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Cain P, Chejor P, Porock D. Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety. BMC Geriatr 2023; 23:444. [PMID: 37468889 DOI: 10.1186/s12877-023-04116-5] [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: 04/08/2023] [Accepted: 06/17/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND The prescription of psychotropic medication to older people living with dementia in residential aged care has become an increasing concern. The use of prescription medication is often prefaced as a way of preventing harm to self and others. However, the use of such medications has been considered a way of managing some of the behavioural and psychological symptoms of dementia. Using a large secondary data set, this study aimed to identify the precursors and mediating factors that influence the use of chemical restraint of older people in residential aged care. METHODS Publicly available documents from the Australian Royal Commission into Aged Care Quality and Safety were used as the data corpus for this study. Keywords were used to search over 7000 documents to extract a set of topic-related content. We identified the cases of seven people in respite or permanent residential aged care who had been prescribed or administered psychotropic medication under circumstances that appeared to demonstrate chemical restraint. All documents relating to the cases were collated for our data set. A descriptive case study approach to analysis was taken. RESULTS Four key descriptive patterns were identified: labelling and limits to tolerance, pushing prescription as a solution, coverups and avoiding consent, and family's fight for liberty. Triangulation across the data and academic literature supports the findings. CONCLUSION Our findings provide some insight into how chemical restrain happens. Featuring throughout the cases were reports of a lack of workforce capacity to care for and support residents exhibiting dementia behaviours. Prescription of psychotropic medications featured as a "first resort" care solution. Family and friends found such approaches to care unacceptable and frequently challenged the practice. Where consent for prescription was explicitly denied, more covert approaches are demonstrated. Family awareness, presence, and advocacy were key to challenging the practice of chemical restraint. Shortfalls in the capacity of the current workforce come into play here. However, workforce shortcomings can no longer mask this ubiquitous practice. Just as importantly the spotlight needs to be turned on the prescribers and the providers.
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Affiliation(s)
- Patricia Cain
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, 6027, Joondalup, WA, Australia.
| | - Pelden Chejor
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, 6027, Joondalup, WA, Australia
| | - Davina Porock
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, 6027, Joondalup, WA, Australia
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2
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Quek HW, Etherton-Beer C, Page A, McLachlan AJ, Lo SY, Naganathan V, Kearney L, Hilmer SN, Comans T, Mangin D, Lindley RI, Potter K. Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation. Arch Gerontol Geriatr 2023; 107:104910. [PMID: 36565605 DOI: 10.1016/j.archger.2022.104910] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/07/2022] [Accepted: 12/17/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation. OBJECTIVES This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month. METHODS The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner. RESULTS There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231). CONCLUSION Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613001204730.
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Affiliation(s)
- Hui Wen Quek
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; School of Allied Health, University of Western Australia, Perth, Western Australia, Australia.
| | - Christopher Etherton-Beer
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Amy Page
- School of Allied Health, University of Western Australia, Perth, Western Australia, Australia; Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Sarita Y Lo
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia; Kolling Institute, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia; Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Leanne Kearney
- Centre for Education and Research on Ageing, Department of Geriatric Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sarah N Hilmer
- Kolling Institute, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tracy Comans
- Menzies Health Institute Queensland, Griffith University, University Drive Meadowbrook, Brisbane, Queensland Australia
| | - Derelie Mangin
- Primary Care Research Unit, Department of Public Health and General Practice, Christchurch School of Medicine & Health Sciences, University of Otago, Christchurch, New Zealand
| | - Richard I Lindley
- Sydney Medical School, University of Sydney, Sydney, New South Wales; Australia and The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kathleen Potter
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, Perth, Western Australia, Australia; Ryman Healthcare, Christchurch, New Zealand
