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Loftus KL, Wand APF, Breen JL, Hunt GE, Peisah C. Factors Associated with Psychotropic Medication Use in People Living with Dementia in the Community: A Systematic Review and Meta-Analysis. Drugs Aging 2023; 40:1053-1084. [PMID: 37943474 PMCID: PMC10682283 DOI: 10.1007/s40266-023-01070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND There has been considerable focus on the use of psychotropic agents in people living with dementia in long-term care. However, psychotropic use often commences well before transitioning to long-term care. OBJECTIVES To synthesize the available literature to identify factors associated with psychotropic medication use in people living with dementia in the community. METHODS This PROSPERO-registered review reports findings from a comprehensive search of Embase, PsycINFO, and PubMed (including MEDLINE) databases according to predefined inclusion and exclusion criteria (2010-2022). Inclusion criteria were original prospective or retrospective design research papers enrolling people diagnosed with dementia utilizing a psychotropic medication and living at home. Quality and risk of bias was assessed Newcastle-Ottawa Quality Assessment Scale. The last search was conducted in November 2022. Thematic analysis was used to synthesize the emergent factors identified, and a meta-analysis was undertaken on suitable data. RESULTS The search identified 619 articles. After review and exclusions, 39 articles were included for synthesis, including 1,338,737 people. The majority of papers (67%) were rated as low risk of bias and corresponding good quality. Thematic analysis suggested associations between psychotropic prescribing and patient and environmental factors, with little data concerning carer and prescriber factors. Such factors included age (< 75 years, > 90 years), sex, more advanced functional decline, and living alone. Meta-analysis identified significant associations between psychotropic use and respite (temporary full-time care or hospitalization) and comorbid psychiatric illness. CONCLUSIONS While it is clear from this review that there remains a significant lack of clarity as to the reasons why these medications are being utilized in this population, this review provides greater insight and understanding into the context of psychotropic use. The study has highlighted an opportunity for further targeted research to be conducted and provides a much-needed context for this to occur. PROSPERO REGISTRATION NUMBER CRD42021286322.
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Affiliation(s)
- Kerryn L Loftus
- Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
- JARA UNIT, Concord Centre for Mental Health, Concord Hospital, 1 Hospital Road, Concord, NSW, 2137, Australia.
| | - Anne P F Wand
- Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Juanita L Breen
- Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Capacity Australia, Australian Centre for Capacity, Ethics and the Prevention of Exploitation of People with Disabilities, Sydney, NSW, Australia
| | - Glenn E Hunt
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Carmelle Peisah
- Discipline of Psychiatry and Mental Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Capacity Australia, Australian Centre for Capacity, Ethics and the Prevention of Exploitation of People with Disabilities, Sydney, NSW, Australia
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Ranglani S, Ward J, Sattar N, Strawbridge RJ, Lyall DM. Testing for associations between HbA1c levels, polygenic risk and brain health in UK Biobank (N = 39 283). Diabetes Obes Metab 2023; 25:3136-3143. [PMID: 37435691 DOI: 10.1111/dom.15207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/09/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
AIM To investigate whether continuous HbA1c levels and HbA1c-polygenic risk scores (HbA1c-PRS) are significantly associated with worse brain health independent of type 2 diabetes (T2D) diagnosis (vs. not), by examining brain structure and cognitive test score phenotypes. METHODS Using UK Biobank data (n = 39 283), we tested whether HbA1c levels and/or HbA1c-PRS were associated with cognitive test scores and brain imaging phenotypes. We adjusted for confounders of age, sex, Townsend deprivation score, level of education, genotyping chip, eight genetic principal components, smoking, alcohol intake frequency, cholesterol medication, body mass index, T2D and apolipoprotein (APOE) e4 dosage. RESULTS We found an association between higher HbA1c levels and poorer performance on symbol digit substitution scores (standardized beta [β] = -0.022, P = .001) in the fully adjusted model. We also found an association between higher HbA1c levels and worse brain MRI phenotypes of grey matter (GM; fully-adjusted β = -0.026, P < .001), whole brain volume (β = -0.072, P = .0113) and a general factor of frontal lobe GM (β = -0.022, P < .001) in partially and fully adjusted models. HbA1c-PRS were significantly associated with GM volume in the fully adjusted model (β = -0.010, P = .0113); however, when adjusted for HbA1c levels, the association was not significant. CONCLUSIONS Our findings suggest that measured HbA1c is associated with poorer cognitive health, and that HbA1c-PRS do not add significant information to this.
