Psychotropic medication use among older adults: what all nurses need to know

The Impact of Training in Multimodal Communication Skills on Psychotropic Medication Use in Dementia Care

Aim This study aimed to assess the trends in psychotropic drug prescriptions among elderly residents with dementia following the continuous implementation of multimodal comprehensive care communication skills training for staff in a long-term care facility. Methods This retrospective single-center cross-sectional study utilized the database of an urban public hospital that included a long-term care facility. The data were collected from 2016 to 2020. All 130 staff members at the hospital (52 nurses, 48 professional caregivers, seven rehabilitation staff members, three physicians, and three pharmacists) initiated multimodal comprehensive care communication skills basic training from October 2014 to December 2015, which was followed by continuous monthly training until the end of 2020. Antipsychotic prescription rates for residents aged over 65 years with dementia were measured throughout the study period. Results A total of 506 eligible residents were identified, the median age was 86.0 years (IQR: 81.0-90.0), and 283 (55.9%) residents were females. The prescription rates for psychotropic drugs among residents with dementia decreased significantly (43.5% in 2016, 27.0% in 2020; p=0.01). Notably, the percentage of patients prescribed anxiolytics decreased significantly (from 4.7% to 0.0%), while the percentage of patients receiving antipsychotic drugs, hypnotics, antidepressants, or antiepileptic drugs remained unchanged over time. The prescription rates for antidementia drugs significantly decreased from 15.3% to 4.0%. Conclusion The prescription rates of psychotropic drugs were significantly reduced following multimodal comprehensive care communication skills training for staff at a long-term care facility. The improvement in communication skills among staff at long-term care facilities has a tangible impact on reducing drug use among elderly residents with dementia.

Musical Bridges to Memory: A Pilot Dyadic Music Intervention to Improve Social Engagement in Dementia

BACKGROUND

Music-based psychosocial interventions may provide effective management of behavioral symptoms in persons with dementia (PWDs). However, there has been a paucity of studies that measured their effect on social engagement. This proof-of-concept study evaluates efficacy of the Musical Bridges to Memory (MBM) intervention on PWD's social engagement, behavioral symptoms, and associated caregiver distress.

METHODS

Twenty-nine PWDs and caregivers (8 control dyads, 21 intervention) participated in this dyadically designed, prospective, blinded, 12-week controlled interventional study. The intervention consisted of weekly MBM sessions, led by board-certified music therapists and performers, including caregiver training, live performances, and social breakout groups. Outcomes were measured by the Verbal and Nonverbal Interaction Scale for Care Receivers (VNVIS-CR) to code interactions between PWDs and caregivers for verbal and nonverbal sociable and unsociable behaviors. Symptom severity and caregiver distress were measured using Neuropsychiatric Inventory.

RESULTS

Nonverbal sociable interactions significantly increased ( P =0.012) in those who completed the MBM program as compared with a decrease observed in the control group. Family/caregiver distress associated with PWDs neuropsychiatric symptoms showed significant improvement in the experimental group as compared with controls ( P =0.045).

CONCLUSIONS

This study provides proof-of-concept that MBM improves nonverbal sociable content of PWDs interactions and reduces caregivers' distress.

The stratified medicalisation of mental health symptoms: educational inequalities in the use of psychotropic medication in Belgium

PURPOSE

Several studies have shown socioeconomic inequalities in psychotropic medication use, but most of these studies are inspired by Andersen's behavioural model of health care use, which strongly focusses on individuals' needs. Andersen's model pays little attention to health care use that is not based on need and insubstantially recognises the context dependentness of individuals. Medicalisation, however, is a context-dependent interactive process that not only interacts with need determinants, but also with non-need determinants that affect health care use. Therefore, this study will examine if psychotropic medication use is stratified, and whether this is not simply the result of differences in need for care, but also influenced by factors not based on need, initiating the stratified medicalisation of mental health symptoms.

METHODS

Data from the Belgian Health Interview Survey (BHIS) are used. This study covers information from five successive waves: 2001, 2004, 2013, 2018. The weighted data represent a sample of the adult Belgian population. The research aims are analysed using stepwise Poisson regression models, where the models are also plotted to detect evolutions over time, using marginal means postestimation.

RESULTS

The results reveal that educational inequalities in psychotropic medication use are significant and persistently visible over time. Even after entering need for care, educational inequalities remain significant.

CONCLUSION

This study shows that psychotropic medication use is stratified and that this is not simply the result of differences in need for care, but also influenced by factors linked to the stratified medicalisation of mental health symptoms.

The understanding and experience of falls among community-dwelling adults aged 50 and over living with mental illness: A qualitative study

OBJECTIVES

Compared to the general older population, older adults living with mental illness are at greater risk of falling and these risks can be present from middle age. This study aimed to explore the understanding of falls and the experiences community-dwelling adults aged 50 years and over living with mental illness who have had a fall, and to identify any falls prevention strategies valued by them.

METHODS

A qualitative descriptive approach was adopted. Ten adults with past experience of falls were recruited at a community mental health service in Sydney, Australia. Semi-structured interviews were conducted between July and September 2018. Interviews were transcribed verbatim and data were thematically analysed.

RESULTS

Three major themes emerged: (1) making sense of falls, (2) being self-reliant and enduring the consequences of falls, and (3) preventing future falls - perceptions and strategies. Most participants in this study were uncertain about the cause of their falls and seemed to have limited understanding of falls risk factors. They were also less likely to seek help after a fall, despite an injury. Consequences of falls included physical injuries and negative emotional impacts experienced following a fall. Most participants expressed a certain degree of concern regarding future falls, however, their strategy to prevent falls was to simply "be careful."

CONCLUSION

Adults aged over 50 years and living with mental illness in the community need support to identify and manage their falls risk. Fall prevention interventions tailored to the needs of this population are needed.