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3
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Association of Psychotropic Education with Quality of Life: A Before-After Study in Residential Aged Care Facilities. Drugs Aging 2022; 39:949-958. [DOI: 10.1007/s40266-022-00982-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 11/12/2022]
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Quality Use of Medicines Indicators and Associated Factors in Residential Aged Care Facilities: Baseline Findings from the Pharmacists in RACF Study in Australia. J Clin Med 2022; 11:jcm11175189. [PMID: 36079117 PMCID: PMC9457045 DOI: 10.3390/jcm11175189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 12/02/2022] Open
Abstract
Prescribing potentially inappropriate medications (PIMs), including antipsychotics and benzodiazepines, has been used as an indicator of the quality use of medicines in residential aged care facilities (RACFs). PIMs are associated with an increased risk of falls and hospitalisations in the elderly. The purpose of this study is to assess the extent of prescribing of PIMs in RACFs at baseline in the Pharmacists in residential aged care facilities (PiRACF) study and examine the association of resident and system factors with the number of PIMs. A cross-sectional analysis of 1368 participants from 15 Australian RACFs was performed to detect PIMs using the American Geriatrics Society 2019 Beers® criteria. Most residents (68.1%) were taking at least one regular PIM; 16.9% were taking regular antipsychotics and 11.1% were taking regular benzodiazepines. Long-term proton pump inhibitors were the most frequent class of PIMs. History of falls and higher Charlson Comorbidity Index were associated with an increased number of prescribed PIMs, while dementia diagnosis and older age (85 years or more) were associated with decreased number of PIMs (p-value <0.05). Residents in facilities with lower nurse-to-resident ratios were more likely to have an increased number of PIMs (p value = 0.001). This study indicates that potentially inappropriate prescribing is common in RACFs and interventions to target residents at highest risk are needed.
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Almutairi H, Stafford A, Etherton-Beer C, Flicker L, Saunders R. Aged care staff perceptions of an online training program for responsive behaviours of residents with dementia. Australas J Ageing 2021; 41:e112-e121. [PMID: 34761499 DOI: 10.1111/ajag.13015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To explore residential aged care staff perceptions of an online training program on the management of antipsychotic medications for responsive behaviour in residential aged care. METHODS A qualitative process evaluation was undertaken in four residential aged care facilities of one organisation in Australia. Five focus group interviews were conducted with 25 participants including nurses, care workers, occupational therapists and assistants. RESULTS Direct care staff found that the training program increased their awareness and knowledge of responsive behaviours associated with dementia. Inductive thematic analysis identified three themes: (1) impact of online learning for dementia care; (2) applying online learning in dementia practice; and (3) realising the benefits and challenges of online learning. CONCLUSION From the perspective of the participants, the online training program had a positive effect on their knowledge, communication and practice of caring for residents with dementia with responsive behaviours.
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Affiliation(s)
- Hend Almutairi
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Stafford
- Faculty of Health Sciences, Curtin Medical School, Perth, Western Australia, Australia
| | | | - Leon Flicker
- Geriatric Medicine, Western Australian Centre for Health & Ageing UWA, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Rosemary Saunders
- Centre for Research in Aged Care, School of Nursing & Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
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Moth AE, Hølmkjær P, Holm A, Rozing MP, Overbeck G. What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators. Drugs Aging 2021; 38:671-685. [PMID: 34231182 PMCID: PMC8342345 DOI: 10.1007/s40266-021-00875-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/03/2022]
Abstract
Background Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood. Objectives The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents. Methods We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately. Results Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) ‘Operationality and routines’; (2) ‘Lack of resources and qualifications’; (3) ‘Patient-related outcomes’, which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) ‘Policies’, including support and buy-in from nursing home leadership; and (5) ‘Collaboration’ between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings. Conclusions Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00875-1.
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Affiliation(s)
| | - Pernille Hølmkjær
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark.
