Federal regulations and the care of patients with dementia in the nursing home

Adverse drug effects in elderly people – a disparity between clinical examination and adverse effects self-reported by the patient

OBJECTIVE

The trend towards polypharmacy is increasing among the elderly, and associated with this trend is an increased risk of adverse drug effects and drug-drug interactions. Our objective was to assess whether drug adverse effects reported by patients are in general agreement with those identified by a physician.

METHODS

We evaluated the medication of 404 randomly selected individuals aged 75 years or older by means of interviews carried out by trained nurses and examinations conducted by a physician. The medication used by these patients was recorded prior to the physician's examination and modified thereafter if considered appropriate. Adverse effects noted by the physician were compared to those self-reported by the patients.

RESULTS

Almost all of the patients (98.8%) were using at least one drug, and the mean total number of drugs used was 6.5. Adverse effects were self-reported by 11.4% of the patients, whereas the physician observed apparent adverse drug effects in 24.0% of the patients. No adverse effects were reported in 53.2% of the patients. There were only seven patients that had adverse effects that were both self-reported and identified by the physician, and only four of these patients reported the same adverse effect that had been identified by the physician.

CONCLUSION

There was a great disparity between the adverse effects identified by the physician and those reported by the patients themselves. Based on our results, it would appear that elderly people tend to neglect adverse drug effects and may consider them to be an unavoidable part of normal ageing. Therefore, physicians should enquire about possible adverse effects even though elderly patients may not complain of any drug-related problems.

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

The quality of nursing home care has been subject to intense investigation and scrutiny, particularly in the US. In particular, there has long been concern about the extensive use of psychotropic agents, notably antipsychotics, hypnotics and anxiolytics, in this setting. These drugs have been described as 'chemical restraints', in that they were used to sedate and subdue patients, partly to compensate for poor staffing levels and to minimise staff contact with patients. However, following a damning Institute of Medicine report to the US Congress, use of such drugs became regulated under a unique administrative initiative: the Nursing Home Reform Act, embedded within the Omnibus Budget Reconciliation Act 1987 (OBRA 87). Research has indicated that psychotropic drug use in nursing homes has declined markedly following the implementation of this regulation. In addition, explicit criteria for potentially inappropriate medication use were incorporated within the guidelines for nursing home inspectors from 1 July 1999. Because regulations have targeted poor prescribing, rather than promoting the use of effective drugs in older residents, it has been difficult to determine whether outcomes have improved for nursing home residents as a result. However, US government agencies have responded to continuing concerns about nursing home care through the implementation of quality indicators which are used to guide and plan inspections of such facilities and to compare nursing homes within the same state. Although there are a limited number of quality indicators relating to prescribing, this represents a move away from adversarial regulation, which focuses on poor practice, and attempts to improve quality of care. An important role for educational initiatives and interventions has been advocated by some commentators and these have proved to be successful in the nursing home environment. Other countries have not implemented such restrictive prescribing regulation in nursing homes. Exemplars of innovative prescribing models, involving pharmacists and encouraging resident-centred care, may offer a more palatable approach to improving drug use in this vulnerable population.

Pharmacotherapy for Long-Term Care Residents With Dementia-Associated Behavioral Disturbance

The Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA) of 1987 have resulted in specific mandates for documentation regarding behavioral indication for psychotropic drugs and the monitoring of their efficacy and side effects. The national guidelines also require drug holidays, behavioral management in lieu of drugs when possible, systematic dosage reductions unless contraindications are documented, and an overall reduction of drugs considered unnecessary. This article describes OBRA 87 guidelines for benzodiazepine and antipsychotic drug use in long-term care facilities. Specific pharmacological interventions for persons with behavioral disturbances associated with dementia, the phenomena most significantly affected by these federal guidelines, are summarized.

Psychiatric assessments of nursing home residents under OBRA-87: should PASARR be reformed? Pre-Admission Screening and Annual Review

OBJECTIVE

As part of nursing home practice reforms, OBRA-87 mandates formal psychiatric assessments (PASARR) of nursing home residents suspected of having mental disorders, a responsibility it delegates individually to states. We describe the initial year of implementation of the PASARR process in King County, Washington, and characterize the mental disorders and mental health services needs of nursing home residents referred for psychiatric screening.

DESIGN

Cross-sectional study.

SETTING

The 54 Medicare-certified King County nursing homes (total beds = 7013).

PARTICIPANTS

All patients referred for psychiatric evaluation under PASARR (n = 510).

MEASUREMENTS

A systematic, multidimensional evaluation including a semistructured psychiatric diagnostic examination, validated measures of cognitive dysfunction, depression, and global psychopathology, functional variables relevant to need for nursing home care, and selected mental health services indicators.

RESULTS

Fewer than 10% of all nursing home residents were referred for psychiatric evaluation. A primary mental illness, evenly divided between psychoses and mood disorders, was found in 60% of the sample, and a psychiatric disorder associated with dementia or mental retardation was found in 25%. Six percent had complex neuropsychiatric features defying classification, and 4% had no mental disorder. Other disorders, such as substance abuse, were rare. Cognitive impairment and global psychopathology were prevalent in all diagnostic groups, and depressive symptoms were common even in patients without affective diagnoses. Eighty-eight percent of the sample were appropriately placed, based on their needs for daily care. Fifty-five percent had unmet mental health services needs.

CONCLUSIONS

The PASARR referral process detected a group of seriously mentally ill, functionally disabled patients, most of whom required the level of care that nursing homes provide. Depressed and psychiatrically impaired dementia patients were underrepresented in the referral pool as measured against widely accepted prevalence figures for mental disorders in nursing home populations. The PASARR process as currently configured appears to be most efficient in identifying schizophrenic patients, who represent a small minority of nursing home residents, and the skewed sample it generates fails to provide an adequate basis for estimating overall mental health services needed in nursing homes. The PASARR process should be altered to improve referral rates for depressed and behaviorally disturbed dementia patients.

Lessons from geriatric psychiatry in the long-term care setting

Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.

Pharmacologic therapies in dementia

OBJECTIVE

To review past and current pharmacologic therapies for cognitive and behavioral problems in elderly patients with dementia.

DESIGN

We surveyed the pertinent medical literature and present detailed findings on results of pharmacotherapeutic interventions for cognitive loss and behavioral disorders.

RESULTS

Numerous drugs have been used in an attempt to reverse or forestall the cognitive decline associated with dementia. Currently available agents are limited by either lack of efficacy or occurrence of adverse effects. Medications are also used to control undesirable behaviors associated with dementia. Depending on the individual circumstance, such pharmacologic therapies may be of limited utility, some may be harmful, and others may be effective. The use of psychotropic agents in nursing homes is strictly regulated by federal law. For appropriate care of elderly patients with dementia, knowledge of the available drug therapies and their effectiveness is necessary.

CONCLUSION

Drug therapies for dementia are associated with adverse effects in the elderly population. Drugs for management of aggressive behaviors associated with dementia should be used only when nondrug strategies have failed. In each patient with dementia, underlying cognitive and behavioral problems must be thoroughly evaluated for selection of the most appropriate drug.