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Affiliation(s)
- Sanskar Ranglani
- School of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
| | - Joey Ward
- School of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Sciences, University of Glasgow, Glasgow, UK
| | - Rona J Strawbridge
- School of Health & Wellbeing, University of Glasgow, Glasgow, UK
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
- HDR-UK, London, UK
| | - Donald M Lyall
- School of Health & Wellbeing, University of Glasgow, Glasgow, UK
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Resnick B, Boltz M, Galik E, Kuzmik A, McPherson R, Drazich B, Kim N, Zhu S, Wells CL. Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01745-9. [PMID: 37580439 PMCID: PMC10864680 DOI: 10.1007/s40615-023-01745-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023]
Abstract
The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA.
| | - Marie Boltz
- Penn State University, University Park, State College, PA, USA
| | - Elizabeth Galik
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Ashley Kuzmik
- Penn State University, University Park, State College, PA, USA
| | | | - Brittany Drazich
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Nayeon Kim
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Shijun Zhu
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
| | - Chris L Wells
- University of Maryland School of Nursing, 655 West Lombard Street, Baltimore, MD, 21218, USA
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Resnick B, Boltz M, Galik E, Kuzmik A, Drazich BF, McPherson R, Wells CL, Renn C, Dorsey SG, Ellis J. Factors Associated With Function-Focused Care Among Hospitalized Older Adults Living With Dementia. Crit Care Nurs Q 2023; 46:299-309. [PMID: 37226921 PMCID: PMC10508903 DOI: 10.1097/cnq.0000000000000466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This article reports a study that was designed to describe the incidence of pain among older hospitalized patients with dementia and to evaluate the factors that influence pain among these individuals. It was hypothesized that function, behavioral and psychological symptoms of dementia, delirium, pain treatment, and patient exposure to care interventions would be associated with pain. Patients who performed more functional activities had less delirium. They also experienced higher quality-of-care interactions and were less likely to have pain. The findings from this study support the relationship between function, delirium, and quality-of-care interactions and pain. It suggests that it may be useful to encourage patients with dementia to engage in functional and physical activity to prevent or manage pain. This study serves as a reminder to avoid neutral or negative care interactions among patients with dementia as a strategy to mediate delirium and pain.
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Affiliation(s)
- Barbara Resnick
- School of Nursing (Drs Resnick, Galik, Drazich, Wells, Renn, and Dorsey, and Ms Ellis) and School of Medicine (Dr McPherson), University of Maryland, Baltimore; and Penn State University, University Park, Pennsylvania (Drs Boltz and Kuzmik)
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Lin YK, Liao HY, Watson K, Yeh TP, Chen IH. Acupressure Improves Cognition and Quality of Life Among Older Adults with Cognitive Disorders in Long-Term Care Settings: A Clustered Randomized Controlled Trial. J Am Med Dir Assoc 2023; 24:548-554. [PMID: 36933568 DOI: 10.1016/j.jamda.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine the effectiveness of acupressure on cognition and quality of life (QoL) among older adults with cognitive disorders residing in long-term care (LTC) settings. DESIGN A clustered, randomized, assessor-blinded, controlled trial with a repeated measures design. SETTING AND PARTICIPANTS Participants were recruited from residential care facilities in Taiwan from August 2020 to February 2021. Ninety-two older residents in 18 facilities were randomized to either the intervention arm (9 facilities, n = 46) or the control arm (9 facilities, n = 46). METHODS Acupressure was performed at Baihui (GV20), Sishencong (EX-HN1), Shenting (GV24), Fengchi (GB20), Shuigou (GV26), Neiguan (PC6), Shenmen (HT7), and Zusanli (ST36). The duration for pressing each acupoint was 3 minutes. The acupressure force was maintained at 3 kg. Acupressure was performed once a day 5 times a week for 12 weeks. The primary outcome measure was the Cognitive Abilities Screening Instrument (CASI). Secondary outcomes included the digit span backward test, the Wisconsin Card Sorting Test (perseverative responses, perseverative errors, and categories completed), semantic fluency tests of categories of animals, fruits, and vegetables, and the Quality of Life-Alzheimer's Disease (QoL-AD). Data were collected at preintervention and postintervention. Three-level mixed effects models were performed. This study complied with the CONSORT checklist. RESULTS After adjusting for covariates, there was a significant increase in CASI scores, the digit span backward test, perseverative responses, perseverative errors, categories completed, semantic fluency tests of categories, and QoL-AD scores in the intervention versus control arm at 3 months. CONCLUSIONS AND IMPLICATIONS This study provides support for the use of acupressure to improve cognition and QoL during care among older residents with cognitive disorders in LTC settings. Acupressure can be integrated into aged care practice to improve cognition and QoL of older residents with cognitive disorders in LTC settings.
