Administrative Initiatives for Reducing Inappropriate Prescribing of Psychotropic Drugs in Nursing Homes

Mental health in nursing homes: The role of immigration in the long-term care workforce

One-fourth of nursing home residents are diagnosed with anxiety disorders and approximately half live with depression. Nursing homes have long struggled with staffing shortages, and the lack of care has further heightened the risk of poor mental health. A key solution to both problems could be immigration. Prior studies have documented how immigrant labor could strengthen the long-term care workforce. We add to this picture by exploring the impact of immigrant inflows on the mental health outcomes of nursing home residents. Using a nationally representative dataset and a shift-share instrumental variable approach, we find empirical evidence that immigration reduces diagnoses of depression and anxiety, the use of antidepressant and antianxiety drugs, and self-assessed symptoms of depression. The results are robust to several sensitivity tests. We further find that the effect is more substantial in facilities with lower direct care staff hours per resident and with likely more immigrants without citizenship. Language barriers tend to be a minor issue when providing essential care. The findings suggest that creating a policy framework that directs immigrant labor to the long-term care sector can mutually benefit job-seeking immigrants and nursing home residents.

Pharmacists working in residential aged care: a survey of pharmacist interest and perceived preparedness

BACKGROUND

Pharmacists involvement in residential aged care facilities has traditionally been limited to that of an external contractor providing medication reviews, or medication supply.

AIM

To explore Australian pharmacists' interest and perceived preparedness to work as on-site pharmacists in residential aged care.

METHOD

National cross-sectional anonymous online survey open for two weeks (September 17th to October 1st 2022) consisting of Likert-type, multiple choice and multiple selection questions. Australian pharmacists were recruited using a broad advertising strategy which included social and traditional media platforms, and snowball sampling. Data were collected on pharmacist self-reported interest and perceived preparedness to work as on-site aged care pharmacists in residential aged care. Data were analysed using descriptive statistics.

RESULTS

Responses were received from 720 participants, 643 were eligible. Most participants were female (n = 466, 73%) and mean (SD) age was 43.5 (SD 12.5) years. Over half the participants were interested or extremely interested in working as an on-site aged care pharmacist (56%, n = 360), and agreed or strongly agreed (n = 475, 76%) that they felt prepared to work as an on-site aged care pharmacist. Most pharmacists felt prepared to engage in a variety of roles within the facilities (> 73% for each role), including resident and system level roles, and the majority agreed they felt prepared to engage with stakeholders, including general practitioners (93%) and medical specialists (86%).

CONCLUSION

Pharmacists reported they are interested and feel prepared to work as on-site aged care pharmacists. These findings will inform the roll-out of this new model of care to enhance multidisciplinary collaboration in residential aged care.

Nursing Home Staffing: Share Of Immigrant Certified Nursing Assistants Grew As US-Born Staff Numbers Fell, 2010-21

Nursing homes have long faced a shortage of direct care workers, a problem that was magnified during the COVID-19 pandemic. Using nationally representative data from three sources, we found that much of the certified nursing assistant (CNA) workforce in US nursing homes is filled by immigrant labor. The number of native-born CNAs has been declining rapidly since the mid-2010s, whereas the number of foreign-born CNAs has remained relatively constant. During the first two years of the COVID-19 pandemic, the share of immigrant CNAs employed by nursing homes surged, which can be explained by a simultaneous drop in the share of native-born staff. Staffing shortages observed during the pandemic would have been worse if not for foreign-born CNAs remaining in the workforce. However, the share of foreign-born CNAs varied considerably across states, from less than 1 percent in West Virginia to more than 70 percent in Hawaii. In an analysis of prepandemic data, we found that nursing homes in regions with a higher share of immigrant CNAs were associated with more direct care staff hours per resident day and better nursing home quality performance. With the growing demand for long-term care, creating pathways for job-seeking immigrants to fill the gaps in direct care will be crucial to meeting future staffing needs.

How Do Pharmacists Practice in Aged Care? A Narrative Review of Models from Australia, England, and the United States of America

Medication management in residential aged care facilities (RACFs) is complex and often sub-optimal. Pharmacist practice models and services have emerged internationally to address medication-related issues in RACFs. This narrative review aimed to explore pharmacist practice models in aged care in Australia, England and the USA, and identify key activities and characteristics within each model. A search strategy using key terms was performed in peer-reviewed databases, as well as the grey literature. Additionally, experts from the selected countries were consulted to obtain further information about the practice models in their respective countries. Thirty-six documents met the inclusion criteria and were included in the review. Four major pharmacist practice models were identified and formed the focus of the review: (1) the NHS’s Medicine Optimisation in Care Homes (MOCH) program from England; (2) the Australian model utilising visiting accredited pharmacists; (3) the Centers for Medicare and Medicaid (CMS) pharmacy services in long-term care from the USA; and (4) the Medication Therapy Management (MTM) program from the USA. Medication reviews were key activities in all models, but each had distinct characteristics in relation to the comprehensiveness, who is eligible, and how frequently residents receive medication review activity. There was heterogeneity in the types of facility-level activities offered by pharmacists, and further research is needed to determine the effectiveness of these activities in improving quality use of medicines in the aged care setting. This review found that in some models, pharmacists have a limited level of collaboration with other healthcare professionals, emphasising the need to trial innovative models with integrated services and increased collaboration to achieve a holistic patient-centred approach to medication management.

Development and feasibility testing of an evidence-based training programme for pharmacist independent prescribers responsible for the medicines-related activities within care homes

INTRODUCTION

The UK pharmacists with independent prescribing rights (pharmacist independent prescribers [PIPs]) are authorised to prescribe within their areas of competence. To enable PIPs to provide pharmaceutical care to residents in care homes and assume responsibility for medicines management, a process for development and assessment of competence is required. The aim of this research was to develop a training and accreditation process (training programme) to enable PIPs to operate safely and effectively within care homes.