Self-Esteem, Anxiety, and Depression in Older People in Nursing Homes

Background: Social environment and type of care may influence mental health in late life. The aim of this study was to assess the associations between depression, anxiety, and self-esteem in older people. Methods: The study evaluated mental health in people older than 65 years of age in Zadar County, Croatia. The participants were interviewed using the Patient Health Questionnaire, the Generalized Anxiety Disorder Scale, and the Rosenberg Self-Esteem Scale. Multiple linear regressions were used to assess the correlations between depression, anxiety, and self-esteem. Results: Compared with elderly people living in their own homes, elderly people in nursing homes reported lower self-esteem, higher depression, and higher anxiety. The level of self-esteem decreased with increased levels of depression. Anxiety was significantly associated with depression, while depression strongly increased with an increase in anxiety. Older age was associated with depression, while widowhood was a negative predictor of self-esteem. Institutionalization was borderline significantly associated with anxiety, while gender was associated with anxiety. Conclusions: The study found associations between self-esteem, anxiety, and depression in the elderly. The strategy of humanization in nursing care for older people should be applied equally in nursing homes and in community-dwelling states. Public health programs aimed at maintaining the mental health of older people are needed.

Is cannabis use associated with prescription psychotropic and pain reliever medication and other substance use among individuals aged 50+ with mental illness?

BACKGROUND

Despite increasing rates of nonmedical and/or medical cannabis use in the 50+ age group, scant research exists on the associations between cannabis use and prescription medication use. In this study, we examined associations of use of prescription tranquilizers, sedatives, stimulants, and pain relievers, tobacco products, any/binge/heavy alcohol, and illicit drugs with cannabis use and use characteristics among U.S. adults aged 50+ years with past-year mental illness (n = 6454).

METHODS

Data are from the 2015-2019 National Survey on Drug Use and Health (NSDUH). We used logistic regression models to examine associations of past-month use of each substance with (1) cannabis use among all those with past-year mental illness, and (2) cannabis use characteristics among cannabis users, controlling for severity of mental illness and sociodemographic and health characteristics.

RESULTS

Of individuals aged 50+, 14.1 % had any past-year mental illness, and 9.7 % of those with mental illness, compared to 4.0 % of those without, reported past-month cannabis use. Compared to nonusers, cannabis users had higher odds of using each substance except antidepressants, with adjusted odds ratios ranging from 1.3 (sedatives) to 3.6 (illicit drugs). Compared to nonmedical cannabis users, medical users had 2-2.5 times higher likelihood of co-use of tranquilizers, sedatives, and prescription pain relievers but lower odds of binge and heavy alcohol use.

CONCLUSIONS

Cannabis users, especially medical cannabis users, are significantly more likely to use prescription psychotropic or pain medications. Healthcare professionals should assess for poly-substance use and potential adverse effects among older adults with mental illness.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care

OBJECTIVES

To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program.

DESIGN

Prospective, observational, longitudinal study.

INTERVENTION

The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews.

SETTING

A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016.

PARTICIPANTS

Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative.

MEASUREMENTS

Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters.

RESULTS

There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal.

CONCLUSIONS

Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.

The Columbia Behavior Scale for Dementia (CBS-8): Validity and Reliability of a Rapidly Administered New Instrument for Dementia-Related Behaviors in Long-Term Care Settings

We developed and evaluated the psychometric properties of the Columbia Behavior Scale for Dementia (CBS-8), a rapid instrument that assesses positive symptoms, to enhance behavioral and psychological symptoms of dementia (BPSD) assessment and treatment in long-term care. Psychometric analyses were performed on CBS-8 data from residents (N = 350, age ≥50 years) in 47 Maryland long-term care facilities referred for neurocognitive and mood evaluation. The CBS-8 demonstrated acceptable internal consistency (α = 0.78) and strong interrater reliability (intraclass correlation coefficient = 1.00). CBS-8 scores were correlated with greater cognitive impairment severity (r = -0.34). The diagnosis of dementia with behavioral disturbance had higher CBS-8 scores than other dementia types (e.g., vascular, unspecified) (p < 0.001, η² = 0.40). Three CBS-8 factors-motor disinhibition, aggression, and psychosis-explained 65% of the variance in overall BPSD. The CBS-8 could enhance BPSD tracking and treatment, strengthen interdisciplinary collaboration, and aid nursing homes in meeting regulations on unnecessary medication use. [Research in Gerontological Nursing, 14(3), 160-168.].

Polypharmacy Management in Older Patients

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.

Paralytic ileus in the United States: A cross-sectional study from the national inpatient sample

Introduction:

Paralytic ileus is a common clinical condition leading to significant morbidity and mortality. Most studies to date have focused on postoperative ileus, a common but not exclusive cause of the condition. There are limited epidemiological data regarding the incidence and impact of paralytic ileus and its relationship to other clinical conditions. In this cross-sectional study, we analyzed national inpatient hospitalization trends, demographic variation, cost of care, length of stay, and mortality for paralytic ileus hospitalizations as a whole.

Methods:

The National Inpatient Sample database was used to identify all hospitalizations with the diagnosis of paralytic ileus (International Classification of Diseases, 9th Revision code 560.1) as primary or secondary diagnosis during the period from 2001 to 2011. Statistical analysis was performed using Cochran–Armitage trend test, Wilcoxon rank sum test, and Poisson regression.

Results:

In 2001, there were 362,561 hospitalizations with the diagnosis of paralytic ileus as compared to 470,110 in 2011 (p < 0.0001). The age group 65–79 years was most commonly affected by paralytic ileus throughout the study period. In-hospital all-cause mortality decreased from 6.03% in 2001 to 5.10% in 2011 (p < 0.0001). However, the average cost of care per hospitalization increased from US$19,739 in 2001 to US$26,198 in 2011 (adjusted for inflation, p < 0.0001).

Conclusion:

There was a significant rise in the number of hospitalizations of paralytic ileus with increased cost of care and reduced all-cause mortality.