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Affiliation(s)
- Yen-Kuang Lin
- Graduate Institute of Athletics and Coaching Science, National Taiwan Sport University, Taoyuan, Taiwan
| | - Hsien-Yin Liao
- College of Chinese Medicine, School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung, Taiwan; Department of Acupuncture, China Medical University Hospital, Taichung, Taiwan
| | - Karen Watson
- Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Tzu-Pei Yeh
- School of Nursing, China Medical University, Taichung, Taiwan; Department of Nursing, China Medical University Hospital, Taichung, Taiwan
| | - I-Hui Chen
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wang Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Ellezian L, Jhawar A, Kyono Y, Flowers SA. Psychotropic Drugs in the Discussion of Antimicrobial-Resistant Microorganisms. DNA Cell Biol 2022; 41:919-923. [DOI: 10.1089/dna.2022.0471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lori Ellezian
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Archana Jhawar
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Pharmacy, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Yasuhiro Kyono
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Stephanie A. Flowers
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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Lipori JP, Tu E, Shireman TI, Gerlach L, Coe AB, Ryskina KL. Factors Associated with Potentially Harmful Medication Prescribing in Nursing Homes: A Scoping Review. J Am Med Dir Assoc 2022; 23:1589.e1-1589.e10. [PMID: 35868350 PMCID: PMC10101239 DOI: 10.1016/j.jamda.2022.06.008] [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: 03/24/2022] [Revised: 06/07/2022] [Accepted: 06/12/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To summarize current evidence regarding facility and prescriber characteristics associated with potentially harmful medication (PHM) use by residents in nursing homes (NHs), which could inform the development of interventions to reduce this potentially harmful practice. DESIGN Scoping review. SETTING AND PARTICIPANTS Studies conducted in the United States that described facility and prescriber factors associated with PHM use in NHs. METHODS Electronic searches of PubMed/MEDLINE were conducted for articles published in English between April 2011 and November 2021. PHMs were defined based on the Beers List criteria. Studies testing focused interventions targeting PHM prescribing or deprescribing were excluded. Studies were characterized by the strengths and weaknesses of the analytic approach and generalizability. RESULTS Systematic search yielded 1253 articles. Of these, 29 were assessed in full text and 20 met inclusion criteria. Sixteen examined antipsychotic medication (APM) use, 2 anticholinergic medications, 1 sedative-hypnotics, and 2 overall PHM use. APM use was most commonly associated with facilities with a higher proportion of male patients, younger patients, and patients with severe cognitive impairment, anxiety, depression, and aggressive behavior. The use of APM and anticholinergic medications was associated with low registered nurse staffing ratios and for-profit facility status. No studies evaluated prescriber characteristics. CONCLUSIONS AND IMPLICATIONS Included studies primarily examined APM use. The most commonly reported facility characteristics were consistent with previously reported indicators of poor NH quality and NHs with patient case mix more likely to use PHMs.