METHODS

Located in England, Scotland and Northern Ireland across four sites and based on a systematic review, it consisted of four phases: (1) initial stakeholder engagement, (2) uni-professional focus groups and interviews, (3) expert panel consensus and (4) feasibility testing. Four PIPs were trained each to provide pharmaceutical care to 10 care home residents. An expert panel synthesised the evidence at each stage to develop each iteration of the training programme. Content analysis was used throughout.

RESULTS

Differences in baseline knowledge of PIPs required inclusion of a Personal Development Framework and the provision of a mentor. Face-to-face training focussed on managing medicines for a complex older person, minimising prescribing costs and supporting people without capacity. Provision of time to understand local context and develop relationships with care homes and general practitioners was identified as a central requirement. PIPs were assessed for competency via viva. Feasibility testing demonstrated that the derived training programme was acceptable, practical and effective.

DISCUSSION

The model seemed to work, but due to small numbers, larger-scale testing of the training programme is now required.

Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: A scoping review

BACKGROUND

Psychotropic medication use in the elderly population is associated with significant adverse effects. Robust evidence for the efficacy of psychotropic medications for behavioural and psychological symptoms of dementia is lacking. Despite national bodies, governments, and policymakers employing interventions to optimise the use of psychotropic medicines in this population, there is little research on their overall impact.

OBJECTIVE

To identify and categorise system level strategies that have been implemented internationally and assess their impact on psychotropic medicine use in aged care facilities.

METHODS

A systematic search of health-related databases including Medline, Embase, CINAHL, Web of Science and Scopus was performed. Empirical studies published in English prior to March 2019 that reported on the impact of system level strategies on psychotropic medicine use in aged care facilities were included. Studies were mapped to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to measure impact and were assessed for risk of bias.

RESULTS

This review identified 36 studies which examined mandatory (n = 22) and non-mandatory (n = 14) system level strategies. The impact of strategies was highly dependent on implementation as well as organisational and patient factors. Mandatory strategies had greater evidence of impact on drug utilisation patterns compared to non-mandatory strategies which primarily focussed on adoption and implementation, rather than outcomes. The Omnibus Budget Reconciliation Act 1987 (OBRA-87) in the United States of America had the greatest reach and implementation of the interventions examined, with an observed reduction in psychotropic medicine use post-implementation. There was no substantive body of evidence reporting on the sustainability of strategies or the influence of cost on outcomes.

CONCLUSIONS

Despite the implementation of system level strategies, psychotropic medicine use in aged care facilities remains problematic. There is a need for revised or novel system level strategies which consider sustainability, economic influences and patient outcomes in their design and implementation.

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process

OBJECTIVES

To develop a training programme to enable pharmacists with prescribing rights to assume responsibility for the provision of pharmaceutical care within care homes, a systematic review and narrative synthesis was undertaken to identify reported approaches to training pharmacists and use this literature to identify potential knowledge requirements.

METHODS

A PROSPERO-registered systematic review was performed using key search terms for care homes, pharmacist, education, training and pharmaceutical care. Papers reporting primary research focussed on care of the older person within the care home setting were included. No restrictions were placed on methodology. Two researchers independently reviewed titles, abstracts and papers. Agreement on inclusion was reached through consensus. Data on titles, training and activities undertaken were extracted and knowledge requirements identified. Findings were synthesised and reported narratively.

KEY FINDINGS

Fifty-nine papers were included, most of which were uncontrolled service evaluations. Four papers reported an accreditation process for the pharmacist. Thirteen papers reported providing tools or specific training on a single topic to pharmacists. The main clinical and therapeutic areas of activity (requiring codified knowledge) were dementia, pain, antipsychotic and cardiovascular medication. Provision of pharmaceutical care, effective multidisciplinary working and care home staff training represented the main areas of practical knowledge.

CONCLUSIONS

Information regarding training and accreditation processes for care home pharmacists is limited. This study provides insight into potential codified and practical knowledge requirements for pharmacists assuming responsibility for the provision of pharmaceutical care within care homes. Further work involving stakeholders is required to identify the cultural knowledge requirements and to develop a training and accreditation process.

The "CHROME criteria": Tool to optimize and audit prescription quality of psychotropic medications in institutionalized people with dementia

OBJECTIVE

Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria.

DESIGN

Observational prospective longitudinal study.

SETTING

Single nursing home in Las Palmas de Gran Canaria, Spain.

PARTICIPANTS

288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia.

INTERVENTION

Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription.

MEASUREMENTS

Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107).

RESULTS

For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005).

CONCLUSIONS

Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents

BACKGROUND/OBJECTIVE

In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use.

DESIGN

Retrospective, propensity score-matched, controlled, patient-level observational analysis.

SETTING

A total of 45 nursing homes in Spain.

PARTICIPANTS

A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls.

INTERVENTION

Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid.

MEASUREMENTS

At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use.

RESULTS

Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints.

CONCLUSION

We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Are Post-Acute Patients with Behavioral Health Disorders Admitted to Lower-Quality Nursing Homes?

OBJECTIVES

We measured the proportion of new post-acute nursing home admissions with behavioral health diagnoses and examined whether patients with these disorders (schizophrenia/psychosis, bipolar, depression/anxiety, personality disorder, and substance abuse) faced disparities in access to high quality facilities.

SETTING/PARTICIPANTS

The analytical sample included 3,729,282 admissions to 15,600 facilities nationwide for 2012-2014.

MEASUREMENT

Quality was measured for overall and staffing domains reported by the Centers for Medicare and Medicaid Services in the Five-Star Quality Rating System. Multinomial logistic regression models were used. The base model included the diagnostic groups of interest and state dummies. Patient sociodemographics, functional and cognitive status, and comorbid conditions were sequentially added to the base model to determine the independent effect of having a behavioral health diagnosis at admission.