Potentially Inappropriate Drug Prescribing in French Nursing Home Residents: An Observational Study

Purpose: To identify the prevalence of potentially inappropriate drug prescription in a sample of nursing home residents in France, combining explicit criteria and implicit approach and to involve pharmacists in the multi-professional process of therapeutic optimization. Methods: A cross-sectional, observational, multicenter study was conducted during a five-month period in a sample of French nursing homes. Information on drug prescription, diseases, and socio-demographic characteristics of nursing home residents was collected. For each prescription, identification of potentially inappropriate drug prescription was done, based on explicit and implicit criteria. Results: Nursing home residents were administered an average of 8.1 (SD 3.2, range 0-20) drugs per day. Nearly 87% (n = 237) of the residents had polypharmacy with five or more drugs prescribed per day. Among the 274 nursing home residents recruited from five nursing homes, 212 (77.4%) had at least one potentially inappropriate drug prescription. According to the Laroche list, 84 residents (30.7%) had at least one drug with an unfavorable benefit-harm balance. An overdosing was found for 20.1% (n = 55) of the residents. Nearly 30% (n = 82) of the residents had a drug prescribed without valid medical indication. Conclusions: This study shows that potentially inappropriate drug prescriptions are highly prevalent among nursing home residents, nevertheless pharmacists can take part in drug utilization review in collaboration with the nursing home staff.

Psychotropic and Opioid-Based Medication Use among Economically Disadvantaged African-American Older Adults

African-American older adults, particularly those who live in economically deprived areas, are less likely to receive pain and psychotropic medications, compared to Whites. This study explored the link between social, behavioral, and health correlates of pain and psychotropic medication use in a sample of economically disadvantaged African-American older adults. This community-based study recruited 740 African-American older adults who were 55+ yeas-old in economically disadvantaged areas of South Los Angeles. Opioid-based and psychotropic medications were the outcome variables. Gender, age, living arrangement, socioeconomic status (educational attainment and financial strain), continuity of medical care, health management organization membership, sleeping disorder/insomnia, arthritis, back pain, pain severity, self-rated health, depressive symptoms, and major chronic conditions were the explanatory variables. Logistic regression was used for data analyses. Arthritis, back pain, severe pain, and poor self-rated health were associated with opioid-based medications. Pain severity and depressive symptoms were correlated with psychotropic medication. Among African-American older adults, arthritis, back pain, poor self-rated health, and severe pain increase the chance of opioid-based and psychotropic medication. Future research should test factors that can reduce inappropriate and appropriate use and prescription of opioid-based and psychotropic medication among economically disadvantaged African-American older adults.

Psychotropic Medication Prescribing Practice Among Residents With Dementia in Nursing Homes: A Person-Centered Care Approach

Despite multiple national initiatives to improve quality of life in nursing home (NH) residents with dementia, inefficiencies still exist regarding inappropriate psychotropic medication use to manage communication of distress. The goals of the current article are to: (a) create a person-centered care plan/process for NH community staff to manage challenging dementia behaviors; (b) provide guidelines for geriatric practitioners (GPs) to decrease psychotropic medication use in residents with dementia; (c) discuss organizational culture and its relationship to the management of non-cognitive neuropsychiatric symptoms (NPS) of dementia; and (d) emphasize nonpharmacological approaches as first-line treatment of NPS in NH residents with dementia. [Journal of Gerontological Nursing, 46(2), 9-17.].

Is greenery associated with mental health among residents of aged care facilities? A systematic search and narrative review

Objectives: Older adults living in residential aged care facilities (RACFs) may be vulnerable to mental health issues. Evidence suggests greenery is beneficial for adults' mental health in community settings. This review aims to summarise evidence of associations between greenery in RACFs and residents' mental health.Method: Six databases were searched with three sets of terms related to: (1) exposure (e.g. garden, green); (2) outcome (e.g. mental health, well-being); and (3) setting (e.g. aged care, nursing home). The inclusion criteria were peer-reviewed journal articles published in English up to 2017, reporting quantitative/qualitative associations between greenery and mental health in RACFs.Results: Of the nine articles identified, seven reported positive associations between greenery (in particular, garden use) at RACFs and some aspect of residents' mental well-being (e.g. quality of life); however, four out of seven studies used observations and perceptions of staff and relatives. One study examined depression and reported reduction in depression following garden use, while one examined physiological indicators of stress (blood pressure, heart rate) and found no association with garden use. Seven studies examined garden use and four examined the presence of greenery (two examined both exposures).Conclusion: Exposure to greenery and use of greenspace in RACFs show promise for promoting mental health. However, the findings relied mainly on non-validated measures of mental health. More robust evidence based on valid and reliable mental health measures is needed. Future studies also need to examine the effect of visual exposure to greenery and the effect of greenery on stress reduction.

Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status

Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.

Association between Potentially Inappropriate Medication Use and Chronic Diseases in the Elderly

Long-term continuous exposure to potentially inappropriate medications (PIMs) can lead to adverse events in the elderly. However, the effects of long-term exposure of the elderly to PIM and the relationship between PIM and chronic diseases remain unclear. The objective of this study was to investigate the continuous use of PIMs in a community-dwelling elderly population. A cross-sectional population-based study was conducted using community pharmacy–filed dispensing records from the Hcare system. Twenty-three community pharmacies were sampled from 2013 to 2015 to obtain records of patients above 65 years-old with continuous prescriptions. PIM were identified according to the 2015 Beers Criteria. The prevalence of patients using PIM was highest in patients with co-morbid mental disorders (40.05%), followed by neurological system disorders (28.91%). Patients who were prescribed a PIM were more than three times as likely to have a mental disorder as those (odds ratio 3.16, 95% confidence interval: 3.06–3.28) with non-chronic diseases. The most prescribed PIM agents were central nervous system drugs (53.16%), and benzodiazepines (35.15%). Patients with mental disorders had the highest rate of long-term persistent PIM exposure, with benzodiazepines being the most frequently dispensed. Drug safety concerns should be closely monitored in elderly patients with the abovementioned conditions.

The relation between falls and medication use among elderly in assisted living facilities

PURPOSE

Many elderly are concerned about falling transfer to assisted living facilities (ALF). Previous literatures studied the medication use and falls in the community, hospitals, or nursing homes, with scanty data about ALF. Therefore, the aim of the current case-control study was to assess the relation between medication use and falls among elderly in ALF.