| | - Anne Holm
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
| | | | - Gritt Overbeck
- Department of General Practice, University of Copenhagen, Copenhagen, Denmark
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7
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Inacio MC, Lang C, Bray SCE, Visvanathan R, Whitehead C, Griffith EC, Evans K, Corlis M, Wesselingh S. Health status and healthcare trends of individuals accessing Australian aged care programmes over a decade: the Registry of Senior Australians historical cohort. Intern Med J 2021; 51:712-724. [PMID: 32359019 PMCID: PMC8251748 DOI: 10.1111/imj.14871] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
Background Understanding the health profile, service and medicine use of Australians in the aged care sector will help inform appropriate service provision for our ageing population. Aims To examine the 2006–2015 trends in (i) comorbidities and frailty of individuals accessing aged care, and (ii) health services, medicine use and mortality after entry into long‐term care. Methods Cross‐sectional and population‐based trend analyses were conducted using the Registry of Senior Australians. Results From 2006 to 2015, 509 944 individuals accessed permanent residential care, 206 394 home care, 283 014 respite and 124 943 transition care. Over this time, the proportion of individuals accessing permanent residential care with high frailty scores (≥0.3) increased (19.7–49.7%), as did the proportion with 5–9 comorbidities (46.4–54.5%), with similar trends observed for those accessing other services. The median number of medicines dispensed in the year after entering permanent residential care increased from 9 (interquartile range (IQR) 6–12) to 10 (IQR 7–14), while remaining stable in home care (2006: 9, IQR 5–12, 2015: 9, IQR 6–13). Short‐term (within 100 days) mortality in those accessing permanent care was higher in 2006 (15.6%, 95% CI 15.2–16.0) than 2015 (14.6%, 95% CI 14.3–14.9). Longer term (101–1095 days, 2006: 44.3%, 95% CI 43.7–45.0, 2015: 46.4%, 95% CI 45.8–46.9) mortality was higher in 2015 compared to 2006. Mortality in individuals accessing home care did not change. Conclusion The health of older Australians accessing aged care programmes has declined while frailty increased, with an increasing use of medicine and worse long‐term mortality in some. Funding and care models need to adapt to this changing profile.
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Affiliation(s)
- Maria C Inacio
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Catherine Lang
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Sarah C E Bray
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Division of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Renuka Visvanathan
- National Health and Medical Research Council Centre of Research Excellence in Frailty and Healthy Ageing, University of Adelaide, Adelaide, South Australia, Australia.,Adelaide Geriatrics Training and Research with Aged Care Centre, University of Adelaide, Adelaide, South Australia, Australia.,Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Craig Whitehead
- Division of Rehabilitation, Aged Care and Palliative Care, Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia.,Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Elizabeth C Griffith
- Clinical Research, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Keith Evans
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Megan Corlis
- Research and Development, Helping Hand Aged Care, Adelaide, South Australia, Australia
| | - Steve Wesselingh
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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Impact of interdisciplinary approaches to deprescribing psychotropics on clinical outcomes in older residents of long-term care facilities. Int Psychogeriatr 2021; 33:543-546. [PMID: 34078496 DOI: 10.1017/s1041610220001453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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9
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Abstract
Most patients with dementia have behavioural and psychological symptoms. The first-line treatments for these symptoms are not drugs, but behavioural and psychological interventions Antipsychotic drugs are widely prescribed for people living with dementia. This is despite a high adverse effect burden and limited evidence of efficacy Most behavioural and psychological symptoms will subside spontaneously within six months. Trials of deprescribing are therefore recommended Behaviours should be seen as symptoms that have an underlying cause. Treatment should target these causes, rather than the resultant behaviours
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Affiliation(s)
- Stephen Macfarlane
- Dementia Centre, Hammond Care, Sydney.,Faculty of Medicine and Health Sciences, Monash University, Clayton, Victoria.,School of Public health and Community Medicine, University of New South Wales, Sydney
