Persistent use of psychotropic drugs in nursing home residents in Norway

Chemical restraint as behavioural euthanasia: case studies from the Royal Commission into Aged Care Quality and Safety

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.

Actual drug-related harms in residential aged care facilities: a narrative review

INTRODUCTION

Older people in residential aged care facilities (RACFs) have a high risk of safety issues and concerns about the potential quality of care received. This narrative review investigates the types of actual drug-related harms, their prevalence, reporting of any standard definitions for these harms, and their identification methods.

AREAS COVERED

The authors conducted a systematic search on Ovid Embase, Ovid Medline, and PubMed from March 2001 to March 2021. This narrative review included all types of studies targeting aged care residents aged 65 years and above with actual drug-related harms.

EXPERT OPINION

The prevalence of actual drug-related harms in residents ranged from 0.07% to 63.0%. Falls, drug-drug interactions, neuropsychiatric symptoms, anaphylaxis, urinary tract infection, hypoglycemia, hypokalaemia, and acute kidney injury are the most common drug-related harms in older residents. Psychotropic drugs are the most common drug class implicated in these harms. Evidence related to the association between individual psychotropic drugs and injury, or harm is also lacking. Due to the variation in study duration, reported prevalence, identification methods, and absence of a definition for actual drug-related harms in most studies, further research is mandated to understand the prevalence and clinical implications of drug-related harms in older residents.

Health professionals' experience of nursing home residents' consumption of alcohol and use of psychotropic drugs

Background:

Nursing home (NH) residents are in most cases in older ages and use prescription drugs. As alcohol interacts with many commonly prescribed drugs, NH residents may be more vulnerable to the effects of alcohol.

Aim:

To investigate the experiences of health professionals in Norwegian NHs when it comes to residents' alcohol consumption and use of psychotropic drugs, and the facilitation of such use in the NH.

Method:

Focus-groups and individual interviews with NH health professionals were performed in 2017 and 2018. The data were analysed using content analysis.

Findings:

Two main themes emerged: (1) the balancing of alcohol consumption, and (2) the use of psychotropic drugs. Each of these themes involved reasoning, which revealed that the informants in general had little attention regarding alcohol consumption among residents, and few institutions had policies regarding serving and consumption of alcohol. The informants reported an increased attention regarding use of psychotropic drugs and a tendency towards less use of psychotropic drugs among the residents than before, but few informants reported use of standardised observations tools of symptoms related to prescribing and discontinuation of drugs.

Conclusion:

Alcohol policies or procedures related to alcohol consumption were uncommon at the NH that the interviewees of this study represented, and the professionals regarded infrequent serving and consumption of alcohol among the residents as a part of everyday life. In cases when residents frequently consumed alcohol, the professionals used dialogue to underpin the adherent risks and they also tried to control the consumption of the resident in different ways. The interviewees were aware of various side-effects of psychotropic drugs; they were also aware of their effects in combination with alcohol.

Personalized Management and Treatment of Alzheimer's Disease

Alzheimer’s disease (AD) is a priority health problem with a high cost to society and a large consumption of medical and social resources. The management of AD patients is complex and multidisciplinary. Over 90% of patients suffer from concomitant diseases and require personalized therapeutic regimens to reduce adverse drug reactions (ADRs), drug−drug interactions (DDIs), and unnecessary costs. Men and women show substantial differences in their AD-related phenotypes. Genomic, epigenetic, neuroimaging, and biochemical biomarkers are useful for predictive and differential diagnosis. The most frequent concomitant diseases include hypertension (>25%), obesity (>70%), diabetes mellitus type 2 (>25%), hypercholesterolemia (40%), hypertriglyceridemia (20%), metabolic syndrome (20%), hepatobiliary disorder (15%), endocrine/metabolic disorders (>20%), cardiovascular disorder (40%), cerebrovascular disorder (60−90%), neuropsychiatric disorders (60−90%), and cancer (10%). Over 90% of AD patients require multifactorial treatments with risk of ADRs and DDIs. The implementation of pharmacogenetics in clinical practice can help optimize the limited therapeutic resources available to treat AD and personalize the use of anti-dementia drugs, in combination with other medications, for the treatment of concomitant disorders.