METHODS

A matched case-control study was conducted. The study was conducted in ALF in Cairo, Egypt. The study participants were 188 individuals; they were subdivided into two groups: fallers and nonfallers; timed up and go test (TUGT) was performed by all subjects. Medication data were collected according to the fall risk-increasing drugs list and the list of drugs that cause or worsen orthostatism. Other fall risk factors, as suggested by American Geriatric Society, were assessed.

RESULTS

The use of vasodilators, diuretics, alpha blockers, opioids, antipsychotics, and sedative hypnotics were more common in fallers than in nonfallers (P < 0.001, P = 0.03, P < 0.001, P = 0.013, P < 0.001, and P < 0.001, respectively). Vasodilators, alpha blockers, and antipsychotics were significant predictors of falls even after adjustment for the possible confounding factors. Vasodilators, alpha blockers, opioids, sedative hypnotics, and recent dose changes in oral hypoglycemics were significant predictors of higher TUGT after adjustment for the possible confounding factors.

CONCLUSION

The current study supported the risk of psychotropic and cardiovascular medications, with especial emphasis on vasodilators, alpha blockers, and antipsychotics, with raising concern about opioids, sedative hypnotics, and recent dose change in oral hypoglycemics.

A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients

Introduction

Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness.

Methods

Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance.

Results

Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium.

Conclusion

It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.

Variation of Follow-Up Rate After Psychiatric Hospitalization of Medicare Beneficiaries by Hospital Characteristics and Social Determinants of Health

OBJECTIVE

Early follow-up after inpatient psychiatric hospitalization is a key part of the care transition process and has been found to reduce the risk of readmission and emergency department utilization. Our objective was to determine the extent to which hospital performance on measures of 7- and 30-day mental health follow-up after hospitalization for Medicare beneficiaries varies by hospital characteristics and hospital neighborhood socioeconomic characteristics.

METHODS

We linked 2015 hospital-level follow-up rates from the Centers for Medicare and Medicaid Services' Hospital Compare website to hospital characteristics obtained from the American Hospital Association Annual Survey and characteristics of the community within a 5-mile radius of the hospital obtained from the American Community Survey. Our population included 1,275 inpatient psychiatric facilities in 2015 in the United States. State fixed effects multivariate linear regression was used.

RESULTS

Hospital 30-day follow-up rates ranged from 16.00% to 95.00%, with an average of 55.80%. After controlling for hospital- and community-level factors, and applying state-level fixed effects, we found that psychiatric specialty hospitals, public hospitals, and minority-serving hospitals were associated with lower rates of mental health follow-up.

CONCLUSION

Hospitals have considerable opportunity to improve the quality of their transitional care processes and increase the percentage of Medicare patients receiving timely mental health follow-up after discharge. Policymakers should consider strengthening the incentives for hospital performance on these quality measures while working to improve the behavioral health infrastructure of minority communities.

Methylphenidate-Induced Psychotic Symptoms in 65-Year-Old Female with ADHD

Methylphenidate, a stimulant, is prescribed commonly in the treatment of attention deficit hyperactivity disorder (ADHD) in children and adults. Methylphenidate is generally considered a safe medication, however, some rare adverse effects, such as psychotic symptoms, may occur with its therapeutic or high doses. Additionally, this medication has a potential of abuse, especially among teenagers. There are several published cases regarding methylphenidate-induced psychosis in young adults. However, psychosis due to methylphenidate has been rarely reported in the elderly. This case presents psychotic manifestations due to methylphenidate in a 65-year-old female who was taking this medication for ADHD. She consumed 3 to 4 methylphenidate hydrochloride tablets per day for several months and thought that they were sleeping pills. Antipsychotic medication was initiated and methylphenidate was discontinued which resulted in improvement of her psychosis. Alternative diagnoses, including bipolar mood disorder with psychotic feature or mood disorder due to general medical condition, were ruled out because her psychotic symptoms appeared after taking several methylphenidate tablets and disappeared after discontinuation of this medication.

Potentially inappropriate medication use among older patients attending a geriatric centre in south-west Nigeria

Objectives

To determine the prevalence and describe factors associated with the use of potentially inappropriate medication (PIM) among older patients.

Methods

Cross sectional study of 400 older patients selected systematically at the geriatric centre, University College Hospital, Ibadan between July and September 2016. With the aid of semi-structured questionnaires, information on the socio-demographic characteristics, lifestyle habits, healthcare utilisation and morbidities was obtained. The Beer's criteria 2015 update was used to identify the PIMs. Predictors of PIMs were determined using multivariate analyses at alpha 0.05.

Results

Age was 70.2 (SD=5.9) years and 240 (60%) were females. General prescription pattern showed antihypertensives (34.7%) as the commonest medications used. The point prevalence of PIMs use was 31%. In all, 10 PIMs were used by the respondents. The majority (81.5%) were using one PIM, while (17.7%) used two PIMs and (0.8%) 3 PIMs. NSAIDs (72.6%) were the commonest PIMs identified, followed by the benzodiazepines (24.2%). Respondents had an average of 1.9 morbidities, and mulitmorbidity found in 60.5%. Logistic regression analysis showed self-rated health assessed as better compared with age-mates [OR =1.718 (1.080-2.725)] and being physically active [OR =1.879 (1.026-3.436)] as the most significantly associated with PIMs use.

Conclusions

The use of PIMs among older patients in our setting was high with NSAIDs being the most frequently used medications. An interdisciplinary approach, of medication review by pharmacists', working with physicians may improve prescribing practices among older persons. Therefore, it is necessary to create public health awareness on the use of PIMs among older persons.

