOI: 10.1177/0046958018787992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/24/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
Specialty care units (SCUs) in nursing homes (NHs) grew in popularity during the 1990s to attract residents while national policies and treatment paradigms changed. Alzheimer disease has consistently been the dominant form of SCU. This study explored the extent to which chain affiliation, which is common among NHs, affected SCU bed designation. Using data from the Online Survey Certification and Reporting (OSCAR) from 1996 through 2010 with 207 431 NH-year observations, we described trends and compared chain-affiliated NHs with independent NHs. Designation of beds for Alzheimer disease SCUs grew from 1996 to 2003 and then declined. At the peak, 19.6% of all NHs had at least one Alzheimer disease SCU bed. In general, chain affiliation promoted Alzheimer disease SCU bed designation across time, chain size, and NH profit status. During the period of largest growth from 1996 to 2003, the likelihood of designation of Alzheimer disease SCU beds was 1.55 percentage points higher among for-profit NHs affiliated with large chains than independent for-profit NHs ( P < .001) and remained 1.28 percentage points higher from 2004 to 2010. However, chain-affiliated NHs generally had a lower percentage of residents with dementia than independent NHs. For example, although for-profit NHs affiliated with large chains had more Alzheimer disease SCU beds, they had nearly 3% fewer residents with dementia than independent NHs ( P < .001). We conclude that organizational decisions to designate beds for Alzheimer disease SCUs may be related to marketing strategies to attract residents since adoption of Alzheimer disease SCUs has fluctuated over time, but did not appear driven by demand.
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Affiliation(s)
| | | | | | | | - Orna Intrator
- University of Rochester, NY, USA
- VA National Geriatrics & Extended Care Data Analysis Center, Canandaigua NY
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Peri K, Kerse N, Moyes S, Scahill S, Chen C, Hong JB, Hughes CM. Is psychotropic medication use related to organisational and treatment culture in residential care. J Health Organ Manag 2015; 29:1065-79. [DOI: 10.1108/jhom-10-2013-0236] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to establish the relationship between organisational culture and psychotropic medication use in residential care.
Design/methodology/approach
– Cross-sectional analyses of staff and resident’s record survey in residential aged care facilities in Auckland, New Zealand (NZ). The competing values framework categorised organisational culture as clan, hierarchical, market driven or adhocracy and was completed by all staff. The treatment culture tool categorised facilities as having resident centred or traditional culture and was completed by registered nursing staff and general practitioners (GP). Functional and behavioural characteristics of residents were established by staff report and health characteristics and medications used were ascertained from the health record. Multiple regression was used to test for associations between measures of culture with psychotropic medication use (anxiolytics, sedatives, major tranquillisers).
Findings
– In total 199 staff, 27 GP and 527 residents participated from 14 facilities. On average 8.5 medications per resident were prescribed and 42 per cent of residents received psychotropic medication. Having a diagnosis of anxiety or depression (odds ratio (OR) 3.18, 95 per cent confidence interval (CI) 1.71, 5.91), followed by persistent wandering (OR 2.53, 95 per cent CI 1.59, 4.01) and being in a dementia unit (OR 2.45, 95 per cent CI 1.17, 5.12) were most strongly associated with psychotropic use. Controlling for resident- and facility-level factors, health care assistants’ assignation of hierarchical organisational culture type was independently associated with psychotropic medication use, (OR 1.29, CI 1.08, 1.53) and a higher treatment culture score from the GP was associated with lower use of psychotropic medication (OR 0.95, CI 0.92, 0.98).
Originality/value
– Psychotropic medication use remains prevalent in residential care facilities in NZ. Interventions aimed at changing organisational culture towards a less hierarchical and more resident-centred culture may be another avenue to improve prescribing in residential aged care.
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Abstract
Assisted living residences have become prominent sites of long-term residential care for older adults with dementia. Estimates derived from national data indicate that seven out of ten residents in these residences have some form of cognitive impairment, with 29 percent having mild impairment, 23 percent moderate impairment, and 19 percent severe impairment. More than one-third of residents display behavioral symptoms, and of these, 57 percent have a medication prescribed for their symptoms. Only a minority of cognitively impaired residents reside in a dementia special care unit, where admission and discharge policies are more supportive of their needs. Policy-relevant recommendations from our study include the need to examine the use of psychotropic medications and cultures related to prescribing, better train assisted living staff to handle medications and provide nonpharmacological treatments, use best practices in caring for people with dementia, and promote consumer education regarding policies and practices in assisted living.
