Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study

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.

Potentially inappropriate medications prescribed for elderly patients through family physicians

The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug-drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.

Changes in Antipsychotic Drug Use Following Shifts in Policy

This case study of antipsychotic drug use in nursing homes illustrates the potential benefits and limits of multilevel hierarchical linear analysis in long-term care research. Multilevel (MLn) logistic regression models were used to assess changes in exposure and average daily dose and their associations with resident and facility characteristics following implementation of the 1987 Omnibus Budget Reconciliation Act regulations. Data were obtained for 8,158 elderly Oregon Medicaid residents residing in 128 facilities between July 1991 and December 1994. Findings support the general hypothesis that resident characteristics are the main determinants of drug use and that drug use decreased over time among some resident populations and some facility types. Although challenges were encountered in the use of the MLn software, hierarchical modeling has advantages that make it attractive for long-term care multilevel applications such as the drug use study reported here.

Changes in Resident and Facility Risk Factors for Psychotropic Drug Use in Nursing Homes Since the Nursing Home Reform Act

The purposes of this article are to identify resident and facility risk factors for the use of psychotropic drugs since the implementation of the Nursing Home Reform Act (NHRA) and to compare these results with resident and facility risk factors prior to the implementation of the NHRA. The results update our knowledge of resident risk factors for psychotropic drug use and identify important but previously unexplored facility risk factors for their use. No evidence was found that particular types of nursing homes, such as for-profits, were systematically more likely to use psychotropic drugs. There was some evidence to suggest that operating characteristics of nursing homes, such as Medicaid census, are more influential in changing psychotropic drug use. In addition, both resident and facility risk factors for psychotropic drug use differed pre and post-implementation of the NHRA. Antipsychotic drug use increased slightly during this study period.

Intended and unintended consequences of minimum staffing standards for nursing homes

Staffing is the dominant input in the production of nursing home services. Because of concerns about understaffing in many US nursing homes, a number of states have adopted minimum staffing standards. Focusing on policy changes in California and Ohio, this paper examined the effects of minimum nursing hours per resident day regulations on nursing home staffing levels and care quality. Panel data analyses of facility-level nursing inputs and quality revealed that minimum staffing standards increased total nursing hours per resident day by 5% on average. However, because the minimum staffing standards treated all direct care staff uniformly and ignored indirect care staff, the regulation had the unintended consequences of both lowering the direct care nursing skill mix (i.e., fewer professional nurses relative to nurse aides) and reducing the absolute level of indirect care staff. Overall, the staffing regulations led to a reduction in severe deficiency citations and improvement in certain health conditions that required intensive nursing care.

Use of antipsychotics among older residents in VA nursing homes

BACKGROUND

Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Affairs (VA) nursing homes [ie, Community Living Centers (CLCs)], we assessed the prevalence and risk factors for antipsychotic use in older residents of VA CLCs.

METHODS

This cross-sectional study included 3692 Veterans age 65 or older who were admitted between January 2004 and June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (eg, schizophrenia, dementia with psychosis). We used multivariable logistic regression and generalized estimating equations to identify factors independently associated with antipsychotic receipt.

RESULTS

Overall, 948/3692(25.7%) residents received an antipsychotic, of which 59.3% had an evidence-based indication for use. Residents with aggressive behavior [odds ratio (OR)=2.74, 95% confidence interval (CI), 2.04-3.67] and polypharmacy (9+ drugs; OR=1.84, 95% CI, 1.41-2.40) were more likely to receive antipsychotics, as were users of antidepressants (OR=1.37, 95% CI, 1.14-1.66), anxiolytic/hypnotics (OR=2.30, 95% CI, 1.64-3.23), or drugs for dementia (OR=1.52, 95% CI, 1.21-1.92). Those residing in Alzheimer/dementia special care units were also more likely to receive an antipsychotic (OR=1.66, 95% CI, 1.26-2.21). Veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR=1.10, 95% CI, 0.82-1.47).

CONCLUSIONS

Antipsychotic use is common among VA nursing home residents aged 65 and older, including those without a documented evidence-based indication for use. Further quality improvement efforts are needed to reduce potentially inappropriate antipsychotic prescribing.

Reasons for psychiatric medication prescription for new nursing home residents

OBJECTIVES

This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission.

METHOD

We extracted data from 73 charts drawn from a convenience sample of individuals who were residents of seven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conducted to explore rationales for psychoactive medication usage.