Gender Differences and Comorbidities in U.S. Adults with Bipolar Disorder

Background: Past studies have evaluated the association of various comorbidities with bipolar disorder. This study analyzes differences in the prevalence and association of medical and psychiatric comorbidities in bipolar patients by gender. Methods: A retrospective analysis was conducted using the Nationwide Inpatient Sample (2010–2014). Using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, we narrowed the study population to comprise those with a primary diagnosis of bipolar disorder and then obtained information about comorbidities. The differences in comorbidities by gender were quantified using chi-square tests and the logistic regression model (odds ratio (OR)). Results: Hypertension (20.5%), asthma (12.5%) and hypothyroidism (8.1%) were the top medical comorbidities found in bipolar patients. Migraine and hypothyroidism were seen three times higher in females (OR = 3.074 and OR = 3.001; respectively). Females with bipolar disorder had higher odds of comorbid inflammatory disorders like asthma (OR = 1.755), Crohn’s disease (OR = 1.197) and multiple sclerosis (OR = 2.440) compared to males. Females had a two-fold higher likelihood of comorbid post-traumatic stress disorder (PTSD) (OR = 2.253) followed by personality disorders (OR = 1.692) and anxiety disorders (OR = 1.663) compared to males. Conclusion: Women with bipolar disorder have a much higher medical comorbidity burden than men and may highly benefit from an integrated team of physicians to manage their condition and improve their health-related quality of life.

Potentially Inappropriate Antidepressant Prescriptions Among Older Adults in Office-Based Outpatient Settings: National Trends from 2002 to 2012

Using data from 2002 to 2012 National Ambulatory Medical Care Survey, we estimated that the prevalence of overall antidepressant prescriptions increased almost twofold from 5.2% in 2002 to 10.1% in 2012 in office-based outpatient visits made by older adults. In addition, older adults were exposed to the risk of potentially avoidable adverse drug events in approximately one in ten antidepressant-related visits, or 2.2 million visits annually. Amitriptyline and doxepin were the two most frequent disease-independent potentially inappropriate antidepressants. Racial/ethnic minorities, and Medicaid beneficiaries had higher odds of potentially inappropriate antidepressant prescriptions (P < 0.05). Efforts to minimize potentially inappropriate antidepressant prescriptions are needed.

Psychotropic medications in older people in residential care facilities and associations with quality of life: a cross-sectional study

BACKGROUND

Psychotropic medications have been associated with many adverse outcomes in older people living in residential care. Home-like models of residential care may be preferable to traditional models of care and we hypothesized that this model may impact on the prevalence of psychotropic medications. The objectives were to: 1) examine associations between psychotropic medications and quality of life in older adults living in residential care facilities with a high prevalence of cognitive impairment and dementia and 2) determine if there was a difference in prevalence of psychotropic medications in facilities which provide a small group home-like model of residential care compared to a 'standard model' of care.

METHODS

Participants included 541 residents from 17 residential aged care facilities in the Investigating Services Provided in the Residential Environment for Dementia (INSPIRED) study. Cross-sectional analyses were completed to examine the above objectives. Quality of life was measured with the dementia quality of life questionnaire (DEMQOL) and the EQ-5D-5L completed by the resident or a proxy.

RESULTS

Overall, 70.8% (n = 380) of the population had been prescribed/dispensed at least one psychotropic medication in the 100 days prior to recruitment. An increased number of psychotropic medications was associated with lower quality of life according to DEMQOL-Proxy-Utility scores (β (SE): - 0.012 (0.006), p = 0.04) and EQ-5D-5L scores (- 0.024 (0.011), p = 0.03) after adjustment for resident-level and facility-level characteristics. Analysis of the individual classes of psychotropic medications showed antipsychotics were associated with lower DEMQOL-Proxy-Utility scores (- 0.030 (0.014), p = 0.03) and benzodiazepines were associated with lower EQ-5D-5L scores (- 0.059 (0.024), p = 0.01). Participants residing in facilities which had a home-like model of residential care were less likely to be prescribed psychotropic medications (OR (95% CI): 0.24 (0.12, 0.46), p < 0.001).

CONCLUSIONS

An increased number of psychotropic medications were associated with lower quality of life scores. These medications have many associated adverse effects and the use of these medications should be re-examined when investigating approaches to improve quality of life for older people in residential care. Home-like models of residential care may help to reduce the need for psychotropic medications, but further research is needed to validate these findings.

Effects of alprazolam and haloperidol on thyroglobulin, antithyroglobulin, anti thyroid peroxidase and TSH in Rat

Background:

A large number of psychotropic drugs can interfere with the thyroid physiology, function and autoimmunity.

Objective:

The aim of the present study was to investigate the effects of alprazolam and haloperidol on thyroglobulin, antithyroglobulin (aTg), antithyroid peroxidase, and thyroid stimulating hormone levels on rats.

Materials and Methods:

First group of adult male Wistar rats was the control, second group received 0.5 mg kg

Results:

We have investigated a decrease in aTg amounts of control group (5.461±0.718) compared with drug treated rats with alprazolam (1.433±0.225) and haloperidol (1.21±0.228). (P

Conclusion:

We found that these two drugs may interfere with the thyroid physiology and metabolism.

Potentially inappropriate prescriptions for elderly people taking antidepressant: comparative tools

Background

The use of psychotropic drugs by elderly people is widely spread around the world, given that prevalence of inappropriate medication is frequent. Strictly speaking, in Brazil, the vulnerable population of elderly people is more likely to use Potentially Inappropriate Psychotropic (PIP) due to the impact of social-economic characteristics, to the Brazilian Public Health System, and to the lack of patient monitoring. However, neither the use pattern nor the prevalence rate of PIP have been studied in Brazil so far. The objectives of this study were to determine the prevalence of PIP in elderly outpatients taking antidepressants, and to compare the performance of two different tools (Beers, STOPP).

Methods

This cross-sectional study involved all the aged outpatients (≥ 60 years of age) taking antidepressants attended by the public health system in a city of the State of São Paulo, Brazil. Data were obtained from a pharmacy database and medical records. All psychotropic drugs evaluated included: antidepressants, antipsychotics, anti-epileptics and benzodiazepines. STOPP and Beers criteria were applied to detect PIP.

Results

One thousand one hundred forty prescriptions from 174 outpatients were subjected to two different screening tools. The average patient age was 67 (interquartile range 63–74) and the median number of drugs used was 3.0 (interquartile 2–4) per patient. The overall prevalence of PIP was 121 (69.5%). The levels of PIP observed according to tools were 39.6% (STOPP) and 29.9% (Beers).The long-term use of benzodiazepines was the most common PIP recognized, and the one which contributed more significantly to higher levels of PIP than other medications.