The Prevalence of Polypharmacy and Potentially Inappropriate Medications and Its Relationship with Cognitive Status in Portuguese Institutionalized Older Adults: A Cross-Sectional Study

The aim of this study was to evaluate the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a population of older adults living in nursing homes. Furthermore, we also intended to assess the possible association between polypharmacy, potentially inappropriate medications and cognitive impairment in institutionalized older adults. A cross-sectional study analyzed data from 193 nursing home residents in the district of Viseu, Portugal, between September 2018 and June 2019, with a mean age of 82.4 ± 6.2 years (ranging from 65 to 95 years old); 72.5% (n = 140) were female participants. Major polypharmacy was presented in 80.8% of the study population, who took 7.6 ± 3.3 drugs per day. Using the Beers Criteria, we found that 79.3% took PIMs. There was a positive association between polypharmacy and PIM (p < 0.001), showing that higher medicines intake increased the number of PIMs. Polypharmacy was not associated with the functionality of the older adults to perform activities of daily living, but was associated with cognitive impairment. The older adults with lower scores on the Mini Mental State Examination (MMSE) took more drugs (p = 0.039) and used more PIM (p < 0.001). Moreover, patients taking five or more prescription drugs per day (major polypharmacy) consuming any psychiatric, gastrointestinal or oral antidiabetic agents (regardless of whether they were considered potentially inappropriate or not) had higher odds of displaying cognitive impairment than those who did not (p < 0.05). Older adult residents of the studied nursing homes were potentially affected by polypharmacy and inappropriate polypharmacy. This observation reveals the need to adopt and implement strategies that make drug therapy more adequate and safer for older adults.

Psychotropic medication deprescribing in residential aged care facilities: An exploratory study of the knowledge and attitudes of family members of residents with dementia

OBJECTIVES

General practitioners face many barriers to deprescribing psychotropic medications in people with dementia in nursing homes, including a lack of knowledge about their medication histories. This study explored the knowledge of family members about residents' medications and their willingness to support deprescribing.

METHODS

Sixty-six family members of residents from seven residential aged care facilities participated in this cross-sectional study. Participation involved nomination of recognised medications, rating their effectiveness and rating level of support for deprescribing.

RESULTS

Fifty-five per cent of medications were recognised by family members; significantly fewer psychotropics were recognised than non-psychotropic medications. Though rated as just as effective, support for deprescribing psychotropics was significantly higher. Most family members were agreeable to deprescribing with general practitioner support.

CONCLUSIONS

Although there is a gap in family members' knowledge about psychotropic medications, overall they are supportive of deprescribing. Findings emphasise the need for psychoeducation among family members. Providing family members with a list of prescribed medications, specifying the type of and reason for prescription and side effects of each, is recommended to facilitate their advocacy for deprescribing on behalf of nursing home residents.

Pharmacogenomics of Alzheimer's Disease: Novel Strategies for Drug Utilization and Development