| | - Colm Cunningham
- Dementia Centre, Hammond Care, Sydney.,Faculty of Medicine and Health Sciences, Monash University, Clayton, Victoria.,School of Public health and Community Medicine, University of New South Wales, Sydney
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Parajuli DR, Kuot A, Hamiduzzaman M, Gladman J, Isaac V. Person-centered, non-pharmacological intervention in reducing psychotropic medications use among residents with dementia in Australian rural aged care homes. BMC Psychiatry 2021; 21:36. [PMID: 33441109 PMCID: PMC7805083 DOI: 10.1186/s12888-020-03033-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND High rates of psychotropic medications are prescribed in aged care homes despite their limited effectiveness and associated adverse effects. We aim to evaluate the changes in prescription patterns for elderly residents with dementia in the 'Harmony in the Bush Dementia Study'. Harmony in the Bush is a person-centered model of dementia care in nursing homes, based on the principles of Progressively Lowered Stress Threshold and person-centered music intervention. METHODS Our larger study (12 weeks period) was a quasi-experimental design conducted in five rural nursing homes in Australia. Medication charts (n = 31) were collected retrospectively from three rural aged care facilities. Medication data for each resident was collected from a three-month medication charts, pre-intervention, and post-intervention. Fifty-three staff participated in 31 semi-structured interviews and 8 focus groups at post-intervention, and at 1-month and 3-months follow up. RESULTS The median age of the participants was 83 years, and 68% of them were female. Polypharmacy was measured in 87% (n = 27) of the participants. Hypertension, hyperlipidemia, diabetes, and the Alzheimer's disease were the major comorbidities identified in residents. None of the residents received more than the maximum dose of psychotropic medications recommended by the guidelines. There was a reduction of 22.4% (77.4% vs 55%) in the use of at least any psychotropic medications, 19.6% (39% vs, 19.4%) reduction in antipsychotics and benzodiazepines (39% vs 19.4%), and 6.5% (42% vs 35.5%) reduction in antidepressants prescription medicines, when comparing residents' medication charts data covering 3-months pre- and post-intervention, however, these changes were not statistically significant. Additionally, there was a decreasing trend in the use of inappropriate medications. Psychotropic medications were prescribed in up to 43% and anti-dementia medications in 44% of participants for more than 6 months. Three themes extracted from qualitative data include decrease behavioral and psychiatric symptoms of dementia due to medication weaning or dose tapering, other strategies to reduce medication use, and environmental or noise control. CONCLUSIONS Our findings indicate that the Harmony in the Bush model as a non-pharmacological approach reduces the prescription of psychotropic medications in rural nursing homes as supported by findings from both quantitative and qualitative data. TRIAL REGISTRATION ANZCTR, ACTRN12618000263291 . Registered on 20th February 2018.
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Affiliation(s)
- Daya Ram Parajuli
- College of Medicine and Public Health, Flinders Rural Health South Australia, Flinders University, Po Box 852, Ral Ral Avenue, Renmark, Australia.
| | - Abraham Kuot
- College of Medicine and Public Health, Flinders Rural Health South Australia, Flinders University, Po Box 852, Ral Ral Avenue, Renmark, Australia
| | - Mohammad Hamiduzzaman
- College of Medicine and Public Health, Flinders Rural Health South Australia, Flinders University, Po Box 852, Ral Ral Avenue, Renmark, Australia
| | - Justin Gladman
- College of Medicine and Public Health, Flinders Rural Health South Australia, Flinders University, Po Box 852, Ral Ral Avenue, Renmark, Australia
| | - Vivian Isaac
- College of Medicine and Public Health, Flinders Rural Health South Australia, Flinders University, Po Box 852, Ral Ral Avenue, Renmark, Australia
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Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study. Aging Clin Exp Res 2021; 33:95-104. [PMID: 32162240 PMCID: PMC7897604 DOI: 10.1007/s40520-020-01518-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/15/2020] [Indexed: 12/29/2022]
Abstract
Background There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry. Aims To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs. Methods A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality. Results In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0–3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18–1.22) and without dementia (1.28, 1.24–1.31). Conclusion Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs. Electronic supplementary material The online version of this article (10.1007/s40520-020-01518-y) contains supplementary material, which is available to authorized users.