Conclusions

The prevalence of PIP was high among the elderly. STOPP criteria identified more PIP than Beers criteria. Knowledge of PIP prevalence should gear efforts to reduce the level of inappropriate prescriptions and may provide the need for developing national criteria.

Ageing and memory medication: social rationales and consumption practices

This article focuses on the social rationales underlying the consumption or rejection of medication for memory by the elderly. Our analysis is set within the wider frame of the current use of psychopharmaceuticals for the enhancement of everyday performance, discussing its relationship to new cultures of ageing. Our results, from a recently concluded study, point to different patterns of investment in memory in old age. On the one hand, we found a willingness to consume medication for memory - a heterogeneous disposition split between the imaginary of disease and that of performance enhancement. On the other hand, we found a cultural resistance and scepticism towards the use of psychopharmaceuticals for performance purposes. This suggests that a new frame of psychopharmaceuticalization of old age - represented by memory medication - is prompting different rationales, ranging from consumption to resistance.

Effects of depression screening on diagnosing and treating mood disorders among older adults in office-based primary care outpatient settings: An instrumental variable analysis

Existing literature shows mixed findings regarding the efficacy and effectiveness of depression screening, and relatively little is known about the effectiveness of depression screening among older adults in primary care visits in the U.S. This study examines the effects of depression screening on the three following outcomes: mood disorder diagnoses, overall antidepressant prescriptions, and potentially inappropriate antidepressant prescriptions among older adults ages 65 or older in office-based outpatient primary care settings. We used data from 2010-2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based primary care outpatient visits among older adults (n=9,313 unweighted). We employed an instrumental variable approach to control for selection bias in our repeated cross-sectional population-based study. Injury prevention and stress management were selected as instrumental variables, as they were considered completely exogenous to outcomes of interests using conceptual and statistical criteria. We conducted multivariate bivariate probit (biprobit) regression analyses to investigate the effect of depression screening on each outcome, when controlled for other covariates. We found that depression screening was negatively associated with potentially inappropriate antidepressant prescriptions (β=-2.17; 95% CI -2.80 to -1.53; p<0.001). However, no significant effect of depression screening on diagnosis of mood disorders and overall antidepressant prescriptions was found. Overall, depression screening had a negative effect on potentially inappropriate antidepressant prescriptions. Primary care physicians and other healthcare providers should actively utilize depression screening to minimize potentially inappropriate antidepressant prescriptions in older adult patients.

A quality improvement initiative on the use of psychotropic drugs in nursing homes in Flanders

INTRODUCTION

Government-funded quality improvement projects aimed to reduce the high psychotropic medication use in Belgian long-term care settings.

DESIGN

A pilot project (2013-2014) with a pre-post and follow-up intervention design.

METHODS

Two nursing homes received three educational courses. In the intervention nursing home (INH) additionally, a transition towards person-centred care through professional support was applied. Drug use was recorded at baseline, after 10 months (post) and after 22 months (follow-up), and coded into the Anatomical Therapeutic Chemical classification.

RESULTS

At baseline, the INH residents' (n = 118) mean age at baseline was 82 years, with 71% females. The control nursing home residents' (CNH, n = 275) mean age was 82.7 years, with 75% females. At baseline, mean drug use was 9 (range 1-21) and 8 (range 0-20), predominantly with a high proportion of psychotropic drug users of 73 and 65%, in INH and CNH respectively. At the time of post-measurement, only the proportion of hypno-sedative users decreased significantly in the INH (by 13%, p = 0.048). No significant changes were found in the CNH. At time of the follow-up, the proportion of hypno-sedative (51% vs. 31%; p = 0.005) and antidepressant users (42% vs. 25%, p = 0.007) decreased significantly in the INH. The decrease of antipsychotic drug users was less distinct. In the CNH, the proportion of hypno-sedative, antidepressant and overall psychotropic drug users did not change significantly.

CONCLUSION

This quality improvement initiative led to a significant decrease in the use of psychotropic drugs in the INH, even after 1-year follow-up. Education only had a limited effect.

Review on Neural Correlates of Emotion Regulation and Music: Implications for Emotion Dysregulation

Previous studies have examined the neural correlates of emotion regulation and the neural changes that are evoked by music exposure. However, the link between music and emotion regulation is poorly understood. The objectives of this review are to (1) synthesize what is known about the neural correlates of emotion regulation and music-evoked emotions, and (2) consider the possibility of therapeutic effects of music on emotion dysregulation. Music-evoked emotions can modulate activities in both cortical and subcortical systems, and across cortical-subcortical networks. Functions within these networks are integral to generation and regulation of emotions. Since dysfunction in these networks are observed in numerous psychiatric disorders, a better understanding of neural correlates of music exposure may lead to more systematic and effective use of music therapy in emotion dysregulation.

Sedative hypnotic use among veterans with a newly reported mental health disorder

BACKGROUND

This study compared sedative hypnotic use by type of mental health diagnosis and determined factors associated with use among older veterans (65+ years) with a newly reported mental health disorder.

METHODS

This study used data from veterans who received primary care services at VA Pittsburgh Healthcare System (VAPHS) from January 1, 2007 to December 31, 2011 (n = 879).

RESULTS

Sedative hypnotics were commonly used in older veterans within 12-months following a newly reported mental health disorder (19.9%), particularly amongst those with insomnia (41.7%). The number of newly reported mental health disorders was a significant factor associated with sedative hypnotic use, with the odds of use increasing by more than 200% in older adults with two newly reported disorders compared to those with one newly reported mental health disorder.

CONCLUSIONS

Continued efforts are needed to improve provider and patient awareness of the risks associated with sedative hypnotic use in older adults, as well as to increase access to and receipt of non-pharmacological mental health treatments for this vulnerable population.