Alzheimer's disease (AD) is a priority health problem in developed countries with a high cost to society. Approximately 20% of direct costs are associated with pharmacological treatment. Over 90% of patients require multifactorial treatments, with risk of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) for the treatment of concomitant diseases such as hypertension (>25%), obesity (>70%), diabetes mellitus type 2 (>25%), hypercholesterolemia (40%), hypertriglyceridemia (20%), metabolic syndrome (20%), hepatobiliary disorder (15%), endocrine/metabolic disorders (>20%), cardiovascular disorder (40%), cerebrovascular disorder (60-90%), neuropsychiatric disorders (60-90%), and cancer (10%).For the past decades, pharmacological studies in search of potential treatments for AD focused on the following categories: neurotransmitter enhancers (11.38%), multitarget drugs (2.45%), anti-amyloid agents (13.30%), anti-tau agents (2.03%), natural products and derivatives (25.58%), novel synthetic drugs (8.13%), novel targets (5.66%), repository drugs (11.77%), anti-inflammatory drugs (1.20%), neuroprotective peptides (1.25%), stem cell therapy (1.85%), nanocarriers/nanotherapeutics (1.52%), and other compounds (<1%).Pharmacogenetic studies have shown that the therapeutic response to drugs in AD is genotype-specific in close association with the gene clusters that constitute the pharmacogenetic machinery (pathogenic, mechanistic, metabolic, transporter, pleiotropic genes) under the regulatory control of epigenetic mechanisms (DNA methylation, histone/chromatin remodeling, microRNA regulation). Most AD patients (>60%) are carriers of over ten pathogenic genes. The genes that most frequently (>50%) accumulate pathogenic variants in the same AD case are A2M (54.38%), ACE (78.94%), BIN1 (57.89%), CLU (63.15%), CPZ (63.15%), LHFPL6 (52.63%), MS4A4E (50.87%), MS4A6A (63.15%), PICALM (54.38%), PRNP (80.7059), and PSEN1 (77.19%). There is also an accumulation of 15 to 26 defective pharmagenes in approximately 85% of AD patients. About 50% of AD patients are carriers of at least 20 mutant pharmagenes, and over 80% are deficient metabolizers for the most common drugs, which are metabolized via the CYP2D6, CYP2C9, CYP2C19, and CYP3A4/5 enzymes.The implementation of pharmacogenetics can help optimize drug development and the limited therapeutic resources available to treat AD, and personalize the use of anti-dementia drugs in combination with other medications for the treatment of concomitant disorders.

Pattern of prescription of psychotropics (antipsychotics, antidepressants and benzodiazepines) in Western Australian residential aged care facilities

Behavioural and psychological symptoms of dementia are exhibited by up to 90% of residents in aged care facilities and are associated with a risk of inappropriate use of psychotropic drugs. This study examined the prevalence pattern of psychotropic drug use in 409 residents from 11 residential aged care facilities in Western Australia. Sixty-four (n = 64; 15.6%) residents were not prescribed any psychotropic drug, 345 (84.4%) were prescribed at least one psychotropic drug and between 4 and 10% were prescribed high doses, depending on the class of psychotropic. Despite increasing awareness of inappropriate psychotropic drug use in this population, targeted and effective interventions are required to improve psychotropic prescribing practices.

Prevalence of psychotropic polypharmacy in nursing home residents with dementia: a meta-analysis

OBJECTIVES

Nursing home (NH) residents with dementia is exposed to high rates of psychotropic prescriptions. Our objectives were to: (1) pool the prevalence estimates of psychotropic polypharmacy from the existing literature and (2) examine potentially influential factors that are related to a higher or lower prevalence.

DESIGN

Meta-analysis of data collected from randomized trials, quasi-experimental, prospective or retrospective cohort, and cross-sectional studies. English-language searches of PubMed and PsycINFO were completed by November 2020. Included studies reported prevalence estimates of psychotropic polypharmacy (i.e. defined as either two-or-more or three-or-more medications concurrently) in NH residents with dementia.

SETTING AND PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Random-effects models were used to pool the prevalence of psychotropic polypharmacy in NH residents with dementia across studies. Estimates were provided for both two-or-more and three-or-more concurrent medications. Heterogeneity and publication bias were measured. Meta-regression examined the influence of the percentage of the sample who were male, mean age of the sample, geographic region (continent), sample size, and study year on the prevalence of psychotropic polypharmacy.

RESULTS

Twenty-five unique articles were included comprising medications data from 92,370 NH residents with dementia in 12 countries. One-in-three (33%, [95% CI: 28%, 39%]) NH residents with dementia received two-or-more psychotropic medications concurrently. One-in-eight (13%, [95% CI: 10%, 17%]) received three-or-more psychotropic medications concurrently. Estimates were highly variable across both definitions of psychotropic polypharmacy (p < 0.001). Among study-level demographics, geographic region, sample size, or study year, only male sex was associated with greater use of two-or-more psychotropic medications (Unadjusted OR = 1.02, p = 0.006; Adjusted OR = 1.04, p = 0.07).