RESULTS

Patients with these conditions experienced disparities accessing to high-quality homes compared to patients without. For example, patients with depression/anxiety had lower access to five-star homes, for the staffing quality domain (Model 3 ORs = 0.88, 0.93, 0.92 in years 1 through 3, respectively) compared to patients with no behavioral health diagnosis. Access disparities were faced not only by patients with serious mental illness, as previously demonstrated, but also patients with substance abuse and with depression/anxiety who account for one-third of all new admissions.

CONCLUSIONS

Our findings demonstrate persistence of disparities in access to high quality facilities over time and for patients with a broad range of behavioral health conditions. Further research is needed to understand the impact of these disparities on outcomes of patients with behavioral disorders.

Nursing home prices and quality of care - Evidence from administrative data

There is widespread concern about the quality of care in nursing homes. On the basis of administrative data of a large health insurance fund, we investigate whether nursing home prices are associated with relevant quality of care indicators at the resident level. Our results indicate negative associations between price and both inappropriate and psychotropic medication. In contrast, we do not find any relationship between the price and impairments of physical health.

Restraint use among selected hospitalized elderly patients in Cairo, Egypt

Objective

This study’s primary objective was to investigate the prevalence of physical and chemical restraint use in selected elderly hospitalized patients.

Results

This study was conducted in April 2014 in four major acute care hospitals. Trained data collectors assessed the use of physical and chemical restraint among all admitted elderly patients. There were 287 elderly patients (median age 64 years, 46% women). 32 patients were restrained. The overall prevalence of restraints was 11.1%, with physical restraint use alone at 3.2% and chemical restraints use alone at 7.3%. Restraint use varied by hospital type, with the highest at the private hospital (22.9%) and the lowest at the two university hospitals (< 6%). In conclusion the prevalence of physical and chemical restraint use among admitted elderly patients in Egypt is comparable to that seen in developed countries. However, the use appears to vary widely by hospital type. The use of restraints in the elderly remains an important question considering the increasing number of elderly.

Electronic supplementary material

The online version of this article (10.1186/s13104-017-2978-x) contains supplementary material, which is available to authorized users.

Antipsychotic Use in Dementia

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.

Long-Term Outcomes of Medication Intervention Using the Screening Tool of Older Persons Potentially Inappropriate Prescriptions Screening Tool to Alert Doctors to Right Treatment Criteria

OBJECTIVES

To compare 24-month outcomes of participants of a prospective randomized controlled trial (RCT) assigned to undergo a medication intervention of orally communicated recommendations based on Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) (intervention group) with outcomes of those assigned to undergo written medication review (control group).

DESIGN

Retrospective cohort study.

SETTING

Chronic care geriatric facility.

PARTICIPANTS

Of 359 participants from a prospective RCT conducted between April 2012 and September 2013, 306 were evaluable for another 12-month follow-up.

MEASUREMENTS

Outcomes at 24-month follow-up included quality of prescribing (assessed according to STOPP/START), hospitalizations, falls, costs of medications, and all-cause mortality. Outcomes were compared with those reported at the beginning (baseline) and end (12-month follow-up) of the RCT.

RESULTS

There was a significant rise in potentially inappropriate prescriptions (PIPs) (P = .01) and potentially prescriptions omissions (PPOs) (P < .001) in the intervention group between 12 and 24 months, although the prevalence of PIPs was significantly lower in the intervention group (33.3%) than the control group (48.4%) at 24-month follow-up (P = .02). Costs of medications were significantly lower in the intervention group than the control group (P < .001) at 24-month follow-up. The average number of falls in both groups dropped significantly between baseline and study closure (P = .04 and P = .008, respectively). There was no significant difference in hospitalizations and mortality between the two groups at 24-month follow-up.

CONCLUSION

The effect of an orally communicated medication intervention with the STOPP/START criteria on falls was maintained over time. Direct communication between pharmacists and prescribing physicians is more efficient than written medication review and is recommended every 6 months in geriatric facilities.

A qualitative study exploring visible components of organizational culture: what influences the use of psychotropic medicines in nursing homes?

BACKGROUND

The influence of organizational culture on how psychotropic medicines are used in nursing homes has not been extensively studied. Schein's theory provides a framework for examining organizational culture which begins with the exploration of visible components of an organization such as behaviors, structures, and processes. This study aimed to identify key visible components related to the use of psychotropic medicines in nursing homes.

METHODS

A qualitative study was conducted in eight nursing homes in Sydney, Australia. Purposive sampling was used to conduct semi-structured interviews with 40 participants representing a broad range of health disciplines. Thematic analysis was used to derive concepts.

RESULTS

Three visible components were related to psychotropic medicine use. These were drugs and therapeutics committee meetings, pharmacist led medication management reviews and formal and informal meetings with residents and their families. We found that only a few nursing homes utilized drugs and therapeutics committee meetings to address the overuse of psychotropic medicines. Pharmacist led medication management reviews provided a lever to minimize inappropriate psychotropic prescribing for a number of nursing homes; however, in others it was used as a box-ticking exercise. We also found that some nursing homes used meetings with residents and their families to review the use of psychotropic medicines.

CONCLUSION

This study was the first to illustrate that visible components of organizational culture do influence the use of psychotropic medicines and explains in detail what of the culture needs to be addressed to reduce inappropriate psychotropic prescribing.

Antipsychotic prescribing in care homes before and after launch of a national dementia strategy: an observational study in English institutions over a 4-year period

OBJECTIVES

To assess associations between the launch of the National Dementia Strategy (NDS) and antipsychotic prescribing in long-term residential care (LTC) in England.