Mental Illness in Assisted Living: Challenges for Quality of Life and Care

An unknown number of mentally ill elders in the U.S. receive care in assisted living [AL], along with persons facing physical or cognitive challenges. While dementia is familiar in AL, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily inter-resident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted living settings having varying presence of mental illness among residents.

The impact of precarious employment on mental health: The case of Italy

Although there has been a sizeable empirical literature measuring the effect of job precariousness on the mental health of workers the debate is still open, and understanding the true nature of such relationship has important policy implications. In this paper, we investigate the impact of precarious employment on mental health using a unique, very large data set that matches information on job contracts for over 2.7 million employees in Italy followed over the years 2007-2011, with their psychotropic medication prescription. We examine the causal effects of temporary contracts, their duration and the number of contract changes during the year on the probability of having one or more prescriptions for medication to treat mental health problems. To this end, we estimate a dynamic Probit model, and deal with the potential endogeneity of regressors by adopting an instrumental variables approach. As instruments, we use firm-level probabilities of being a temporary worker as well as other firm-level variables that do not depend on the mental illness status of the workers. Our results show that the probability of psychotropic medication prescription is higher for workers under temporary job contracts. More days of work under temporary contract as well as frequent changes in temporary contract significantly increase the probability of developing mental health problems that need to be medically treated. We also find that moving from permanent to temporary employment increases mental illness; symmetrically, although with a smaller effect in absolute value, moving from temporary to permanent employment tends to reduce it. Policy interventions aimed at increasing the flexibility of the labour market through an increase of temporary contracts should also take into account the social and economic cost of these reforms, in terms of psychological wellbeing of employees.

Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: a review of the literature

AIMS

To explore the potential benefits of massage within daily routine care of the older person in residential care settings.

BACKGROUND

Globally, the proportion of people over 65 years is rapidly rising. Increased longevity means older people may experience a rise in physiological and psychological health problems. These issues potentially place an increased demand for quality long-term care for the older person. Complementary approaches such as massage appear to be needed in quality residential care.

DESIGN

A critical literature review was undertaken.

METHODS

A literature review pertaining to massage in the older resident was conducted using a range of online databases. Fourteen studies dated 1993-2012 met the inclusion criteria and were critically evaluated as suitable resources for this review.

RESULTS

Evidence suggests massage may be advantageous from client and nursing perspectives. Clients' perceive massage to positively influence factors such as pain, sleep, emotional status and psychosocial health. Evidence also demonstrates massage to benefit the client and organisation by reducing the necessity for restraint and pharmacological intervention. Massage may be incorporated into care provision and adopted by care providers and family members as an additional strategy to enhance quality of life for older people.

CONCLUSION

Massage offers a practical activity that can be used to enhance the health and well-being of the older person in residential care.

IMPLICATIONS FOR PRACTICE

Massage offers benefit for promoting health and well-being of the older person along with potential increased engagement of family in care provision. Integration of massage into daily care activities of the older person requires ongoing promotion and implementation.

Influence of urban residence on use of psychotropic medications in Pennsylvania, USA: cross-sectional comparison of older adults attending senior centers

BACKGROUND

Differences in medication use by geographic region may indicate differences in access to specialist medical care, especially in the case of prescriptions for psychotropic medications. We assessed the effect of more or less urbanized residence on likelihood of psychotropic medication use in a large cohort of older adults in Pennsylvania, USA.

METHODS

Community-dwelling older adults were recruited from senior centers across Pennsylvania. Participant residences were geocoded and categorized according to US Department of Agriculture Rural-Urban Continuum Codes. We used the codes to identify respondents who live in relatively urban counties with 250,000 or more residents (n = 1,360) or less urban counties with fewer than 250,000 residents (n = 401). Participants reported prescription medications in a clinical interview. Psychotropic medications were categorized by class. Logistic regression models were estimated to assess the independent effect of residence on likelihood of psychotropic medication use.

RESULTS

Geographic region was significantly associated with use of psychotropic medications. Psychotropic medication use was higher in less urban areas (19.7%) relative to more urban areas (14.2%), p = 0.007. In adjusted models, degree of urban residence was a significant correlate in models that adjusted for sociodemographic features and medical status (odds ratio 1.62; 95% confidence interval 1.13-2.31, p < 0.01). Use of psychotropic medications on the Beers list also increased with less urban residence (13.0 vs. 8.3%, p = 0.005).

CONCLUSIONS

Older adults living in less urbanized areas are more likely to be prescribed psychotropic drugs. This difference may indicate a health disparity based on access to geriatric specialists or mental health care.

A study of the prescription and administration of sedative PRN medication to older adults at a secure hospital

BACKGROUND

There is a paucity of research into PRN medication use in older psychiatric inpatients. This is an important topic given the risks of polypharmacy, adverse drug reactions, and high dose medication.

METHOD

In 2013, we carried out a cross-sectional survey of the prescription and administration of sedative PRN medication to older adult inpatients on seven wards at a UK tertiary referral centre. We compared them with 242 patients of working age.

RESULTS

Of the 92 patients studied, 56 (60.9%) were prescribed PRN sedation and 25 (27.2%) had received one or more doses in the previous fortnight. In total, 70 doses had been administered; all by mouth and all but one as single doses. Lorazepam was by far the most commonly prescribed and administered PRN drug. Agitation was the main indication, although violence was the most commonly cited reason for administration but documentation of antecedents, non-pharmacological strategies and outcome including side effects was uniformly poor with only 37 (52.9%) doses recorded in the case notes. Those with organic disorders were just as likely to receive PRN as those with functional illnesses. Patients very rarely actually received high dose antipsychotics or antipsychotic polypharmacy as a result of PRN prescriptions. Older patients were less likely than adults of working age to be prescribed PRN and dosages were smaller.

CONCLUSION

Prospective studies of PRN prescription and administration are needed to better understand the reasons underpinning its use and to gain objective data upon its effectiveness or otherwise in this vulnerable patient group.

Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem

Falls are a common health problem for older people, and psychotropic medications have been identified as an important independent fall risk factor. The objective of this paper was to review the literature relating to the effect of psychotropic medications on falls in older people, with a particular focus on evidence supporting minimization of their use to reduce risk of falls. A literature search identified 18 randomized trials meeting the inclusion criteria for the review of effectiveness of psychotropic medication withdrawal studies, including four with falls outcomes. One of these, which targeted reduced psychotropic medication use in the community, reported a 66% reduction in falls, while the other studies demonstrated some success in reducing psychotropic medication use but with mixed effects on falls. Other randomized trials evaluated various approaches to reducing psychotropic medications generally or specific classes of psychotropic medications (e.g. benzodiazepines), but did not report fall-related outcomes. Overall, these studies reported moderate success in reducing psychotropic medication use, and a number reported no or limited worsening of key outcomes such as sleep quality or behavioural difficulties associated with withdrawal of psychotropic medication use. Reduced prescription of psychotropic medications (e.g. seeking non-pharmacological alternatives to their use in place of prescription in the first place or, for those patients for whom these medications are deemed necessary, regular monitoring and efforts to cease use or wean off use over time) needs to be a strong focus in clinical practice for three reasons. Firstly, psychotropic medications are commonly prescribed for older people, both in the community and especially in the residential care setting, and their effectiveness in a number of clinical groups has been questioned. Secondly, there is strong evidence of an association between substantially increased risk of falls and use of a number of psychotropic medications, including benzodiazepines (particularly, the long-acting agents), antidepressants and antipsychotic drugs. Finally, the largest effect of any randomized trial of falls prevention to date was achieved with a single intervention consisting of weaning psychotropic drug users off their medications.

Administration of PRN medications and use of nonpharmacologic interventions in acute geropsychiatric settings: implications for practice

Despite the known risks and the widespread administration of PRN (pro re nata or "as needed") psychotropic medications in inpatient settings, little is known about their use with hospitalized older adults. This exploratory descriptive study examined the use of PRN psychotropic medications and nonpharmacologic interventions to manage symptoms in older adults hospitalized in two acute care geropsychiatric settings. A retrospective chart audit was conducted. A major finding was the lack of documentation regarding PRN administration. In 81.3% of cases at Site A and 55.3% of cases at Site B, no reason for administration was documented. No medication response was documented in 92.4% of cases at Site A and 47.5% of cases at Site B. No nonpharmacologic interventions were documented for 69% of Site A patients or 64% of Site B patients. To ensure patient safety and to inform best clinical practice, the lack of documentation surrounding administration of PRN medications and nonpharmacologic interventions must be resolved.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

The effects of Canine-Assisted Interventions (CAIs) on the health and social care of older people residing in long term care: a systematic review

EXECUTIVE SUMMARY

Background: Animal-assisted interventions are classified as 'any therapeutic process that intentionally includes or involves animals as part of the process'. Providing these interventions within the long term care environment may potentially reduce or alleviate symptoms of disease and illness and increase quality of life. Many people suggest that the use of animal-assisted interventions produces beneficial effects, however an examination of the current evidence base reveals a lack of rigorous quantitative research in this area.Objective The aim of the review was to synthesise the best available evidence on the effects of canine-assisted interventions on the health and social care of the older population residing in long-term care.Data sources A comprehensive search was undertaken on 32 electronic databases from their inception to 2009. The search was restricted to English language and both published and unpublished studies were considered.Review methods Studies that examined canine-assisted interventions used for older people residing in long term care were considered. Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments. Data extraction was via the Joanna Briggs Institute standard data extraction form for evidence of effectiveness.Results Eight randomised controlled trials were included in the review of which half were doctoral theses. Due to the presence of heterogeneity, meta-analyses were not appropriate and a narrative summary was provided.Based on the results of single studies, the evidence suggests that providing canine-assisted interventions in long term care facilities can provide some short term benefits to residents, both physically and emotionally, however they appear to be no more effective than other interventions such as visits from humans and providing opportunities to interact with inanimate objects. Providing sessions once a week seems to be just as effective as providing session three times a week in the short term and more research is needed to determine if providing interventions on an individual basis is actually more effective than group interactionsConclusion The current evidence base for the effects of canine-assisted interventions in long term care facilities is methodologically weak and is unable to be pooled. No solid recommendations can be made, however some preliminary conclusions based on the results of single studies are provided. Caution is advised when interpreting these results.Implications for practice Due to the poor quality of evidence located on this topic the use of canine-assisted interventions cannot currently be recommended nor refuted. If, however, a long term care facility is considering implementing canine-assisted interventions for older residents they should be aware that canine-assisted activities may produce some short term beneficial effects but they are similar to those seen from organising visits from people or arranging interactions with animal-like inanimate objects.Implications for research Due to the lack of well-designed trials further higher quality experimental studies that examine the effects of canine-assisted interventions on older long term care residents should be conducted. Trials need to be conducted following a standardised rigorous process.

Ethical perspectives on relations between industry and neuropsychiatric medicine

Conflicts of interest may influence medical research. In particular, the study on psychotropic treatment of ageing subjects suffering from neurological disorders and comorbid neuropsychiatric phenomena may be hypothetically considered economically non-advantageous, or even of negative impact on drug reputation, because of the high probability of non-response or side effects. Thus, studies on this issue may be disregarded from industry. We aimed to verify whether the global commitment of medical research reflects the actual relevance of depression in the world ageing population, associated or not with neurological conditions. Here, we: 1) have reviewed the literature on this issue, 2) have examined world published data concerning population by age, burden of disease and frequency of depressive disorders and antidepressant therapies, and 3) have reviewed the frequency of published papers on depression and its treatment associated with three neurological conditions. The overall rate of papers about depressive disorders in ageing people reflects adequately the world population and the prevalence of depression in the elderly. However, the rate of papers concerning medical experimentation for antidepressant treatment in Alzheimer's disease, Parkinson's disease and stroke is quite inadequate with respect to the rate of depressive disorders associated to these conditions. Thus, innovative medical experimentation must be encouraged, also in areas apparently of dubious economical advantage but of undoubted clinical relevance and the adoption of strategies to limit the detrimental effect of conflicts of interest in research must be enhanced.