CONCLUSIONS

Psychotropic polypharmacy is common among NH residents with dementia. Identifying the causes of utilization and the effects on resident health and well-being should be prioritized by federal entities seeking to improve NH quality.

Do prescription rates of psychotropic drugs change over three years from nursing home admission?

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 .

A pharmacist-led pilot using a performance dashboard to improve psychotropic medication use in a skilled nursing facility

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.

[Geriatric Psychiatry in Nursing Homes in the Canton Basel-Stadt - The View of General Practitioners]

Geriatric Psychiatry in Nursing Homes in the Canton Basel-Stadt - The View of General Practitioners Abstract. Background: This cross-sectional study intends to examine the potential need for an outpatient geronto-psychiatric service and evaluates GPs' views of the frequency of psychiatric symptoms among residents of nursing homes in the canton of Basel-Stadt, Switzerland. Results: Nine out of ten (89 %) see a need for a geronto-psychiatric service. Two thirds (58,9 %) of them prefer a service available during office hours. GPs estimate that 63 % of their nursing home residents suffer from psychiatric symptoms (dementia in 60 %, depression in 23 %, sleep disorders in 11 %). Antipsychotics are prescribed most often (in 50,6 %). Discussion: GPs in the canton of Basel-Stadt see a need for an outpatient geronto-psychiatric service. Psychiatric symptoms are common among residents of nursing homes.

Less Is More: The Impact of Deprescribing Psychotropic Drugs on Behavioral and Psychological Symptoms and Daily Functioning in Nursing Home Patients. Results From the Cluster-Randomized Controlled COSMOS Trial

OBJECTIVE

To investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL).

DESIGN

Four-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial.

SETTING

Thirty-three Norwegian nursing homes including 67 nursing home wards (clusters).

PARTICIPANTS

A total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control).

INTERVENTION

The COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments.

MEASUREMENTS

Mean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS).

RESULTS

Compared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group.

CONCLUSION

Medication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.

A Cluster Randomized Controlled Trial Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents With Dementia

OBJECTIVE

The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity, and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level.

DESIGN

This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (FBFC-CI) or educational control [Function and Behavior Focused Care Education (FBFC-ED)].

SETTING AND PARTICIPANTS

Twelve nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment.

MEASURES

Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen-Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia), and psychotropic medication use.

RESULTS

The participants were 82.6 (SD = 10.1) years of age, mostly female, and were moderate to severely cognitively impaired (Mini-Mental State Exam of 7.8, SD = 5.1). There was a significantly greater increase in time spent in total activity (P = .004), moderate activity (P = .012), light activity (P = .002), and a decrease in resistiveness to care (P = .004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention at treatment sites.

CONCLUSIONS AND IMPLICATIONS

This study provides some support for the use of the FBFC-CI Intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Does Psychotropic Drug Prescription Change in Nursing Home Patients the First 6 Months After Admission?

OBJECTIVES

To explore the course of psychotropic drug (PTD) prescription from admission (BL) to 6-month follow-up (6m) in Norwegian nursing homes (NHs). To examine how clinical variables, such as neuropsychiatric symptoms (NPS), cognition, physical health, and NH characteristics at BL are associated with prescription rates at 6 months.

DESIGN

An observational longitudinal cohort study (data from the Resource Use and Disease Course in Dementia-Nursing Home study) designed to examine the course of dementia, psychiatric and somatic diseases, and drug prescriptions in NH patients during the first 6 months after admission.

SETTING AND PARTICIPANTS

We included 696 patients at admission to 47 representative Norwegian NHs.

METHODS

Demographic and clinical characteristics at BL and 6m are presented. Dementia severity was assessed by the Clinical Dementia Rating scale and the Functional Assessment Staging of Alzheimer's Disease scale. Final diagnosis was made by 2 of the authors (G.S. and S.B.) according to ICD-10 criteria. Prevalence, incidence, and persistence rates of PTD prescriptions for people with dementia are presented. Generalized mixed models were used to identify possible predictors for the course of PTD prescription from BL to 6m.