SETTING AND PARTICIPANTS

Retrospective analysis of prescribing patterns in 616 LTC institutions (31 619 residents) following launch of the NDS, using information from electronic medicines management system.

PRIMARY AND SECONDARY OUTCOME MEASURES

Antipsychotic prescribing point prevalence (PP) for all residents in a cross section of LTC settings over a 4-year period following NDS launch. Secondary outcomes included dosages, length of treatment and use of recommended second-generation antipsychotics (SGAs) versus first-generation antipsychotics (FGAs). Associations between facility-level PP values and institutional characteristics, resident demographics were explored. Variations across geographical areas examined. Prescription net ingredient costs calculated.

RESULTS

No statistically significant difference was observed in overall prescribing rates over the 4-year period (Kolmogorov-Smirnov (KS) test p=0.60), and there was no significant shift towards newer SGAs (KS test p=0.32). Dosages were above the maximum indicated in only 1.3% of cases, but duration of prescribing was excessive in 69.7% of cases. Care homes in the highest prescribing quintile were more likely to be located in a deprived area (rate ratio (Q5/Q1) RR=5.89, 95% CI 4.35 to 7.99), registered for dementia (RR=3.38, 95% CI 3.06 to 3.73) and those in the lowest quintile were more likely to be served by a single general practitioner (GP) practice (RR=0.48; 95% CI 0.37 to 0.63); p<0.001 all. A sixfold variation in PP levels was observed between geographical areas. The average annual expenditure on antipsychotics was £65.6 per person resident (2012 prices).

CONCLUSIONS

The NDS in England was not associated with reduced PP levels or the types of antipsychotic prescribing in care homes. Further research is needed to explore why. Clear standards specifying recommended agents, dosages and length of treatment, together with routine monitoring and greater accountability for antipsychotic prescribing, may be required.

Drug overprescription in nursing homes: an empirical evaluation of administrative data

A widely discussed shortcoming of long-term care in nursing homes for the elderly is the inappropriate or suboptimal drug utilization, particularly of psychotropic drugs. Using administrative data from the largest sickness fund in Germany, this study was designed to estimate the effect of institutionalization on the drug intake of the frail elderly. Difference-in-differences propensity score matching techniques were used to compare drug prescriptions for the frail elderly who entered a nursing home with those who remained in the outpatient care system; findings suggest that nursing home residents receive more doses of antipsychotics, antidepressants, and analgesics. The potential overprescription correlates with estimated drug costs of about €87 million per year.

Proton Pump Inhibitors and the Prescribing Cascade

ACTIVITY OBJECTIVES: 1. Describe the prescribing cascade of proton pump inhibitors (PPI) in nursing home residents. 2. Identify the statistically significant factors related to the use of PPI and H2 receptor blockers. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current study examined the use of proton pump inhibitor (PPI) drugs in 248 nursing home residents and factors associated with being prescribed a PPI. Ninety-three percent of residents taking a PPI had done so for longer than recommended durations. As anticholinergic burden, vitamin/supplement use, and number of oral products taken daily increased, residents were more likely to be taking a PPI. Higher anticholinergic burden (p = 0.031) and number of oral products taken daily (p = 0.04) were two statistically significant predictors in the final logistic regression model. Significant predictors of PPI use in the current study may be explained by the association between polypharmacy and dyspepsia and the lowering of esophageal sphincter pressure by anticholinergic drugs. High use of PPIs in nursing home residents may represent a prescribing cascade.

Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes

OBJECTIVES

Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use.

METHOD

A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions.

RESULTS

Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement.

DISCUSSION

Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement.

Feasibility Testing of a Protocol to Stop Ineffective Drug and Nondrug Treatments

Ineffective treatments continue to be given to nursing home residents with dementia, and many more treatments are started than stopped. The Track and Trigger Treatment (T(3)) Protocol assists nurses to track responses to new treatments and get ineffective treatments stopped or altered. This preliminary study determined feasibility for end users and examined differences between two randomized groups in assessments, treatment changes, nurse time, and drug costs over 8 weeks. Controlling for number of medical diagnoses, 41 residents in the T(3) group had significantly more treatments stopped than 37 residents in the usual care group. Treatments were most commonly stopped because of ineffectiveness (33%), followed by the problem being resolved (29%), side effects (18%), and a change in goals of care (20%). Assessment quality was a statistically significant mediator, and drug costs were significantly less for the T(3) group. The T(3) processes were rated as useful and easy, with one caveat.

The Effects of Antipsychotic Quality Reporting on Antipsychotic and Psychoactive Medication Use

OBJECTIVE

The objective of this study is to examine how nursing homes changed their use of antipsychotic and other psychoactive medications in response to Nursing Home Compare's initiation of publicly reporting antipsychotic use in July 2012.

RESEARCH DESIGN AND SUBJECTS

The study includes all state recertification surveys (n = 40,415) for facilities six quarters prior and post the initiation of public reporting. Using a difference-in-difference framework, the change in use of antipsychotics and other psychoactive medications is compared for facilities subject to public reporting and facilities not subject to reporting.

PRINCIPAL FINDINGS

The percentage of residents using antipsychotics, hypnotics, or any psychoactive medication is found to decline after public reporting. Facilities subject to reporting experienced an additional decline in antipsychotic use (-1.94 vs. -1.40 percentage points) but did not decline as much for hypnotics (-0.60 vs. -1.21 percentage points). Any psychoactive use did not vary with reporting status, and the use of antidepressants and anxiolytics did not change.

CONCLUSION

Public reporting of an antipsychotic quality measure can be an effective policy tool for reducing the use of antipsychotic medications--though the effect many only exist in the short run.