RESULTS

Eighty-nine percent of the residents who received psychoactive medications during the first three months of residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a written physician's order. Mental status was monitored by staff, and psychoactive medications were titrated based on changes in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review (PASRR) evaluations were completed during the admissions process. Further, while 73% had mental health diagnoses at admission, 85% of the NH residents were on a psychoactive medication three months after admission, and 19% were on four or more psychoactive medications. Although over half of the residents had notes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their number was eclipsed by the number receiving psychopharmacological treatment.

CONCLUSIONS

While the results suggest that NHs may be providing more mental health care than in the past, psychopharmacological treatment remains the dominant approach, perhaps because of limited mental health training of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals. A critical review of the role of the PASRR process is suggested.

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

Psychotropic medications are commonly administered to elderly clients to manage behavior and psychiatric symptoms. These drugs are known to have potentially serious side effects, to which older adults are more vulnerable. Nurses care for older adults in many different practice settings but have varying degrees of knowledge about these kinds of medications. The purposes of this article are to (a) provide information to geriatric nurses in all settings about how the most commonly prescribed psychotropic medications (i.e., anxiolytic, antidepressant, and antipsychotic drugs) differentially affect older adults; (b) examine recent concerns about the use of psychotropic medications with older adults; and (c) discuss nursing implications for those administering psychotropic medications to older adults.

Duplicative medications in patients who visit multiple medical institutions among the insured of a corporate health insurance society in Japan

OBJECTIVE

The objective of this paper is to describe the frequency of duplicative medication use and to estimate the drug cost associated with duplicative medications in patients who visit multiple medical institutions in Japan.

METHODS

The subjects of this study were insurants of a corporate health insurance society. We examined claims of insurants who received prescriptions from multiple medical institutions in April 2002. We examined characteristics of insurants who received duplicative medications and calculated the cost of duplicated drugs.

RESULTS

8.8% received drugs with the same mechanism of action for overlapping administration periods. In terms of comparison among three age groups, 0-19 years old, 20-69 years old, and 70 years old or older, the percentage was higher in 0-19-year-old patients than in the other age groups. The cost of duplicated drugs was found to be 0.7% or 0.5% of the total drug cost, when calculated with higher-priced drugs and lower-priced drugs, respectively.

CONCLUSIONS

This study suggests that pediatric and teenage patients as well as elderly patients require prudent management of medication to avoid duplicative medications and that at least an estimated 5.2-7.2 billion yen may be saved if duplicative medications can be completely eliminated nationwide.

Psychotropic use in community residential care facilities: A prospective cohort study

BACKGROUND

Psychotropic medication use in community residential care (CRC) facilities has been reported to be similar to that found in nursing homes before the implementation of the Omnibus Budget Reconciliation Act of 1987.

OBJECTIVES

The objectives of this study were to (1) describe patterns of psychotropic medication use at baseline and after 1 year of follow-up in adult residents aged > or =65 years supported by Medicaid in CRC facilities, (2) describe the quality of psychotropic use, and (3) examine the relationship between psychotropic use and resident and facility characteristics.

METHODS

This was a planned analysis of a larger prospective cohort study conducted in CRC facilities (assisted living, adult family home, adult residential care) in a 3-county area in the state of Washington. Interviews and state Medicaid databases were used to collect resident characteristics (demographic data, medication use, activities of daily living, self-reported health, and frequency of memory and behavior problems) and facility characteristics (type, staffing, and occupancy rates). Residents were classified as users or nonusers of psychotropic medications. Suboptimal psychotropic use was defined as use of agents with a higher side-effect profile (tertiary amine tricyclic antidepressants, long-acting benzodiazepines, and low-potency conventional antipsychotics). Logistic regression was used to examine characteristics associated with any psychotropic use at baseline.

RESULTS

The typical resident was a white woman, aged 83 years, receiving 7 medications. Nearly half (46.8%) of all residents used > or =1 psychotropic medication at baseline, whereas 16.7% used multiple agents. Antidepressants accounted for the greatest amount of psychotropic use (31.2%). Suboptimal antidepressants, sedative/anxiolytics, and antipsychotics were used by 19.3%, 16.7%, and 7.3% of medication users in each class, respectively. Only age (odds ratio [OR] = 0.97; 95% CI, 0.35-1.00), number of medications (OR = 1.06; 95% CI, 1.00-1.11), and the Revised Memory and Behavior Problems Checklist score (OR = 2.03; 95% CI, 1.28-3.23) were associated with psychotropic use at baseline.