RESULTS

Prescription rates of antidepressants, antipsychotics, anxiolytics, sedatives, and hypnotics increased in people with dementia from BL (67.5% received at least 1 PTD) to 6m (74.0% received at least 1 PTD). Younger age and higher Neuropsychiatric Inventory-affective subsyndrome score at BL were associated with higher odds of antidepressant prescription, whereas patients with higher comorbidity at BL had lower odds of receiving antidepressants, both at BL and 6m. Higher Neuropsychiatric Inventory-affective subsyndrome scores at BL were associated with higher odds of sedative and hypnotic prescription at both assessment points.

CONCLUSIONS AND IMPLICATIONS

PTD prescription rates increase from BL to 6m. Medication appropriateness should be frequently evaluated after admission to optimize PTD prescriptions.

Variation between nursing homes in drug use and in drug-related problems

BACKGROUND

Residents at nursing homes (NHs) are at particular risk for drug related harm. Regular medication reviews using explicit criteria for pharmacological inappropriateness and classification of drug related problems (DRPs) have recently been introduced as measures to improve the quality of medication use and for making the treatment more uniform across different institutions. Knowledge about variation in DRPs between NHs is scarce. To explore if increased attention towards more appropriate drug treatment in NHs have led to more uniform treatment, we have analyzed variations between different nursing homes' drug use and DRPs.

METHODS

Cross-sectional medication review study including 2465 long-term care residents at 41 NHs in Oslo, Norway. Regular drug use was retrieved from the patients' medical records. DRPs were identified by using STOPP/START and NORGEP criteria and a drug-drug interactions database. NHs were grouped in quartiles based on average levels of drug use. The upper and lower quartiles were compared using independent samples t-test and associations between drug use and DRPs were tested by logistic regression.

RESULTS

Patients' mean age was 85.9 years, 74.2% were women. Mean numbers of regular drugs per patient was 6.8 and varied between NHs from 4.8 to 9.3. The proportion of patients within each NH using psychotropic and analgesic drugs varied largely: antipsychotics from three to 50%, benzodiazepines from 24 to 99%, antidepressants from nine to 75%, anti-dementia drugs from no use to 42%, opioids from no use to 65% and paracetamol from 16 to 74%. Mean DRPs per patient was 2.0 and varied between NHs from 0.5 to 3.4. The quartiles of NHs with highest and lowest mean drugs per patient (7.7 vs. 5.7, p < 0.001) had comparable mean number of DRPs per patient (2.2 vs. 1.8, p = 0.2). Using more drugs and the use of opioids, antipsychotics, benzodiazepines and antidepressants were associated with more DRPs.

CONCLUSIONS

The use of psychotropic and analgesic drugs was high and varied substantially between different NHs. Even if the use of more drugs, opioids and psychotropic drugs was associated with DRPs, no difference was found in DRPs between the NHs with highest vs. lowest drug use.

Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017

Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

OBJECTIVES

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.

DESIGN

Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.

SETTING AND PARTICIPANTS

Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.

MEASURES

Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.

INTERVENTION

Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.

RESULTS

At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.

CONCLUSIONS/IMPLICATIONS

The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Prolonged use of antipsychotic medications in long-term aged care in Australia: a snapshot from the HALT project

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.

Gender Differences in Function, Physical Activity, Falls, Medication Use, and Life Satisfaction Among Residents in Assisted Living Settings

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.].

Association between Physician Intensity of Antibiotic Prescribing and the Prescription of Benzodiazepines, Opioids and Proton-Pump Inhibitors to Nursing Home Residents: a Population-Based Observational Study

BACKGROUND

Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown.

OBJECTIVE

To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults.

DESIGN

Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients.

PARTICIPANTS

1926 physicians who provided care among 128,979 physician-patient pairs in 2015.

MAIN MEASURES

Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics.

KEY RESULTS

Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers.

CONCLUSIONS

The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

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.