Improving antipsychotic prescribing practices in nursing facilities: The role of surveyor methods and surveying agencies in upholding the Nursing Home Reform Act

BACKGROUND

Inappropriate prescribing of antipsychotics is a longstanding challenge to providing high quality care in nursing facilities. The 1987 Nursing Home Reform Act (NHRA) had an initial impact in reducing inappropriate prescribing, but rates returned to pre-NHRA levels. While the recent Partnership to Improve Dementia Care in Nursing Homes (Partnership) initiative has been successful in reducing the prescribing of antipsychotics in skilled nursing facilities/nursing facilities (NF), it is not known how this guidance initiative impacted prescribing practices and other care processes concerning NF residents with dementia.

OBJECTIVES

The objectives of this study were to explore surveyor observations of NF care practices subsequent to participation the Partnership guidance program and to use a social ecological framework to estimate how these observations were influenced by individual, organizational, and contextual factors.

METHODS

A total of 320 NF surveyors responded to a 49-item questionnaire designed in collaboration with CMS officials and state surveying agency personnel, and distributed by state agency directors. Three outcome variables: measuring improvements in clinical care, deficiencies in clinical care, and falsification of records in response to the Partnership initiative, were created from survey responses. A four-level social ecological framework describing the NF surveyor's environment was used to identify potential influences on surveyors' care observations. Logistic regression was used to evaluate the relationship between environment and outcome variables.

RESULTS

Surveyors observed both improvements in clinical care, including 80.6% reporting nursing facility providers responding to consultant pharmacists' recommendations, and deficits in clinical care in response to the Partnership initiative. Furthermore, 39.7% of surveyors observed a new, but false, diagnosis of psychosis (as defined by the surveyor). Surveyor characteristics and methods and surveying agency and culture were found to substantially impact the success of the Partnership initiative. The most distal level of the framework evaluated in this study, state contextual effects, was found not to impact care observations.

CONCLUSIONS

There is substantial variation in surveyor observations of changes to clinical care in response to the Partnership guidance initiative. Further investigation is needed into the type and severity of falsification of records observed by nursing facility surveyors. When constructing interventions to care for residents in NFs, policymakers must consider the environment in which surveyors operate.

Policies to protect persons with dementia in assisted living: déjà vu all over again?

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Antipsychotic medication use in nursing homes: a proposed measure of quality

OBJECTIVE

The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms.

METHODS

The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure.

RESULTS

We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure.

CONCLUSION

The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.

Instrumental variable applications using nursing home prescribing preferences in comparative effectiveness research

PURPOSE

Nursing home residents are of particular interest for comparative effectiveness research given their susceptibility to adverse treatment effects and systematic exclusion from trials. However, the risk of residual confounding because of unmeasured markers of declining health using conventional analytic methods is high. We evaluated the validity of instrumental variable (IV) methods based on nursing home prescribing preference to mitigate such confounding, using psychotropic medications to manage behavioral problems in dementia as a case study.

METHODS

A cohort using linked data from Medicaid, Medicare, Minimum Data Set, and Online Survey, Certification and Reporting for 2001-2004 was established. Dual-eligible patients ≥65 years who initiated psychotropic medication use after admission were selected. Nursing home prescribing preference was characterized using mixed-effects logistic regression models. The plausibility of IV assumptions was explored, and the association between psychotropic medication class and 180-day mortality was estimated.

RESULTS

High-prescribing and low-prescribing nursing homes differed by a factor of 2. Each preference-based IV measure described a substantial proportion of variation in psychotropic medication choice (β(IV → treatment): 0.22-0.36). Measured patient characteristics were well balanced across patient groups based on instrument status (52% average reduction in Mahalanobis distance). There was no evidence that instrument status was associated with markers of nursing home quality of care.

CONCLUSION

Findings indicate that IV analyses using nursing home prescribing preference may be a useful approach in comparative effectiveness studies, and should extend naturally to analyses including untreated comparison groups, which are of great scientific interest but subject to even stronger confounding.

Assessment of antipsychotic prescribing in Belgian nursing homes

BACKGROUND

Given the potential adverse effects of antipsychotics, high use in nursing homes creates concern. Our study goal was to explore the use of antipsychotics in relation to resident characteristics, and to assess the appropriateness of antipsychotic prescribing in Belgian nursing homes.

METHODS

Data were used from a cross-sectional study (Prescribing in Homes for the Elderly; PHEBE) conducted in 76 nursing homes in Belgium. Antipsychotics were classified into typical and atypical, using the anatomical therapeutic and chemical classification. Ten inappropriate antipsychotic prescribing indicators were selected from the updated Beers criteria (2003), Bergen District Nursing Home Study (BEDNURS) indicators, and Screening Tool of Older People's Prescriptions criteria (STOPP).

RESULTS

The residents' mean age was 84.8 years, 78.1% of whom were female. The prevalence of antipsychotic utilization was 32.9%. Antipsychotics were mainly indicated for dementia-related agitation, and psychosis with/without dementia. Higher use of antipsychotics was found for dementia (OR: 3.27; 95% CI: 2.61-4.09), insomnia (OR: 1.38; 95% CI: 1.10-1.73), depression (OR: 1.30; 95% CI: 1.03-1.65), and age <80 years (OR: 1.79; 95% CI: 1.38-2.33). Inappropriate antipsychotic prescribing indicators scoring the highest among users were: long-term use (92.6%), use despite risk of falling (45.6%), combined use with other psychotropics (31.8%), and duplicate use (15.1%). Inappropriate prescribing was associated with depression (OR: 3.41) and insomnia (OR: 2.17).

CONCLUSION

The indicator-driven analysis of antipsychotic prescribing quality revealed a need for improvement, with the main prescribing problems relating to duration and combination of therapies. Risks/benefits of off-label use need to be evaluated more consciously at the start of therapy, and at periodic re-evaluations.