CONCLUSIONS

Psychotropic medication use was high in CRC facilities (46.8%), with antidepressants being the most frequently used drugs. Use of suboptimal (19.3% of antidepressant users, 16.7% of sedative/anxiolytic users, 7.3% of antipsychotic users) and multiple psychotropics (16.7%) was low.

Does Organisational Culture Influence Prescribing in Care Homes for Older People?

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.

Drug Use in a Geriatric Long-Term Care Setting

BACKGROUND AND OBJECTIVE

Advanced age, co-morbid diseases, functional dependence and frailty are associated with polypharmacy and overall high health expenditures. Polypharmacy is commonly defined as the concomitant ingestion of four or more medications, particularly in community-dwelling patients, but the number of drugs being taken by institutionalised and hospitalised patients may be as high as ten. The aim of this study was to compare drug use in newly admitted patients (AP) to a geriatric medical centre for long-term care (LTC) with that of institutionalised patients (IP) at the centre.

METHODS

A cross-sectional study was conducted, between January 2001 and December 2002, in 324 functionally dependent and cognitively impaired elderly patients (> or = 65 years of age), consisting of 167 IP (127 females, 40 males) staying at the centre for > or = 3 months and 157 (117 females, 40 males) consecutive new admissions for LTC. All patients underwent a comprehensive geriatric assessment, which included a structured medical history, history of drug use, physical examination and functional and cognitive examinations. Overall drug use, drug categories and the basis of use (regular and/or as needed) were compared between the two groups of patients. The pattern of drug use was defined as use of drugs either on a 'regular' basis or on an 'as needed' basis at any time during the 3 weeks preceding the comprehensive geriatric assessment.

RESULTS

IPs were younger, more dependent, more cognitively impaired, had more co-morbidity and had nonsignificantly higher overall drug use than APs. APs used drugs mainly on a 'regular' basis. All of the IPs and most (97%) of the APs were taking drugs according to regular regimens. However, advanced age in IPs was associated with lower overall drug use, predominantly of medications taken on a 'regular' basis, and higher use of drugs taken on an 'as needed' basis, whereas in APs, advanced age was associated with higher use of both types of medications.

CONCLUSION

IPs used more drugs on an 'as needed' basis, probably because of closer medical supervision of these patients than those in the community. Better knowledge of the patient's medical condition and treatment, together with better monitoring in the community through patient caregiver instruction, on the one hand, and computerisation of medical data accessible to all healthcare providers, on the other hand, might reduce drug use on a regular basis and, consequently, the costly and adverse effects of polypharmacy.

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults

BACKGROUND

Use of potentially inappropriate medications is common in nursing facilities (NFs), in which frail older adults are particularly vulnerable to adverse drug effects. The community-dwelling elderly are generally healthier and have lower overall rates of medication use, but their prescribed medications are not subjected to the same degree of regulatory scrutiny as those of residents in NFs. Frail elderly (FE) adults who are nursing home eligible but are receiving home- and community-based services (HCBS) constitute a distinct group sharing a high disease burden and high levels of medication use with the NF population.

OBJECTIVE

The goal of this study was to examine the relationship between disease burden and inappropriate medication use in these 3 cohorts, with adjustment for demographic and clinical differences.

METHODS

We performed retrospective analyses of Medicaid claims data from May 2000 through April 2001 to identify 3 cohorts of Kansas Medicaid beneficiaries: community-dwelling older adults (the ambulatory cohort); persons receiving HCBS through the Kansas Frail Elderly Program (the FE cohort); and elderly NF residents (the NF cohort). Demographic, clinical, and medication data were extracted from the Medicaid claims data. Unconditionally inappropriate medications were identified using the 1997 Beers criteria. The Cumulative Illness Rating Scale for Geriatrics was used to calculate the disease burden sum, classified as 0 or 1, 2 or 3, 4 or 5, or > or =6 disease categories. Odds ratios for inappropriate medication use at each level of disease burden in each cohort were derived using multivariable models adjusted for demographic and clinical factors, including overall level of medication use.