Drug Use before and after Initiating Treatment with Acetylcholinesterase Inhibitors

Background/Aims

The aim was to study the prevalence of use of different drugs prescribed for behavioral and psychological symptoms of dementia in persistent users of acetylcholinesterase inhibitors (AChEIs) before and after AChEI initiation, and to compare with the use in the general population.

Methods

Use of antidepressants, antipsychotics, and analgesics in the 4 years before and 2 years after AChEI initiation was studied based on data from the Norwegian Prescription Database 2004–2016.

Results

The prevalence of use of antidepressants and antipsychotics the year before AChEI initiation was twice the prevalence in the age-adjusted general population and continued to rise in the first 2 years after initiation of AChEIs. The prevalence of weak analgesics and antipsychotics increased strongly in the last year before AChEI initiation. The increase in the use of antidepressants started at least 4 years before initiation of AChEIs. Opioid use was generally lower than in the general population and was not influenced by AChEI initiation.

Conclusion

Increased use of antidepressants and antipsychotics was observed both before and after initiation of AChEIs and may indicate that behavioral symptoms occur in a preclinical or early phase of Alzheimer's disease. The prescription pattern of analgesics with a low use of opioids may indicate an undertreatment of pain in people with dementia.

A retrospective comparison of inappropriate prescribing of psychotropics in three Norwegian nursing homes in 2000 and 2016 with prescribing quality indicators

Background

Inappropriate prescribing of psychotropics is a persistent and prevalent problem in nursing homes. The present study compared inappropriate prescribing of psychotropics in nursing homes 16 years apart with prescribing quality indicators. The purpose was to identify any change in inappropriate prescribing of relevance for medical informatics.

Methods

Three Norwegian nursing homes were audited in 2000 and 2016 with regard to prescribing quality. Psychotropics among 386 patients in 2000, and 416 patients in 2016, included combinations of antidepressants, antipsychotics, anxiolytics-hypnotics, and antiepileptics. Prescribing quality indicators included psychotropic polypharmacy (defined as concurrent use of three or more psychotropics) and potential inappropriate psychotropic substances or combinations. Furthermore, potential clinically relevant psychotropic interactions were classified as pharmacodynamic or pharmacokinetic using an interaction database. The first ranked (most important) interaction in each patient was selected with the following importance of categories in the database; recommended action > documentation > severity. Three levels (from low to high) within each category were used for ranking.

Results

From 2000 to 2016, psychotropic polypharmacy increased from 6.2 to 29.6%, potential inappropriate psychotropic substances was reduced from 17.9 to 11.3% and potential inappropriate psychotropic combinations increased from 7.8 to 27.9%. Changes in polypharmacy and combinations were predominantly associated with prescribing of anxiolytics-hypnotics. Sixty-three patients (16.3%) had psychotropic interactions in 2000 increasing to 146 patients (35.1%) in 2016. The increase in interactions was associated with prescribing of antidepressants. First ranked interactions, more than 60% of all interactions in both years, were increasingly pharmacodynamic, from 69.9 to 91.0%. Interactions in 2016 were associated with a lower level of recommended action and documentation, but not severity compared to 2000. The inappropriate prescribing of antipsychotics and antiepileptics was reduced in 2016 compared to 2000.

Conclusions

Using prescribing quality indicators we observed the importance of antidepressants and anxiolytics-hypnotics for inappropriate prescribing in 2016 while the role of antipsychotics and antiepileptics were reduced compared to 2000. A change to mainly pharmacodynamic interactions that lack good documentation was also observed. The present findings can be used for medical informatics-based approaches to address specific problems with prescribing, and prescribing quality indicators, in Norwegian nursing homes.

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care at baseline

Background

Little is known about the use of psychotropic drugs in older adults receiving domiciliary care. The first aim was to describe the prevalence and persistency of use of psychotropic drugs in older adults (≥ 70 years) with and without dementia receiving domiciliary care. Furthermore, the second aim was to explore factors associated with persistent drug use at two consecutive time-points. Lastly, we aimed to examine if use of psychotropic drugs changed after admission to a nursing home.