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Helgesen AK, Athlin E, Larsson M. Relatives’ participation in everyday care in special care units for persons with dementia. Nurs Ethics 2014; 22:404-16. [DOI: 10.1177/0969733014538886] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Research concerning relatives’ participation in the everyday care related to persons living in special care units for persons with dementia is limited. Research questions: To examine relatives’ participation in their near one’s everyday care, the level of burden experienced and important factors for participation, in this special context. Design: The study had a cross-sectional design, and data collection was carried out by means of a study-specific questionnaire. Participants and context: A total of 233 relatives from 23 different special care units participated. Ethical consideration: The study was approved by the Norwegian Social Science Data Services. Results: A great majority of relatives reported that they visited weekly and were the resident’s spokesperson, but seldom really participated in decisions concerning their everyday care. Participation was seldom reported as a burden. Discussion: This study indicated that relatives were able to make a difference to their near one’s everyday life and ensure quality of care based on their biographical expertise, intimate knowledge about and emotional bond with the resident. Since knowing the resident is a prerequisite for providing individualised care that is in line with the resident’s preferences, information concerning these issues is of utmost importance. Conclusion: This study prompts reflection about what it is to be a spokesperson and whether everyday care is neglected in this role. Even though relatives were satisfied with the care provided, half of them perceived their participation as crucial for the resident’s well-being. This indicated that relatives were able to offer important extras due to their biographical expertise, intimate knowledge about and emotional bond with the resident. Good routines securing that written information about the residents’ life history and preferences is available and used should be implemented in practice.
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15
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Brandenburg H. [Quality of life of people with severe dementia in nursing oases: empirical results and methodological implications]. Z Gerontol Geriatr 2013; 46:417-24. [PMID: 23283397 DOI: 10.1007/s00391-012-0396-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Nursing oases (NOs) are a variant of segregated care for people with severe dementia in nursing homes. They can be understood as a constant living arrangement in one room for 4-7 persons with a special care concept and environmental design. During the daytime nurses are permanently present. Quality of life (QoL) is the focus because the efficacy of medical and nursing interventions should include measurement of QoL. There is a controversy whether NOs are really different from the traditional caring settings in long-term care. Advocates see NOs as a substantial contribution to improve QoL, especially for people with severe dementia but critics fear a rollback to the era of multibed rooms in nursing homes and emphasize the risk of losing autonomy. This article is differentiated into four parts. Firstly, reasons are given why NOs are an option for a professional and adequate fulfillment of needs for people with severe dementia and a definition of NOs is given. Secondly, selected results of NOs studies in Germany are shown which have mainly documented positive effects. Thirdly, on the background of US American research into Special Care Units methodological questions are discussed. The focus is on designs and the utilization of standardized and non-standardized instruments. In the concluding remarks it is discussed whether QoL is an adequate indicator of a good life for people with severe dementia in long-term care.
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Affiliation(s)
- H Brandenburg
- Lehrstuhl für Gerontologische Pflege, Pflegewissenschaftliche Fakultät, Philosophisch-Theologische Hochschule Vallendar, Pallottistr. 3, 56179, Vallendar, Deutschland.
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Abstract
BACKGROUND The quality of nursing home care for residents with advanced dementia has been described as suboptimal. One relatively understudied factor is the impact of special care units (SCUs) for dementia for residents at the end stage of this disease. OBJECTIVE To examine the association between residence in an SCU and the quality of end-of-life care for nursing home residents with advanced dementia. RESEARCH DESIGN This study used longitudinal data on 323 nursing home residents with advanced dementia living in 22 Boston-area facilities. Using multivariate methods, we analyzed the association between residence in an SCU and measures of quality of end-of-life care including: treatment of pain and dyspnea, prevalence of pressure ulcers, hospitalization, tube feeding, antipsychotic drug use, advance care planning, and health care proxy (HCP) satisfaction with care. RESULTS A total of 43.7% residents were cared for in an SCU. After multivariate adjustment, residents in SCUs were more likely to receive treatment for dyspnea, had fewer hospitalizations, were less likely to be tube fed, and more likely to have a do-not-hospitalize order, compared with non-SCU residents. However, non-SCU residents were more likely to be treated for pain, had fewer pressure ulcers, and less frequent use of antipsychotic drugs than SCU residents. HCPs of SCU residents reported greater satisfaction with care than HCPs of non-SCU residents. CONCLUSIONS Residence in an SCU is associated with some, but not all, markers of better quality end-of-life care among nursing home residents with advanced dementia.