RESULTS

The final sample included 3185 persons in the 3 cohorts (1163 ambulatory, 858 FE, 1164 NF). Inappropriate medication use was determined to have occurred in 21%, 48%, and 38% of the respective cohorts and was highest in FE cohort members with the greatest disease burden (61%). For the ambulatory and FE cohorts, inappropriate medication use rose as the disease burden increased. The same was not observed in the NF cohort, in whom rates of inappropriate medication use showed little variation regardless of disease burden.

CONCLUSIONS

The relationship between disease burden and inappropriate medication use varied by setting. Those members of the FE cohort with the highest disease burden had the greatest risk for inappropriate medication use.

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.

Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review

OBJECTIVE

To review the role of oral atypical antipsychotic drugs in the management of the behavioural and psychological symptoms of dementia (BPSD).

DATA SOURCES

Medline, Embase, and the Cochrane Library. Reference lists were reviewed and experts were contacted to identify additional trials.

STUDY SELECTION

Double blind randomised controlled trials that evaluated the four oral atypical antipsychotic therapies for BPSD.

REVIEW METHODS

Two reviewers assessed trial validity independently.

DATA EXTRACTION

Demographics of patients, study duration, dose of antipsychotic, primary end points, adverse events.

RESULTS

77 abstracts were reviewed. Five randomised trials (1570 patients) evaluating risperidone and olanzapine were identified. The quality of trials was generally good. Most participants were in an institution (> 96%), elderly (weighted mean 82.3 years), and had Alzheimer's disease (76.3%). Trials lasted 6-12 weeks. Treatment with atypical antipsychotic drugs was superior to placebo for the primary end point in three of the five trials. Two trials comparing risperidone with haloperidol did not find any differences in the primary measures of efficacy. Adverse events were common and included extrapyramidal symptoms, somnolence, and abnormal gait.

CONCLUSIONS

Although atypical antipsychotic drugs are being used with increasing frequency, few randomised trials have evaluated their use for BPSD. Limited evidence supports the perception of improved efficacy and adverse event profiles compared with typical antipsychotic drugs.

Neuroleptic Drug Therapy in Older Adults Newly Admitted to Nursing Homes: Incidence, Dose, and Specialist Contact

OBJECTIVES

To describe the incidence and dose of neuroleptic drug therapy newly dispensed for behavioral disorders to older adults admitted to nursing homes and to determine whether this use is associated with patient characteristics and contact with specialists.

DESIGN

A retrospective cohort study using administrative data from a comprehensive and universal drug program.

SETTING

All licensed nursing homes in Ontario, Canada.

PARTICIPANTS

All 19,780 adults aged 66 and older who had no evidence of neuroleptic drug use in the previous year and no history of major psychosis and were newly admitted to a nursing home between April 1, 1998, and March 31, 2000.

MEASUREMENTS

Exposure to neuroleptic drug therapy and initial dose were measured using claims submitted to the Ontario Drug Benefit Program.

RESULTS

A prescription for a neuroleptic therapy was dispensed to 17% of older adults with no previous neuroleptic exposure within 100 days and to 24% within 1 year of their nursing home admission. New exposure to a neuroleptic therapy was less likely in women (odds ratio (OR)=0.7, 95% confidence interval (CI)=0.6-0.8) and more likely in residents with dementia (OR=3.5, 95% CI=3.2-3.8). Almost 10% of nursing home residents received an initial dose that exceeded recommended thresholds. Only 14% of those newly exposed had prior contact with a geriatrician or psychiatrist.

CONCLUSION

Incident use of neuroleptics in Ontario nursing homes is substantial. Use of high doses suggests that some physicians may need better information about using these agents, particularly given the rapid adoption of atypical neuroleptic drug therapies.

Inappropriate medications for elderly patients

The use of medications is common in elderly persons, and this population has the highest risk of medication-related problems. Elderly persons are more susceptible to the effects of various medications for a number of reasons. It is well known that polypharmacy is one of the most serious problems in caring for elderly persons; however, many of these patients continue to receive medications that have an increased risk of causing harm. In 1991, an important article was published about inappropriate medication use in the elderly population. This article raised awareness of the problem and presented explicit criteria for determining which medications were inappropriate for elderly patients residing in long-term care facilities. This list of drugs is still used for evaluating medications taken by elderly persons and for determining whether satisfactory prescribing practices are being used. We reviewed the medications described as inappropriate for elderly persons and searched the scientific literature to determine whether evidence exists to defend or refute the labeling of particular drugs. At times, evidence was difficult to find, and many of the original studies were dated. For most medications listed as inappropriate, we found evidence to support these designations.