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Affiliation(s)
- Jessica P Lipori
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Tu
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Lauren Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Kira L Ryskina
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Nalls V, Galik E, Klinedinst NJ, Barr E, Brandt N, Lerner N, Resnick B. Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment. Sr Care Pharm 2022; 37:448-457. [PMID: 36039002 DOI: 10.4140/tcp.n.2022.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.
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Affiliation(s)
- Victoria Nalls
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Elizabeth Galik
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | | | - Erik Barr
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Nicole Brandt
- 2 School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Nancy Lerner
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
| | - Barbara Resnick
- 1 School of Nursing, University of Maryland, Baltimore, Maryland
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Resnick B, Zimmerman S, Gaugler J, Ouslander J, Abrahamson K, Brandt N, Colón-Emeric C, Galik E, Gravenstein S, Mody L, Sloane PD, Unroe K, Verbeek H. Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care. J Am Med Dir Assoc 2022; 23:330-338. [PMID: 35219505 PMCID: PMC9446464 DOI: 10.1016/j.jamda.2021.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 01/12/2023]
Abstract
As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA.
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Gaugler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Stefan Gravenstein
- Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Lona Mody
- University of Michigan and Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathleen Unroe
- Indiana University School of Medicine and Regenstrief Institute, Inc, Center for Aging Research, Indianapolis, IN, USA
| | - Hilde Verbeek
- Maastricht University and Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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Resnick B, Zimmerman S, Gaugler J, Ouslander J, Abrahamson K, Brandt N, Colón-Emeric C, Galik E, Gravenstein S, Mody L, Sloane PD, Unroe K, Verbeek H. Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care. J Am Geriatr Soc 2022; 70:718-730. [PMID: 35195283 PMCID: PMC8904288 DOI: 10.1111/jgs.17699] [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: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA,Address correspondence to Barbara Resnick, PhD, CRNP, University of Maryland School of Nursing, 655 W Lombard St, Baltimore, MD 21201, USA. (B. Resnick)
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Gaugler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Stefan Gravenstein
- Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Lona Mody
- University of Michigan and Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathleen Unroe
- Indiana University School of Medicine and Regenstrief Institute, Inc, Center for Aging Research, Indianapolis, IN, USA
| | - Hilde Verbeek
- Maastricht University and Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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Resnick B, Zimmerman S, Gaugler J, Ouslander J, Abrahamson K, Brandt N, Colón-Emeric C, Galik E, Gravenstein S, Mody L, Sloane PD, Unroe K, Verbeek H. Pragmatic trials in long-term care: Research challenges and potential solutions in relation to key areas of care. Geriatr Nurs 2022; 44:293-301. [PMID: 35219534 PMCID: PMC9446463 DOI: 10.1016/j.gerinurse.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA.
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Gaugler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Stefan Gravenstein
- Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Lona Mody
- University of Michigan and Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathleen Unroe
- Indiana University School of Medicine and Regenstrief Institute, Inc, Center for Aging Research, Indianapolis, IN, USA
| | - Hilde Verbeek
- Maastricht University and Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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12
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Williams KN, Coleman CK, Shaw CA, Perkhounkova Y, Hein M, Cramer E, Beachy T, Berkley A, Kantartjis M. Changing Talk Online: Protocol for a cluster pragmatic trial testing communication education to reduce behavioral and psychological symptoms of dementia in nursing home care. Contemp Clin Trials 2021; 109:106550. [PMID: 34478869 PMCID: PMC8556275 DOI: 10.1016/j.cct.2021.106550] [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: 05/20/2021] [Revised: 07/16/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022]
Abstract
Nursing home (NH) care of persons living with dementia is often made challenging by behavioral and psychological symptoms of dementia (BPSD) such as aggression, vocal outbursts, wandering, and withdrawal that occur due to cognitive and communication changes. Staff frequently communicate to NH residents using "elderspeak" which is patronizing speech similar to baby talk. Residents respond to elderspeak with increased BPSD that prompts use of psychotropic medication to control symptoms. The Changing Talk (CHAT) training educates staff about effective, person-centered communication strategies and reduces elderspeak by staff and subsequent BPSD among residents. This study will test effects of an adapted online version (CHATO) increasing access and dissemination of education to busy staff across diverse care settings. Nursing homes (N = 128) will be stratified and then randomized to CHATO education (n = 64) or to the control group (n = 64). Data on behavioral symptoms (primary outcomes) and psychotropic medication use (secondary outcomes) will be extracted from the Center for Medicare and Medicaid Services Minimum Data Set before and after education and will be compared between the groups using generalized linear mixed modeling. It is hypothesized that after completing the CHATO education residents will have reduced behavioral symptoms and psychotropic medication use compared to residents in control NHs. Additionally, factors related to NH participation and cost of the intervention will be determined. The overall goal of this study is to prepare for large scale dissemination and implementation of the evidence-based nonpharmacological CHATO intervention to reduce BPSD in residents with dementia across long-term care settings.