Sedative load of medications prescribed for older people with dementia in care homes

BACKGROUND

The objective of this study was to determine the sedative load and use of sedative and psychotropic medications among older people with dementia living in (residential) care homes.

METHODS

Medication data were collected at baseline and at two further time-points for eligible residents of six care homes participating in the EVIDEM-End Of Life (EOL) study for whom medication administration records were available. Regular medications were classified using the Anatomical Therapeutic Chemical classification system and individual sedative loads were calculated using a previously published model.

RESULTS

At baseline, medication administration records were reviewed for 115 residents; medication records were reviewed for 112 and 105 residents at time-points 2 and 3 respectively. Approximately one-third of residents were not taking any medications with sedative properties at each time-point, while a significant proportion of residents had a low sedative load score of 1 or 2 (54.8%, 59.0% and 57.1% at baseline and time-points 2 and 3 respectively). More than 10% of residents had a high sedative load score (≥ 3) at baseline (12.2%), and this increased to 14.3% at time-points 2 and 3. Approximately two-thirds of residents (66.9%) regularly used one or more psychotropic medication(s). Antidepressants, predominantly selective serotonin re-uptake inhibitors (SSRIs), were most frequently used, while antipsychotics, hypnotics and anxiolytics were less routinely administered. The prevalence of antipsychotic use among residents was 19.0%, lower than has been previously reported for nursing home residents. Throughout the duration of the study, administration of medications recognised as having prominent sedative adverse effects and/or containing sedative components outweighed the regular use of primary sedatives.

CONCLUSIONS

Sedative load scores were similar throughout the study period for residents with dementia in each of the care homes. Scores were lower than previously reported in studies conducted in long-term care wards which have on-site clinical support. Nevertheless, strategies to optimise drug therapy for care home residents with dementia which rely on clinicians external to the care home for support and medication review are required.

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.

Pharmacy interventions on prescribing in nursing homes: from evidence to practice

Prescribing of medicines for older people who live in nursing homes is a very common intervention. Undoubtedly, medicines have contributed to longevity and improved health outcomes in the population, but they are not without their side effects and can give rise to adverse events. The nursing home population is particularly at risk as residents have multiple comorbidities and receive multiple medications. Moreover, the quality of prescribing has been criticised with long-standing concerns about inappropriate prescribing, particularly overuse of medications which are not clinically indicated or which are no longer required. It has been suggested that pharmacists could use their skills to improve prescribing in the nursing home population and this review paper outlines the evidence for this type of intervention. The studies which have been included were rigorously designed and conducted. A number of interventions consisted of medication reviews, which often focused on specific drugs, notably antipsychotics, hypnotics and anxiolytics. In some cases, the pharmacist was solely responsible for the delivery of the intervention while in others a multidisciplinary approach was taken involving other key healthcare professionals. A number of outcome measures were employed to assess the impact of the intervention, ranging from a change in the number of inappropriate medications to differences in hospitalizations or health-related quality of life. Owing to the variation across studies, it is difficult to be definitive about the impact of pharmacy interventions in this setting. In an older, frail population such as nursing home residents, consideration needs to be given to appropriate and relevant outcome measures including a reduction in inappropriate prescribing, optimization of prescribing, reduced costs and improved health-related quality of life. Pharmacists and other healthcare professionals should continue to strive to meet these challenges in this particular demographic.

Drug utilization in Belgian nursing homes: impact of residents' and institutional characteristics

PURPOSE

This study aims to investigate drug utilization in Belgian nursing homes in relation to the characteristics of residents and the institution.

METHODS

A cross-sectional study design was used. A total of 2510 residents were randomly selected from a stratified random sample of 76 Belgian nursing homes with at least 30 beds, including high-intensity care beds. Data collection was based on medical chart review supplemented with clinical information from general practitioners (GPs)

RESULTS

The residents included had a mean age of 85 and 77% were female. They presented a median of 2 clinical problems (range 0-10), three care problems (range 0-10) and 48% had dementia. Their medical consumption amounted to a mean of 8.4 prescriptions including 7.1 for chronic treatment. Mean expenditure per month for chronic medication was 140 EUR (SD 125), including 53 EUR out-of-pocket payment.This study confirmed that multiple comorbidity was associated with polypharmacy. After peaking in the seventh decade, medical consumption decreased in older age groups. In palliative care, the number of prescriptions decreased while expenditure increased. A marked decrease in prescriptions, particularly of pain-relieving medication, was observed with increasing dementia. Larger public institutions, with an active coordinating physician and served by hospital pharmacists, had lower consumption and expenditure.

CONCLUSION

A high level of drug utilization, influenced by the characteristics of residents and the institution, was observed in Belgian nursing homes. There is a need to develop a comprehensive monitoring system of prescribing quality for nursing home residents.

Are interventions recommended by pharmacists during Home Medicines Review evidence-based?

INTRODUCTION

Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence-based medicine have been investigated, the extent to which medication review recommendations are evidence-based is not known.

OBJECTIVE

To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence-based guides at the time of the review; and (2) the nature and extent of drug-related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs.

METHOD

A retrospective review of Home Medicines Review cases performed on 224 community-dwelling older people (65 years or older). The chi-squared test for categorical variables was used to compare the proportion of recommendations that were evidence-based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria.

RESULTS

Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence-based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected.

CONCLUSION

The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting resources, can help to improve the quality use of medicines in this at-risk population.