[Prevalence, associated factors, and misuse of medication in the elderly: a review]

Most elderly people use at least one medication, and about one-third use more than five drugs simultaneously. Many patients have no access to the drugs they most need, and others use unnecessary or dangerous drugs. The mean number of drugs used by the elderly, as quoted in different studies, varies from 2 to 5. Significant predictors for such misuse of medication are older age, female gender, precarious health conditions, and depression. Cardiovascular drugs, anti-rheumatics, and analgesics are the most frequently consumed therapeutic classes. Multiple use, prescription of contraindicated drugs, redundant use, and inadequate training of the health care team are associated with adverse drug effects and interactions. Better quality of prescriptions and research on drug use can bring benefits to people aged 60 years or older.

Psychotropic prescription in non-psychiatric hospital settings

A study was conducted to assess differences in psychotropic prescription (PP) in various non-psychiatric hospital settings. After adjustment for demographic, medical and psychological status, rates of PP were significantly lower for surgical, intensive care and outpatients and higher for geriatric patients than for patients in other settings, suggesting inadequate consideration of psychiatric problems in certain contexts, in particular intensive care units.

Assessment, measures and approaches to easing caregiver burden in Alzheimer's disease

The reduction of caregiver burden for those caring for patients with Alzheimer's disease (AD) is especially important given the prevalence of AD as populations age. This paper reviews the complex nature of caregiver burden, how it is measured, and possible interventions that may affect caregiver burden. Caregiver characteristics as well as symptoms exhibited by patients contribute to burden. A number of specific quantitative measures which have been developed to better evaluate caregiver burden are discussed. Such measures are also useful in measuring the impact of interventions on caregiver burden. Pharmacological treatment of patients with AD through the use of acetylcholinesterase inhibitors has positively affected cognition, activities of daily living, and behavioural problems. These benefits significantly reduce caregiver burden. The same is true for psychosocial interventions for the caregiver. It has been suggested that combining both approaches should be utilised for optimal management. Our knowledge of caregiver burden has greatly increased over the past two decades with clear benefits for both patients and caregivers. However, many aspects still clearly require further research. Given the significance of caregiver burden, various aspects have been extensively studied including contributing and protective factors, quantitative assessment, and pharmacological and psychosocial intervention. It is important for clinicians to be aware of this knowledge so that they can effectively incorporate it into their treatment plans for those affected by AD.

Gender, aggression and serotonergic function are associated with response to sertraline for behavioral disturbances in Alzheimer's disease

BACKGROUND

Indications for serotonergic medications in the treatment of behavioral disorders associated with Alzheimer's disease (AD) remain to be established.

METHOD

Sertraline (100 mg OD) was evaluated in a double-blind, randomized, placebo-controlled cross-over study in 22 nondepressed patients with severe probable AD and significant behavioral disturbance. Each subject was given a fenfluramine challenge to evaluate central serotonergic tone.

RESULTS

Eight of 21 (38%) completers responded to sertraline. Drug responsive behaviors included aggression/agitation, irritability and aberrant motor behavior. Low aggression, female gender and large prolactin increase were associated with a better response. There was a trend for decreased aggression during sertraline versus placebo (p = 0.08).

CONCLUSION

Aggression, gender and serotonergic function were associated with sertraline response. Larger randomized controlled trials are needed to clarify the profile of responders.

Use of neuroleptics in a general hospital

BACKGROUND

This study investigates the clinical use of neuroleptics within a general hospital in acutely ill medical or surgical patients and its relation with dementia three months after admission compared with control subjects.

METHODS

Cases were defined as every adult patient to whom a neuroleptic medication was prescribed during their hospitalization in our Hospital from February 1st, to June 30th, 1998. A control matched by age and sex was randomly selected among patients who had been admitted in the same period, in the same department, and had not received neuroleptics drugs (205 cases and 200 controls). Demographic, clinical and complementary data were compared between cases and controls. Crude odds ratios estimating the risk of dementia in non previously demented subjects compared with the risk in non-demented control subjects were calculated.

RESULTS

205 of 2665 patients (7.7%) received a neuroleptic drug. The mean age was 80.0 +/- 13.6 years and 52% were females. They were older and stayed longer than the rest of the population. Only 11% received a psychological evaluation before the prescription. Fifty two percent were agitated while 40% had no reason justifying the use of neuroleptic drug. Three months after neuroleptic use 27% of the surviving cases and 2.6% of the surviving controls who were judged non-demented at admission were identified as demented.