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Helgesen AK, Larsson M, Athlin E. How do relatives of persons with dementia experience their role in the patient participation process in special care units? J Clin Nurs 2012; 22:1672-81. [DOI: 10.1111/jocn.12028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Ann K Helgesen
- Department of Nursing; Karlstad University; Karlstad Sweden
- Faculty of Health and Social Studies; Østfold University College; Halden Norway
| | - Maria Larsson
- Department of Nursing; Karlstad University; Karlstad Sweden
| | - Elsy Athlin
- Department of Nursing; Karlstad University; Karlstad Sweden
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Campo M, Chaudhury H. Informal social interaction among residents with dementia in special care units: Exploring the role of the physical and social environments. DEMENTIA 2011. [DOI: 10.1177/1471301211421189] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite a continued recognition of the importance of relational aspects of quality of life for people with dementia, little research has examined environmental influences on informal social interaction in dementia care settings. The purpose of this ethnographic study was to identify and explore key elements of the physical and social environments that act as facilitators or barriers for social interaction among people with dementia living in special care units. We conducted in-depth interviews with staff members and completed a series of resident observations. Findings suggest that social factors such as staff work roles and resident group size, and physical factors such as a non-institutional character, the nursing station location, and adequate seating and sightlines are influential for prompting or supporting informal social interactions. Design recommendations are provided with the intent to create physical environments that foster informal social interactions among people in dementia care environments.
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Helgesen AK, Larsson M, Athlin E. ‘Patient participation’ in everyday activities in special care units for persons with dementia in Norwegian nursing homes. Int J Older People Nurs 2010; 5:169-78. [DOI: 10.1111/j.1748-3743.2010.00223.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Grabowski DC, Aschbrenner KA, Rome VF, Bartels SJ. Quality of mental health care for nursing home residents: a literature review. Med Care Res Rev 2010; 67:627-56. [PMID: 20223943 DOI: 10.1177/1077558710362538] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.
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Affiliation(s)
- David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115-5899, USA.
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Wolter DK. Risiken von Antipsychotika im Alter, speziell bei Demenzen 1Prof. Dr. Hans Gutzmann zum 60. Geburtstag gewidmet. ACTA ACUST UNITED AC 2009. [DOI: 10.1024/1011-6877.22.1.17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antipsychotika werden häufig zur Behandlung von herausforderndem Verhalten bei Demenz eingesetzt. Antipsychotika der zweiten Generation («atypische Neuroleptika») spielen dabei mittlerweile eine größere Rolle als die älteren Substanzen. Der nur mäßigen Wirksamkeit stehen schwerwiegende Risiken gegenüber: so ist unter allen Antipsychotika die Mortalität insgesamt erhöht, aber auch das Risiko für plötzlichen Herztod, Schlaganfallereignisse oder venöse Thrombosen. Die Unterschiede zwischen Antipsychotika der ersten und der zweiten Generation sind dabei gering: hochpotente Antipsychotika der ersten Generation führen häufiger zu extrapyramidalmotorischen Symptomen, unter Antipsychotika der zweiten Generation ist das allgemeine Mortalitätsrisiko wahrscheinlich etwas geringer, andererseits wahrscheinlich venöse Thrombosen und metabolische Nebenwirkungen häufiger. Für die übrigen Nebenwirkungen bestehen keine gesicherten Unterschiede. Angesichts der großen Heterogenität der Antipsychotika erscheint der Nutzen einer pauschalen Aufteilung in Antipsychotika der ersten und zweiten Generation fragwürdig. Für die Auswahl einer Substanz sind substanzspezifische Nebenwirkungen, Dosierung, Aufdosierungsgeschwindigkeit sowie Beachtung von Komorbidität, Kontraindikationen und Arzneimittelinteraktionen in Relation zum individuellen Patienten erheblich wichtiger als die Wahl nach bloßer pauschaler Zuordnung zu einer dieser beiden Gruppen. Am wichtigsten ist aber, dass Antipsychotika nur bei klarer Indikation zur Anwendung kommen!
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Affiliation(s)
- Dirk K. Wolter
- Fachbereich Gerontopsychiatrie, Inn-Salzach-Klinikum, Wasserburg a. Inn
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