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Affiliation(s)
- Kristine N Williams
- University of Kansas Medical Center School of Nursing, 3901 Rainbow Blvd, Kansas City, KS 66160, USA.
| | - Carissa K Coleman
- University of Kansas Medical Center School of Nursing, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Clarissa A Shaw
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA
| | - Yelena Perkhounkova
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA
| | - Maria Hein
- University of Iowa College of Nursing, 50 Newton Rd, Iowa City, IA 52242, USA
| | - Emily Cramer
- University of Kansas Medical Center School of Nursing, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Tim Beachy
- University of Iowa College of Public Health, 200 Newton Rd, Iowa City, IA 52242, USA
| | - Amy Berkley
- University of Kansas Medical Center School of Nursing, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Michalis Kantartjis
- University of Iowa Interdisciplinary Graduate Program in Health Informatics, 201 Gilmore Hall, Iowa City, IA 52242, USA
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13
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Callegari E, Šaltytė Benth J, Selbæk G, Grønnerød C, Bergh S. Do prescription rates of psychotropic drugs change over three years from nursing home admission? BMC Geriatr 2021; 21:496. [PMID: 34530728 PMCID: PMC8447606 DOI: 10.1186/s12877-021-02437-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND In this longitudinal study, we describe how psychotropic drugs (PTDs) are prescribed in nursing home (NH) patients from admission and over a 3-year period, to understand which clinical and environmental factors are associated with PTD prescription. METHODS We used data from the Resource Use and Disease Course in Dementia - Nursing Home (REDIC-NH) study, examining physical and mental health, dementia, and PTD prescription during a 3-year period from admission to a NH. Data were collected every six months. At baseline, we included 696 participants from 47 Norwegian NHs. We presented prevalence, incidence, and deprescribing rates of PTD prescriptions for each assessment point. We calculated the odds of receiving PTDs and used a generalized linear mixed model to analyze the variables associated with a change in odds throughout the 3-year period. RESULTS PTD prescriptions were frequent throughout the 3-year period. Antidepressants had the highest prescription rates (28.4%-42.2%). Every PTD category had the highest incidence rate between admission and six months, and antipsychotics had the highest values (49.4%). Deprescribing rates were comparable between assessment points. The odds of antipsychotic prescriptions were lower for older people (OR = 0.96, 95%CI:0.92-0.99, p = 0.023). People with more severe dementia had lower odds of being prescribed sedatives/hypnotics (OR = 0.89, 95%CI:0.85-0.94, p < 0.001). CONCLUSIONS PTDs, particularly antidepressants, are widely prescribed over time to NH patients. Older patients are less likely to receive antipsychotics. A higher severity of dementia decreases the odds of being prescribed sedatives/hypnotics. Close attention should be paid to PTD prescriptions during long-term NH stay to avoid prolonged and excessive treatment with these types of drugs. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01920100 .