CONCLUSIONS

The most common reason for neuroleptic treatment was to manage agitation symptomatically in hospitalised patients. Organic mental syndromes were rarely investigated, and mental status exams were generally absent. Most of neuroleptic recipients had either recognised or unrecognised dementia.

A videotape-based training method for improving the detection of depression in residents of long-term care facilities

PURPOSE

This article reviews the effectiveness of a new training program for improving nursing staffs' detection of depression within long-term care facilities. The course was designed to increase recognition of the Minimal Data Set (MDS) Mood Trigger items, to be brief, and to rely on images rather than didactics.

DESIGN AND METHODS

This study used a delayed intervention design. Twenty nurses from two facilities participated in all four sessions of the study.

RESULTS

Staff exposed to the intervention (Site 1) improved significantly in their ability to detect mood symptoms in videotaped patients after completing the training course compared with those exposed to the delayed intervention (Site 2). Improvement in detection skills at Site 2 following the training confirmed the intervention's utility. The improvement was demonstrated across levels of staff (licensed and unlicensed). Maintenance of skills was demonstrated at the 4-month follow-up.

IMPLICATIONS

Staff successfully improved knowledge and skill of MDS mood triggers. This method may lend itself to other MDS domains.

Possible medication errors in home healthcare patients

OBJECTIVE

To determine the frequency of possible medication errors in a population of older home healthcare patients according to expert panel objective criteria.

DESIGN

A cross-sectional survey.

SETTING

Two of the largest urban home healthcare agencies in the United States.

PARTICIPANTS

Home healthcare patients age 65 and older admitted to selected offices of these agencies between October 1996 and September 1998.

MEASUREMENTS

We used two sets of consensus-based expert panel criteria to define possible medication errors. The Home Health Criteria identify patients with patterns of medication use and signs and symptoms that indicate sufficient likelihood of a medication-related problem to warrant reevaluating the patient. The Beers criteria identify medications that experts have deemed generally inappropriate for older patients.

RESULTS

The 6,718 study subjects took a median of five drugs; 19% were taking nine or more medications. A possible medication error was identified for 19% of patients according to Home Health Criteria, 17% according to the Beers criteria, and 30% according to either. Possible errors increased linearly with number of medications taken. When patients taking one to three medications were compared with those taking nine or more drugs, the percentages with possible errors were, respectively, 10% and 32% for the Home Health Criteria, 8% and 32% for the Beers criteria, and 16% and 50% for both.

CONCLUSION

Nearly one-third of the home healthcare patients surveyed had evidence of a potential medication problem or were taking a drug considered inappropriate for older people. More-effective methods are needed to improve medication use in this vulnerable population.

Recommendations for the management of behavioral and psychological symptoms of dementia

BACKGROUND

The behavioral and psychological symptoms of dementia (BPSD) are common, serious problems that impair the quality of life for both patient and caregiver. In order to provide recommendations based upon the best available evidence, a qualitative literature review was performed.

METHODS

A search of the English language medical literature published between 1966 and 2000 was performed. The quality of the studies was assessed by considering the subjects, trial design, analysis and results. Final recommendations were based upon the quality of available evidence.

RESULTS

The management of BPSD begins with a thorough assessment to search for underlying causes of behaviour change. Concomitant medical illness should be treated and sensory impairment ameliorated. Nonpharmacological approaches should be instituted prior to medication use. These interventions include music, light, changes in level of stimulation and specific behavioral techniques. Antipsychotics are the best studied pharmacological intervention for agitation and aggression and have demonstrated modest but consistent efficacy. Antidepressants such as trazodone and selective serotonin re-uptake inhibitors, as well as anticonvulsants such as carbamazepine and valproic acid have also demonstrated efficacy. Benzodiazepines can be used for short-term treatment as p.r.n. agents when necessary. Pharmacotherapy must be monitored closely for both effectiveness and side effects, with consideration of medication withdrawal when appropriate.

CONCLUSION

The management of BPSD can significantly improve the quality of life for the patient and caregiver. Their assessment and management are essential components of the treatment of dementia.

Medication use in residential care facilities for the elderly

OBJECTIVE

To describe medication use by residents of residential care facilities for the elderly (RCFEs).

DESIGN

A cross-sectional survey of medication use.