A multidisciplinary approach to improve drug therapy in nursing homes

Management of drug therapy in nursing home patients is challenging due to complex health problems, use of multiple medications, and age-related changes in pharmacokinetics and pharmacodynamics. The objective of this study was, first, to examine the effect of systematic medication reviews conducted by multidisciplinary nursing home teams on prescribing quality and, second, to evaluate if drug therapy changes were maintained over time. Patients in a large nursing home in Oslo, Norway, were prospectively followed during a 1.5-year period. Systematic comprehensive medication reviews were carried out and the identified drug-related problems (DRPs) were discussed at multidisciplinary team meetings. After 3 months, the patients’ drug regimens were reviewed again to evaluate if drug therapy changes were maintained. Altogether, 93 patients were included (89% women, mean age 87 years). In total, 234 DRPs were identified in 82 patients, and 151 drug therapy changes were performed in 73 patients. The most common DRPs were ‘drug treatment without a clear indication’ (37% of all DRPs) and ‘treatment with an inappropriate drug’ (20%). After 3 months, 85 patients (91%) were available for follow-up. In these patients, 133 (88%) of the drug therapy changes were maintained, and the mean number of DRPs had decreased from 2.6 to 1.0 per patient (P < 0.01). We were able to demonstrate that medication reviews conducted by multidisciplinary teams were effective to improve the quality of drug treatment in nursing home patients by significantly reducing both number of drugs and number of DRPs. The large majority of drug therapy changes were maintained after 3 months.

Geriatric drug utilisation of psychotropics in Belgian nursing homes

OBJECTIVE

To determine the prevalence of psychotropic drug use in Belgian nursing homes, in relation to residents' and institutional characteristics.

METHODS

The PHEBE project (Prescribing in Homes for the Elderly in Belgium, 2005) was a cross-sectional study, investigating drug use in 76 nursing homes. Psychotropics were categorised into antidepressants, antipsychotics, benzodiazepines and anti-dementia drugs using the ATC classification.

RESULTS

Residents' mean age (n=1730) was 85 (SD: 8) years and 78% were female. The overall prevalence of psychotropic drug use among nursing home residents was 79%. Benzodiazepines were used by 54% and antipsychotics by 33% of all residents. Residents received a higher number of antipsychotics ( p<0.001) but fewer antidepressants (and other medicines) with increasing severity of dementia. Antidepressants were prescribed in 40% of which 2/3 was indicated for depression and 1/3 for insomnia. Anti-dementia drugs were used by 8%. Institutional characteristics showed no relationship with psychotropic drug use, except for a lower use when medication was dispensed by a hospital pharmacist (p=0.001).

CONCLUSION

As in other European countries, the prevalence of psychotropic utilisation in Belgian nursing homes is exceedingly high, with excessive duplicate use. Guidelines, education and clinical practice recommendations focusing on initiation, reassessment and withdrawal of psychotropic therapy, are needed.

Antipsychotic drug use since the FDA black box warning: survey of nursing home policies

OBJECTIVES

To use a nationwide survey to assess changes in antipsychotic utilization patterns and usage policies in nursing homes (NHs) in the United States since the introduction of the black box warning by the FDA.

DESIGN/SETTING/PARTICIPANTS

A survey was distributed online and was completed by 250 directors of nursing of NH. The directors of nursing answered questions concerning policies about and use of antipsychotic medications.

MEASUREMENTS/RESULTS

The most commonly reported intervention to manage symptoms in residents with dementia since the black box warning was to lower doses of antipsychotics. Over half of facilities report obtaining more frequent psychiatry/psychology consults. One-hundred seven facilities have a policy regarding informing family members of residents about the black box warning. Most facilities (63.6%) with a policy require family to sign consent. In the NH setting, the presence or absence of a policy did not correlate with the reported change in use of antipsychotics or types of alternative interventions.

CONCLUSION

Notably, a large number of NH facilities have policies regarding informed consent on the use of antipsychotics. However, in our study, the rate of use of antipsychotics did not change in many facilities since the black box warning. In addition, having a policy did not correlate with decreased antipsychotic use or with use of alternate agents or nonpharmacologic methods to address symptoms. The results of this survey suggest that NH administrators should worry less about the legal exposure of using antipsychotics and focus on actions that result in improved patient care.

Demystifying federal nursing home regulations to improve the effectiveness of psychopharmacological care

PURPOSE

This paper attempts to demystify the federal regulations that govern the administration of medications to nursing home residents, describing the intent and correct implementation of F329 Unnecessary Drugs of the Omnibus Budget Reconciliation Act of 1987, most recently revised in 2006.

DESIGN AND METHODS

Methods included a comprehensive review of the literature and cases from clinical practice.

FINDINGS AND PRACTICE IMPLICATIONS

Although the regulatory language is complex, less so with each subsequent revision, its requirements nevertheless parallel good clinical practice and insure that vulnerable older adults have a quality of life that includes freedom from unnecessary medication--defined as any medication prescribed in a nursing home without adequate indication, in an excessive dose, for excessive duration, as duplicate therapy, without adequate monitoring of efficacy and tolerance, or in the presence of adverse consequences.

Quality of mental health care for nursing home residents: a literature review

Because of the high proportion of nursing home residents with a mental illness other than dementia, the quality of mental health care in nursing homes is a major clinical and policy issue. The authors apply Donabedian's framework for assessing quality of care based on the triad of structure, process, and outcome-based measures in reviewing the literature on the quality of mental health care in nursing homes. Quality measures used within the literature include mental health consultations and hospitalizations, inappropriate use of medications, and mental health survey deficiencies. Factors related to the resident's welfare (nurse staffing), provider norms (locality), and financial factors (payer mix) were associated with the quality of mental health care. Although future research is necessary, the extant literature suggests that persons with mental illness are frequently admitted to nursing homes and their care is often of poor quality and related to a series of resident and facility factors.

The relationship between variations in antipsychotic prescribing across nursing homes and short-term mortality: quality of care implications

BACKGROUND

High rates of antipsychotic drug prescribing in nursing homes can signal poor quality processes, but also raise concerns about drug safety due to the mortality risk of this therapy. Determining the extent to which variations in antipsychotic use are a symptom of facility-level quality problems as compared with a drug safety issue is important for selecting the correct interventions to effect change.