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Affiliation(s)
- Enrico Callegari
- grid.412938.50000 0004 0627 3923Østfold Hospital Trust, Sykehuset Østfold HF, postboks 300, 1714 Grålum, Norway ,grid.5510.10000 0004 1936 8921Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jūratė Šaltytė Benth
- grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway ,grid.412929.50000 0004 0627 386XResearch Centre for Age-related Functional Decline and Diseases, Innlandet Hospital Trust, Ottestad, Norway ,grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Geir Selbæk
- grid.5510.10000 0004 1936 8921Faculty of Medicine, University of Oslo, Oslo, Norway ,grid.417292.b0000 0004 0627 3659Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway ,grid.55325.340000 0004 0389 8485Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Cato Grønnerød
- grid.412938.50000 0004 0627 3923Østfold Hospital Trust, Sykehuset Østfold HF, postboks 300, 1714 Grålum, Norway ,grid.5510.10000 0004 1936 8921Faculty of Social Sciences, Department of Psychology, University of Oslo, Oslo, Norway
| | - Sverre Bergh
- grid.412929.50000 0004 0627 386XResearch Centre for Age-related Functional Decline and Diseases, Innlandet Hospital Trust, Ottestad, Norway ,grid.417292.b0000 0004 0627 3659Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
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Muñiz R, López-Álvarez J, Perea L, Rivera S, González L, Olazarán J. CHROME Criteria and Quality of Life: A Pilot Study from Maria Wolff-Albertia. J Alzheimers Dis Rep 2021; 5:613-624. [PMID: 34632299 PMCID: PMC8461744 DOI: 10.3233/adr-210015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia. OBJECTIVE Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL). METHODS Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME's diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115). RESULTS Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p < 0.0005). Substantive reduction in prescribing frequency was observed for antidepressants (76.9% pre-intervention, 33.8% post-intervention) and for atypical neuroleptics (38.8% pre-intervention, 15.1% post-intervention). There was improvement in patient's response to surroundings (p < 0.0005) and total NPS (p < 0.01), but small worsening occurred in social interaction (p < 0.02, completer subjects). Safety measurements remained stable. CONCLUSION CHROME criteria appear to optimize psychotropic prescriptions, avoid chemical restraints, and allow external verification of quality prescriptions. Extensive use seems feasible, related to substantial reduction of prescriptions, and of benefit for people with dementia as de-prescriptions are not associated to increased NPS or QoL loss.
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Affiliation(s)
| | - Jorge López-Álvarez
- Maria Wolff Foundation, Madrid, Spain
- Psychiatry Department, University Hospital 12 de Octubre, Madrid, Spain
| | - Luis Perea
- Albertia Servicios Sociosanitarios, Madrid, Spain
| | - Sofía Rivera
- Albertia Servicios Sociosanitarios, Madrid, Spain
| | | | - Javier Olazarán
- Maria Wolff Foundation, Madrid, Spain
- Neurology Service, University Hospital Gregorio Marañón, Madrid, Spain
- Memory Disorders Clinic, HM Hospitals, Madrid, Spain
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15
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Bell K, Hartmann C, Baughman AW. A pharmacist-led pilot using a performance dashboard to improve psychotropic medication use in a skilled nursing facility. BMJ Open Qual 2021; 9:bmjoq-2020-000997. [PMID: 32816865 PMCID: PMC7430330 DOI: 10.1136/bmjoq-2020-000997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/01/2020] [Accepted: 07/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives Inappropriate use of psychotropic medications in the elderly, particularly those with dementia, is a critical safety and quality concern. This pilot quality improvement study used a novel Department of Veterans Affairs (VA) Psychotropic Drug Safety Initiative performance dashboard (PDSI dashboard) to implement a pharmacist-led intervention to improve psychotropic medication prescribing practices in a VA skilled nursing facility (SNF). While clinical dashboard data have become commonplace, literature describing successful implementation for improved clinical care is scant. Methods This study took place from November 2015 to February 2016 at a 112-bed VA SNF. A pharmacist used the PDSI dashboard to identify ‘actionable’ patients with potentially inappropriate psychotropic prescribing and then completed chart reviews to confirm clinical indications. The pharmacist provided recommendations to providers for dose reductions or deprescribing via in-person communication and notes written in the electronic medical record. SNF providers completed anonymous surveys about their experience in receiving recommendations. Results Over a 5-month period, the PDSI dashboard identified 21 patients with potentially inappropriate psychotropic medication use, with approximately one new patient identified each week. Prescribing recommendations were accepted 66% of the time. All seven SNF providers reported that recommendations were helpful in improving their psychotropic prescribing practices. Conclusions The PDSI dashboard was efficient and effective in identifying patients at risk for inappropriate use of psychotropic medications. A clinical pharmacist was essential for implementing and communicating recommendations from the dashboard to providers.