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12
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Bui TNT, Stahl HJ, Kaplan J, Hotham E, Loffler H, Corlis M, Suppiah V. Administration of As-Needed Psychotropic Medications in Aged Care: Decision Matrix Employed by Nursing Staff. J Am Med Dir Assoc 2020; 22:721-723.e1. [PMID: 33388298 DOI: 10.1016/j.jamda.2020.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/17/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Tien Ngoc Thi Bui
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Hope J Stahl
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Josef Kaplan
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Elizabeth Hotham
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Helen Loffler
- Helping Hand Organisation, Adelaide, South Australia, Australia
| | - Megan Corlis
- Helping Hand Organisation, Adelaide, South Australia, Australia
| | - Vijayaprakash Suppiah
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia; Australian Centre for Precision Health, University of South Australia, Adelaide, South Australia, Australia
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Evrard P, Henrard S, Foulon V, Spinewine A. Benzodiazepine Use and Deprescribing in Belgian Nursing Homes: Results from the COME-ON Study. J Am Geriatr Soc 2020; 68:2768-2777. [PMID: 32786002 DOI: 10.1111/jgs.16751] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/02/2020] [Accepted: 07/03/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVES To describe the use and deprescribing of benzodiazepine receptor agonists (BZRAs) among nursing home residents (NHRs), to evaluate appropriateness of use and to identify factors associated with BZRA use and deprescribing. DESIGN Posthoc analysis of the Collaborative Approach to Optimize Medication Use for Older People in Nursing Homes (COME-ON) study, a cluster controlled trial that evaluated the impact of a complex intervention on potentially inappropriate prescriptions (PIPs) in nursing homes (NHs). SETTING A total of 54 NHs in Belgium. PARTICIPANTS A total of 797 NHRs included in the study who had complete medical, clinical, and medication information at baseline and at the end of the study (month 15). MEASUREMENTS Data were recorded by participating healthcare professionals. Reasons why BZRA use was considered as PIPs were assessed using the 2019 American Geriatrics Society Beers Criteria® and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria, version 2. Deprescribing included complete cessation or decreased daily dose. We identified factors at the NHR, prescriber, and NH levels associated with BZRA use and BZRA deprescribing using multivariable binary and multinomial logistic regression, respectively. RESULTS At baseline, 418 (52.4%) NHRs were taking a BZRA. The use of BZRA for longer than 4 weeks, with two or more other central nervous system active drugs, and in patients with delirium, cognitive impairment, falls, or fractures was found in more than 67% of BZRA users. Eight NHR-related variables and two prescriber-related variables were associated with regular BZRA use. Deprescribing occurred in 28.1% of BZRA users (32.9% in the intervention group and 22.1% in the control group). In addition to four other factors, dementia (odds ratio [OR] = 2.35; 95% confidence interval [CI] = [1.45-3.83]) and intervention group (OR = 1.74; 95% CI = 1.07-2.87) were associated with deprescribing. CONCLUSION Use of BZRAs was highly prevalent, and reasons to consider it as PIP were frequent. Deprescribing occurred in one-fourth of NHRs, which is encouraging. Future interventions should focus on specific aspects of PIPs (ie, indication, duration, drug-drug and drug-disease interactions) as well as on nondementia patients.
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Affiliation(s)
- Perrine Evrard
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium
| | - Séverine Henrard
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium.,Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels, Belgium.,Pharmacy Department, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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14
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McDerby N, Kosari S, Bail K, Shield A, Peterson G, Naunton M. Pharmacist-led medication reviews in aged care residents with dementia: A systematic review. Australas J Ageing 2020; 39:e478-e489. [PMID: 32748980 DOI: 10.1111/ajag.12827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate outcomes associated with pharmacist-led medication reviews in residential aged care facility (RACF) residents with dementia. METHODS Six scientific databases were searched. All study designs investigating pharmacist-led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681). RESULTS One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi-faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy. CONCLUSION Pharmacist-led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT.
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Affiliation(s)
- Nicole McDerby
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Kasia Bail
- Discipline of Nursing, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Alison Shield
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia
| | - Greg Peterson
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia.,Discipline of Pharmacy, Faculty of Health, University of Tasmania, Hobart, TAS, Australia
| | - Mark Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT, Australia
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15
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Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki. Drugs Aging 2020; 37:27-34. [PMID: 31705445 PMCID: PMC6965041 DOI: 10.1007/s40266-019-00720-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The use of drugs with anticholinergic properties (DAPs) is common among older adults despite their known adverse effects, such as cognitive decline. Professionals should pay attention to DAPs, since evidence on their adverse effects has been accumulating during the last decade. However, to our knowledge previous studies exploring temporal trends in the use of DAPs are scarce. Objective The aim of this study was to assess temporal trends in the use of DAPs from 2003 to 2017 in long-term care facilities in Helsinki. Methods Four cross-sectional studies were conducted in 2003, 2007, 2011, and 2017. Participants included older people (≥ 65 years) living in nursing homes (NHs) in 2003 (n = 1979), 2011 (n = 1568), and 2017 (n = 750), and in assisted living facilities (ALFs) in 2007 (n = 1336), 2011 (n = 1556), and 2017 (n = 1673) in Helsinki, Finland. Data on demographics, medication use, and diagnoses were collected by structured questionnaires. The assessments were conducted as a point prevalence over 1 day. The use of DAPs and the total anticholinergic burden were defined by the Anticholinergic Risk Scale (ARS). Results In ALFs, there has been an increasing trend in the use of DAPs over a 10-year period (41.2% in 2007 and 53.7% in 2017). In NHs, by contrast, the use of DAPs remained quite stable (52.3% in 2003 and 52.4% in 2017). The burden of DAPs measured by ARS score decreased in NHs and remained stable in ALFs. Marked changes occurred in the DAPs used; antidepressants, especially mirtazapine, increased in both settings, whereas the use of hydroxyzine and urinary antispasmodics nearly disappeared. The proportion of users of DAP antipsychotics increased in ALFs. Participants with dementia had a lower anticholinergic burden than those without dementia, in both settings. Conclusions Despite increased knowledge of the harms of DAPs, they remain widely used. Physicians seem to be aware of the harms of DAPs among people with dementia, and some other favorable trends in prescribing were also observed. Clinicians should especially consider the indications behind the use of DAP antidepressants and antipsychotics, and carefully weigh their potential benefits and harms.
