Modifiable factors associated with neuropsychiatric symptoms in nursing homes: The impact of unmet needs and psychotropic drugs

Comparison of neuro-psychiatric disorders between older adults living in foster families or nursing homes

Professional foster families for dependent older adults are a housing model perceived as an alternative to nursing homes in the French West Indies. The clinical profile of older adults in foster families remains to be determined, particularly concerning neuropsychiatric symptoms (NPS) in the presence of major cognitive disorders. In this cross-sectional analysis from twin studies conducted in foster families (n = 107, mean age: 81.8 years, male/female ratio: 38/62) and nursing homes (n = 332; (mean age: 81.3 years, male/female ratio: 51/49), we compare the prevalence and severity of NPS, along with psychotropic drugs prescription, between older adults (≥ 60 years) living in both arrangements. The prevalence of major cognitive disorders and the total number of NPS (3.4 ± 2.7 in foster families vs. 3.4 ± 2.5; p = 0.946) were similar between the two groups. The prevalence of each NPS was similar except for apathy (20.0% in nursing homes vs. 8.5% in foster families, p = 0.006), aberrant motor behavior (22.1% in nursing homes vs. 36.2% in foster families, p = 0.004) and eating disorders and appetite (23.0% vs. 9.3%, respectively, p = 0.002). The use of antipsychotics was more frequent in nursing homes (36.7% vs. 26.2%, p = 0.046). This study suggests that the foster families' environment may be well suited for managing older adults with psycho-behavioral disorders.

Therapeutic Lying as a Non-Pharmacological and Person-Centered Approach in Dementia for Behavioral and Psychological Symptoms of Dementia

The acceptance and ethics behind therapeutic lying (TL) as a non-pharmacological intervention for behavioral and psychological symptoms of dementia (BPSD) among persons with dementia continues to generate heated debates. This article presents a discussion of the ethical and cultural challenges on the perception of TL by people with dementia, their families, and health care professionals. Additionally, decision-making before TL was analyzed, including the types of TL, its efficacy and implications, alternatives to TL, and the ethical principles behind it. The results from this analysis show that TL is a common practice for BPSD. Its benefits include the reduction of these symptoms as well as the use of physical or chemical restraints. However, there is no consensus on its suitability as an approach, nor on the appropriate way it should be used. More experimental studies are needed to create legal and clinical intervention protocols that respect the fundamental rights of people with dementia promoting coherence, good ethical practices, and guidelines for person-centered care.

Exploring changes to resident thriving and associated factors in Swedish nursing homes: A repeated cross-sectional study

OBJECTIVE

This study aimed to explore changes to resident thriving in Swedish nursing homes over a 5-year period and describe changes in associated factors.

METHODS

Cross-sectional data were collected from a randomised sample of Swedish nursing homes in 2013/2014 (baseline) and 2018/2019 (follow-up). Descriptive statistics, independent samples t-tests, and chi squared tests were used to statistically evaluate differences between the samples. Simple and multiple linear regression analyses were used to explore associations between thriving and the study variables.

RESULTS

Resident characteristics were relatively consistent between the full baseline (N = 4831) and follow-up (N = 3894) samples. Within a sub-sample of nursing homes that participated in both data collections mean thriving scores were found to have increased from 152.9 to 155.2 (p ≤ 0.003; d =0.09) and overall neuropsychiatric index scores had decreased from 16.0 to 14.3 (p ≤ 0.004; d =0.09), as had the prevalence of several neuropsychiatric symptoms. Thriving was found to have a positive association with the neuropsychiatric symptom of elation/euphoria, and negative associations with the symptoms of aggression/agitation, depression/dysphoria, apathy, and irritability.

CONCLUSIONS

The results show an increase in overall thriving scores and a decrease in overall neuropsychiatric scores between baseline and follow-up. This study confirmed associations between thriving and certain neuropsychiatric symptoms and established comparative knowledge regarding changes in resident thriving, characteristics, and symptom prevalence. These findings could inform future care and organisational policies to support thriving in nursing homes, particularly among residents at risk of lower thriving due to cognitive impairment or neuropsychiatric symptoms.

Human Rights to Inclusive Living and Care for Older People With Mental Health Conditions

Although older persons wish to age at home, many older persons with mental health conditions and psychosocial disability (MHC-PSD) spend the last few years of their life in residential facilities. This paper will examine the impact of ageism and human rights violations manifested in environmental design, specifically regarding social isolation, loneliness, inadequate psychosocial, environmental, recreational and spiritual support. This is compounded by failure to meet basic care needs-nutrition, hydration, pain and medication support. This paper highlights two innovative initiatives from the Netherlands, which show that older persons' rights can be maintained in innovative, collective living arrangements. It is concluded that the creation of inclusive and safe environments for older persons with MHC-PSD can facilitate the enjoyment of Human Rights.

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals

BACKGROUND

It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support.

METHODS

This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale.

RESULTS

The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses.

CONCLUSIONS

It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

The Homestead: Developing a Conceptual Framework through Co-Creation for Innovating Long-Term Dementia Care Environments

Alternative care environments for regular nursing homes are highly warranted to promote health and well-being of residents with dementia that are part of an age-friendly and dementia-friendly city and society. Insight is lacking on how to translate evidence-based knowledge from theory into a congruent conceptual model for innovation in current practice. This study reports on the co-creation of an alternative nursing home model in the Netherlands. A participatory research approach was used to co-create a conceptual framework with researchers, practitioners and older people following an iterative process. Results indicate that achieving positive outcomes for people with dementia, (in)formal caregivers, and the community is dependent on how well the physical, social and organizational environment are congruently designed. The theoretical underpinnings of the conceptual model have been translated into "the homestead," which is conceptualized around three main pillars: activation, freedom and relationships. The Homestead Care Model is an illustrative example of how residential care facilities can support the development of age-friendly communities that take into consideration the needs and requirements of older citizens. However, challenges remain to implement radical changes within residential care. More research is needed into the actual implementation of the Homestead Care Model.

Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.

OBJECTIVE

This study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.

DESIGN, SETTING, AND PARTICIPANTS

Participants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.

OUTCOME MEASUREMENTS

Included measures were scores on the Neuropsychiatric Inventory-Questionnaire and the Cornell Scale for Depression in Dementia.

RESULTS

Participants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = -2.09; 95% CI -3.44, -0.75; t = -3.10; p = 0.003; df = 85), NPS severity (b = -3.82; 95% CI -7.19, -0.45; t = -2.26; p = 0.03; df = 80), and depressive symptom severity (b = -2.94; 95% CI: -5.93, 0.06; t = 1.70; p = 0.05; df = 89).

CONCLUSION

Among patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.