Methods

In total, 1001 community-dwelling older adults receiving domiciliary care at inclusion participated in the study. Information about psychotropic drug use was collected at baseline, after 18 months and after 36 months. The participants’ cognitive function, neuropsychiatric symptoms (NPS) and physical health were assessed at the same assessments. Participants were evaluated for dementia based on all gathered information. Formal level of care (domiciliary care or in a nursing home) was registered at the follow-up assessments.

Results

Prevalence and persistent use of psychotropic drugs in older adults receiving domiciliary care was high. Participants with dementia more often used antipsychotics and antidepressants than participants without dementia. The majority of the participants using antipsychotic drugs used traditional antipsychotics. Younger age was associated with higher odds for persistent use of antipsychotics and antidepressants, and lower odds for persistent use of sedatives. Severity of NPS was associated with persistent use of antidepressants. The odds for use of antipsychotics and antidepressants were higher in those admitted to a nursing home as compared to the community-dwelling participants at the last follow-up.

Conclusion

There was a high prevalence and persistency of use of psychotropic drugs. The prevalence of use of traditional antipsychotics was surprisingly high, which is alarming. Monitoring the effect and adverse effects of psychotropic drugs is an important part of the treatment, and discontinuation should be considered when possible due to the odds for severe adverse effects of such drugs in people with dementia.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1126-y) contains supplementary material, which is available to authorized users.

Association between changes in the use of psychotropic drugs and behavioural and psychological symptoms of dementia over 1 year among long-term care facility residents

AIM

Pharmacological treatments are often used in treating the behavioural and psychological symptoms of dementia (BPSD) in nursing homes, despite the fact that non-pharmacological treatments are recommended as a first-line treatment and can provide a suitable alternative. Because the course of BPSD is known to fluctuate depending on individual symptoms over time, the frequencies of drug use and BPSD, as well as their association, should be observed over a longer period. We investigated the association between the changes in psychotropic drug (PD) use and BPSD, focusing on the number of symptoms, severity, and care burden over 1 year among long-term care facility residents.

METHODS

A 1-year follow-up study was conducted among older residents with dementia or similar symptoms (n = 312 at baseline; n = 237 at follow-up) by using a care staff questionnaire in 10 long-term care facilities in Hokkaido, Japan. Medication use was determined based on prescription information. The brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

RESULTS

Among residents followed up for 1 year, new users of PD-particularly anxiolytics and hypnotics-had a significantly increased number and severity of BPSD, compared with non-PD users. Continuing PDs was also related to increased severity over the year. Among residents with any persistent BPSD for 1 year, new use of PDs-particularly anxiolytics and hypnotics-was significantly associated with an increased care burden of BPSD, compared with the non-use of PDs. The discontinuation of PDs was significantly associated with a decreased care burden, compared with the non-use of PDs.

CONCLUSIONS

Our study suggests that PDs, particularly anxiolytics and hypnotics, may be prescribed carefully in response to exacerbation of BPSD in terms of the number of symptoms, severity, and care burden in long-term care facilities. Continuous monitoring of PDs use and BPSD is important to effectively address BPSD.

Prescribing of psychotropic medication for nursing home residents with dementia: a general practitioner survey

Objective

The aim of this study was to identify factors influencing the prescribing of psychotropic medication by general practitioners (GPs) to nursing home residents with dementia.

Subjects and methods

GPs with experience in nursing homes were recruited through professional body newsletter advertising, while 1,000 randomly selected GPs from southeastern Australia were invited to participate, along with a targeted group of GPs in Tasmania. An anonymous survey was used to collect GPs’ opinions.

Results

A lack of nursing staff and resources was cited as the major barrier to GPs recommending non-pharmacological techniques for behavioral and psychological symptoms of dementia (BPSD; cited by 55%; 78/141), and increasing staff levels at the nursing home ranked as the most important factor to reduce the usage of psychotropic agents (cited by 60%; 76/126).

Conclusion

According to GPs, strategies to reduce the reliance on psychotropic medication by nursing home residents should be directed toward improved staffing and resources at the facilities.