SETTING

Licensed, private RCFEs recruited from a roster of all licensed RCFEs in the Los Angeles area.

SUBJECTS

Residents who were > or =60 years of age and whose medications were centrally stored in the facility.

MEASURES

Age, gender, race, health insurance coverage, dietary restrictions, ambulation status, medical diagnoses, and medication profile.

RESULTS

A total of 818 residents were surveyed. Residents were primarily white women who were >80 years. The average number of medications per resident was five; 94% of the sample took at least one medication. Cardiovascular drugs, central nervous system drugs, analgesics, diuretics, and potassium supplements were most commonly used. Use of multiple drugs within a therapeutic class was also common, with means ranging from 1.46 to 1.81 per resident for the most commonly prescribed classes. Diagnoses supporting the use of many medications were not documented in the residents' health records.

CONCLUSIONS

This RCFE sample was medically frail and took many medications. The frequent use of cardiovascular medication reflected the prevalence of cardiac disease in the elderly. The frequency of psychotropic drug use without a corresponding indication suggested prescribing for symptoms rather than documented medical conditions. Lack of recorded diagnoses limited the ability to evaluate drug therapy. Improved record keeping; periodic medication review; and resident, staff, and prescriber education are necessary to ensure appropriate medication use in this setting.

Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs

OBJECTIVES

To evaluate critically the evidence linking psychotropic drugs with falls in older people.

DESIGN

Fixed-effects meta-analysis.

DATA SOURCES

English-language articles in MEDLINE (1966 - March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION

Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older.

DATA EXTRACTION

Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs.

RESULTS

Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing > or =1 with > or = 2 falls, mean subject age <75 versus > or =75 years old, communities with <35% versus > or =35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug.

CONCLUSION

There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Medication safety: a protocol for nursing action. NICHE Faculty

Medication consumption represents a significant source of adverse events, therapeutic misadventure, and toxicity to older Americans. Estimates indicate that as many as 25% to 40% of all U.S. prescriptions are written for older people. Hospital admission rates for drug-related problems and toxicity in elders approach 33% in some studies. This article addresses some of the physiological changes associated with aging and their effects on the absorption, distribution, and metabolic fate of common medications in elders. High-risk medications are identified, and strategies for combating their adverse effects are suggested.

A model for improving medication use in home health care patients

OBJECTIVES

(1) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care; (2) To select the most important identifiable problems and develop structured procedures for their resolution.

DESIGN

Expert panel review, problem selection, and development of a problem resolution model and guidelines.

SETTING

Home health care.

PARTICIPANTS

A panel with expertise in home health nursing, pharmacy, clinical pharmacology, gerontology, pharmacoepidemiology, and health services research.

INTERVENTIONS

A list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel. Problems that were controversial or that could not be identified in the home care setting were excluded. Panel members individually ranked the remainder. Detailed procedures for identification and resolution of the 15 top-ranking problems were developed.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Potential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects, to ensure that clinically relevant problems would be identified. The model developed for problem assessment and resolution was centered on the drug utilization review (DUR) coordinator and the attending home health nurse. Following guidelines developed by the panel, the DUR coordinator advises the home health nurse about identified problems and how to resolve them. One of these practitioners, usually the nurse, then contacts the attending physician to explain their concerns, offer potential solutions, and request instructions.

CONCLUSION

A potentially useful model for the identification and resolution of medication problems in the home health care setting was developed. This model is currently being evaluated in a randomized controlled trial.

Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients

OBJECTIVES

To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes).

SETTING

Twenty-five community nursing homes in western Washington.

PARTICIPANTS

Older nursing home residents (N = 48) receiving a low-dose neuroleptic for the treatment of agitation and behavioral disturbances.

INTERVENTION

Randomized, double-blind, crossover trial of alprazolam and low dose haloperidol. Data were gathered at baseline and at the end of 6 and 12 weeks from direct observation and from clinical forms completed routinely by trained nurses.

MEASUREMENTS

Number of behavioral episodes, activities of daily living as measured by the Blessed Dementia Scale, extrapyramidal symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS), and psychopathology as measured by the Clinical Global Impressions (CGI) and the Sandoz Clinical Assessment - Geriatric (SCAG) scales.

RESULTS AND CONCLUSIONS

No significant differences were observed between patients using haloperidol or alprazolam in terms of behavioral episodes per week. Further, with few exceptions, no significant differences were found in other outcome scales. Essentially the same findings were found when analyses were repeated for subgroups of patients with high levels of cognitive impairment and for patients with low and high levels of recorded problematic behavioral episodes. Alprazolam was as effective as low dose haloperidol in this population.