OBJECTIVE

To determine whether nursing homes with higher rates of antipsychotic dispensing had higher rates of short-term mortality among their residents.

METHODS

This population-based study examined 60,105 older adults newly admitted to nursing homes in Ontario between April 1, 2000 and March 31, 2004. Using adjusted Cox proportional hazard models, we explored the relationship between facility-level dispensing rates and mortality, controlling for resident characteristics. Facilities were grouped into quintiles according to mean antipsychotic rate. All-cause mortality at 30 and 120 days after admission was stratified by recent hospital discharge and analyzed by quintile.

RESULTS

Average antipsychotic dispensing ranged from 11.6% in the lowest quintile to 30.0% in the highest. Among residents with no recent hospitalization, all-cause mortality at 30 days was 2.5% in the lowest compared with 3.3% in the highest quintile (adjusted hazard ratio: 1.28, confidence interval: 1.06-1.56) and at 120 days was 9.3% compared with 11.7% (adjusted hazard ratio: 1.25, confidence interval: 1.13-1.39).

CONCLUSION

Residents were at increased risk of death simply by being admitted to a facility with a higher intensity of antipsychotic drug use, despite similar clinical characteristics at admission.

Adherence to the Components of the Fleetwood Model: Self-Reported Process Measures in the Fleetwood Phase III Study

OBJECTIVE

To compare the pharmacist-reported adherence to Fleetwood model process components in intervention with control groups in the Fleetwood Phase III study.

DESIGN

Demonstration project.

SETTING

Kinston, North Carolina (intervention site) and Mooresville, North Carolina (control site).

PARTICIPANTS

Twelve dispensing and 15 consultant pharmacists employed by a single pharmacy provider.

INTERVENTIONS

Fleetwood model or usual practice by dispensing and consultant pharmacists.

MAIN OUTCOME MEASURE(S)

Pharmacist adherence to elements of the Fleetwood model most or all of the time.

RESULTS

More dispensing and consultant pharmacists in the intervention group performed all elements of the Fleetwood model most or all of the time compared with individuals in the control group. The greatest change occurred in the activities of the dispensing pharmacists in the intervention group.

CONCLUSION

Dispensing and consultant pharmacists can integrate elements of the Fleetwood model (prospective review, pharmaceutical care planning, direct communications with physicians) into their practices.

Targeting suboptimal prescribing in the elderly: a review of the impact of pharmacy services

OBJECTIVE

To review the currently available literature on the impact of interventions by pharmacists on suboptimal prescribing in the elderly.

DATA SOURCES

MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention.

STUDY SELECTION AND DATA EXTRACTION

To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study.

DATA SYNTHESIS

A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications.

CONCLUSIONS

Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare impact of reducing suboptimal prescribing.

Transforming long-term care pain management in north america: the policy-clinical interface

BACKGROUND

The undertreatment of pain in older adults who reside in long-term care (LTC) facilities has been well documented, leading to clinical guideline development and professional educational programs designed to foster better pain assessment and management in this population. Despite these efforts, little improvement has occurred, and we postulate that focused attention to public policy and cost implications of systemic change is required to create positive pain-related outcomes.

OBJECTIVE

Our goal was to outline feasible and cost-effective clinical and public policy recommendations designed to address the undermanagement of pain in LTC facilities.

METHODS

We arranged a 2-day consensus meeting of prominent United States and Canadian pain and public policy experts. An initial document describing the problem of pain undermanagement in LTC was developed and circulated prior to the meeting. Participants were also asked to respond to a list of relevant questions before arriving. Following formal presentations of a variety of proposals and extensive discussion among clinicians and policy experts, a set of recommendations was developed.

RESULTS AND CONCLUSIONS

We outline key elements of a transformational model of pain management in LTC for the United States and Canada. Consistent with previously formulated clinical guidelines but with attention to readily implementable public policy change in both countries, this transformational model of LTC has important implications for LTC managers and policy makers as well as major quality of life implications for LTC residents.

Antipsychotic drug use among elderly nursing home residents in the United States

BACKGROUND

Antipsychotic utilization in elderly nursing home residents has increased substantially in recent years, primarily due to the use of atypical antipsychotic agents. However, few studies have examined antipsychotic utilization patterns in nursing home residents in the United States since the introduction of atypical agents in the 1990s.

OBJECTIVE

The goal of this study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States.

METHODS

This study involved a cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey (NNNHS). The analysis focused on the use of 11 typical and 6 atypical antipsychotic agents among a nationally representative sample of elderly patients (aged > or =65 years). Descriptive weighted analysis was performed to examine antipsychotic prevalence patterns. Multiple logistic regression analysis within the conceptual framework of the Andersen behavioral model was used to examine the factors associated with antipsychotic drug use among the elderly nursing home residents.

RESULTS

According to the 2004 NNHS, 0.32 million elderly nursing home residents received antipsychotic medications, for an overall prevalence of 24.82%. Most received atypical agents (23.45%), while 1.90% received typical agents. Frequently reported diagnoses among the elderly using an antipsychotic agent were dementia (70%), depression (41%), and anxiety (18%). Among the predisposing characteristics, female gender and age (> or =85 years) were negatively associated with antipsychotic drug use. Need factors such as increasing dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, history of falls, and bowel incontinence were positively associated with antipsychotic drug use. In addition to the use of antipsychotic agents in schizophrenia and bipolar mania, this study found high use in conditions such as dementia, anxiety, depression, and parkinsonism in the elderly.

CONCLUSIONS

Nearly 1 in 4 elderly nursing home residents in the United States received antipsychotic agents. Predisposing and need factors played a vital role in determining the use of antipsychotic agents in these elderly patients. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in US nursing homes in light of recent efficacy and safety data on atypical agents.