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16
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Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project. Int Psychogeriatr 2020; 32:335-345. [PMID: 31969207 DOI: 10.1017/s1041610219002011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents. DESIGN We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial. SETTING Twenty-four long-term care facilities in Sydney, Australia. PARTICIPANTS The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline. MEASUREMENTS Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible). RESULTS Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD. CONCLUSION Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.
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17
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Shafiee Hanjani L, Hubbard RE, Freeman CR, Gray LC, Scott IA, Peel NM. Medication use and cognitive impairment among residents of aged care facilities. Intern Med J 2020; 51:520-532. [PMID: 32092243 DOI: 10.1111/imj.14804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Potentially inappropriate polypharmacy is common in residential aged care facilities (RACF). This is of particular concern among people with cognitive impairment who, compared with cognitively intact residents, are potentially more sensitive to the adverse effects of medications. AIM To compare the patterns of medication prescribing of RACF residents based on cognitive status. METHODS De-identified data collected during telehealth-mediated geriatric consultations with 720 permanent RACF residents were analysed. Residents were categorised into cognitively intact, mild to moderate impairment and severe impairment groups using the interRAI Cognitive Performance Scale. The number of all regular and when-required medications used in the past 3 days, the level of exposure to anti-cholinergic/sedative medications and potentially inappropriate medications and the use of preventive and symptom control medications were compared across the groups. RESULTS The median number of medications was 10 (interquartile range (IQR) 8-14). Cognitively intact residents were receiving significantly more medications (median (IQR) 13 (10-16)) than those with mild to moderate (10 (7-13)) or severe (9 (7-12)) cognitive impairment (P < 0.001). Overall, 82% of residents received at least one anti-cholinergic/sedative medication and 26.9% were exposed to one or more potentially inappropriate medications, although the proportions of those receiving such medications were not significantly different across the groups. Of 7658 medications residents were taking daily, 21.3% and 11.7% were classified as symptom control and preventive medications respectively with no significant difference among the groups in their use. CONCLUSION Our findings highlight the need for optimising prescribing in RACF residents, with particular attention to medications with anti-cholinergic effects.
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Affiliation(s)
- Leila Shafiee Hanjani
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ruth E Hubbard
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,PA-Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Christopher R Freeman
- Centre for Optimising Pharmacy Practice-based Excellence in Research, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
| | - Leonard C Gray
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ian A Scott
- PA-Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nancye M Peel
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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18
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Hasan SS, Zaidi STR, Nirwan JS, Ghori MU, Javid F, Ahmadi K, Babar ZUD. Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis. J Clin Med 2019; 8:E1292. [PMID: 31450830 PMCID: PMC6780105 DOI: 10.3390/jcm8091292] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents. METHODS MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated. RESULTS A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%). CONCLUSION The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.
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Affiliation(s)
- Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK.
| | | | - Jorabar Singh Nirwan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Muhammad Usman Ghori
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Farideh Javid
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Keivan Ahmadi
- Lincoln Medical School-Universities of Nottingham and Lincoln, College of Science, Lincoln LN6 7TS, UK
| | - Zaheer-Ud-Din Babar
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
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