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Affiliation(s)
- Kristin Bell
- Pharmacy, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Christine Hartmann
- Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA.,Public Health, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Amy Wisteria Baughman
- Geriatrics and Extended Care, Veterans Affairs Boston Healthcare System, Boston, MA, United States .,Harvard Medical School, Boston, MA, United States
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16
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Ferreira AR, Simões MR, Moreira E, Guedes J, Fernandes L. Modifiable factors associated with neuropsychiatric symptoms in nursing homes: The impact of unmet needs and psychotropic drugs. Arch Gerontol Geriatr 2020; 86:103919. [DOI: 10.1016/j.archger.2019.103919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/01/2019] [Accepted: 07/24/2019] [Indexed: 01/15/2023]
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17
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Resnick B, Boltz M, Galik E, Holmes S, Fix S, Zhu S. Gender Differences in Function, Physical Activity, Falls, Medication Use, and Life Satisfaction Among Residents in Assisted Living Settings. Res Gerontol Nurs 2020; 13:31-40. [PMID: 31584687 PMCID: PMC6980912 DOI: 10.3928/19404921-20190930-02] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/06/2019] [Indexed: 11/20/2022]
Abstract
The purpose of the current study was to test for gender differences among residents living in assisted living settings. This was a secondary data analysis using data from the first 64 facilities participating in the ongoing Function Focused Care for Assisted Living study using the Evidence Integration Triangle (FFC-AL-EIT). A total of 593 residents were recruited. Differences by gender with regard to function, physical activity, falls, total number of medications, and satisfaction with assisted living were tested using multivariate analysis of variance. There were 166 (28%) men and 427 (72%) women with a mean age of 88 (SD = 7.5 years). Participants had five (SD = 2) comorbidities and took on average 6.88 medications (SD = 3.47). Participants had moderate functional impairment with a mean of 64.13 (SD = 19.09) on the Barthel Index and engaged in 43.8 (SD = 76.12) minutes daily of moderate level physical activity. Women reported higher satisfaction with activities (4.32 [SD = 1.14]) than men (3.85 [SD = 1.51]), and women received more medications than men (7.09 [SD = 3.51] vs. 6.34 [SD = 3.31]). Current study findings suggest that deprescribing may be particularly important for women versus men and focusing on expanding activity options to include those preferred by men should be considered in assisted living settings. [Research in Gerontological Nursing, 13(1), 31-40.].
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Pergolizzi JV, Raffa RB, Paladini A, Varrasi G, LeQuang JA. Treating pain in patients with dementia and the possible concomitant relief of symptoms of agitation. Pain Manag 2019; 9:569-582. [DOI: 10.2217/pmt-2019-0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Dementia is an irreversible, progressive form of cognitive dysfunction that can affect memory, learning ability, thinking, orientation, comprehension, calculation, linguistic skills and executive function but which does not impair consciousness. Pain prevalence is high among the elderly who are also at elevated risk for dementia. Pain control for dementia patients is important but can be challenging for clinicians as cognitive deficits can make it difficult to identify, localize and assess pain. Cerebral changes associated with dementia may change how people process and experience pain in ways that are not entirely elucidated. Agitation is a frequent symptom of dementia and may be associated with untreated pain as agitation and aggression symptoms decrease when pain is effectively addressed.
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Affiliation(s)
| | - Robert B Raffa
- University of Arizona, Department of Pharmacy, Tucson, AZ 85721, USA
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