Newer psychotropic medication use in nursing home residents

OBJECTIVE

To evaluate the use of newer psychotropic agents in nursing home residents in the era of new Health Care Financing Administration (HCFA) guidelines.

DESIGN

Retrospective chart review of referrals to an on-site geriatric psychiatry service in seven Eastern Massachusetts facilities during 1995-1996.

SUBJECTS

The 298 patients examined included 226 women and 72 men with a mean (SD) age of 81.9 (9.4) years.

MEASUREMENTS

Patient demographics, psychiatric history and medical diagnoses, prescribed medication information, and mental status examination results were recorded systematically. Descriptive statistics of demographics, medication use, and dosing were generated, and comparative analyses were performed by chi-square, ANOVA, and Tukey's tests.

RESULTS

Overall, 69% of subjects were taking at least one psychotropic medication. Although benzodiazepines (32%) and antipsychotics (42%) were used by a large portion of subjects, antidepressants (61%) were the most commonly prescribed psychotropic, with 53% taking serotonin reuptake inhibitors. The atypical antipsychotic, risperidone, accounted for more than 30% of antipsychotic prescriptions. Low rates of anticholinergic use and low doses and rates of tricyclic antidepressant use were found in Alzheimer's disease patients. Mean dosing of the psychotropic agents fell within HCFA guidelines.

CONCLUSIONS

Newer-generation psychotropics have had a significant impact on the prescribing practices of primary physicians in treating nursing home residents. Of clinical importance is the high rate of antidepressant use in a population that has traditionally received inadequate pharmacotherapy for depression. More studies are needed to examine a shift to the use of other psychotropic drugs in this population in the post-HCFA area.

Use of antipsychotic drugs in nursing homes: current compliance with OBRA regulations

OBJECTIVE

To examine the degree and patterns of compliance with the Omnibus Budget Reconciliation Act (OBRA) regulations regarding the use of antipsychotic drugs in nursing homes.

DESIGN

Retrospective chart review of all resident records.

PARTICIPANTS

Eight nursing homes: five community, two county-owned, and one university-affiliated Veterans Administration facility.

MEASUREMENTS

A structured assessment instrument to track compliance with each aspect of the OBRA regulations regarding antipsychotic drug use.

RESULTS

A total of 1573 nursing home residents' pharmacy records were reviewed between August 1994 and March 1996. Two hundred seventy-nine residents were actively taking antipsychotic medications (prevalence = 17.7%). Mean compliance greater than 70% was found for (1) appropriate diagnostic indication (mean = 70.9%), (2) dosage within recommended limits (mean = 90.1%), and 3) documented appropriate target symptoms (mean = 90.4%). Dosages were more likely to exceed limits in those patients with histories of major mental illness, particularly schizophrenia.

CONCLUSIONS

Nursing homes were better able to comply with those guidelines that are most specific. Educational interventions now need to focus on behavioral interventions, monitoring of adverse effects, and efficacy. These data are useful in establishing threshold levels of performance and can be used by nursing homes for continuous quality improvement. OBRA continues to impact neuroleptic drug prescribing practices in nursing homes significantly.

Physician and staff assessments of drug interventions and outcomes in Swedish nursing homes

OBJECTIVE

To describe the type and frequency of drug-related problems discussed in regular team meetings conducted in 15 Swedish nursing homes and report physician and staff assessments of these interventions and residents' outcomes.

DATA SOURCES AND METHODS

The data were collected within the context of a controlled trial with the primary aim of exploring the effects of regular team interventions on drug prescribing practices in Swedish nursing homes. In 15 experimental nursing homes, the residents' drug therapy was discussed regularly by a team consisting of a pharmacist, a physician, nurses, undernurses (similar to licensed practical nurses), and nurse's aides. The pharmacist documented problems, made changes, and observed outcomes. Following the intervention period, a questionnaire was sent to the medical staff that contained items regarding perceived outcomes, the intervention's impact on knowledge of drug therapy in the elderly, and attitudes toward the pharmacist's role.

RESULTS

Unclear indication and problematic choice of drugs were the most common drug-related problems discussed. In 19% of the situations, therapy changes were reported to have had a beneficial effect on the residents' clinical status; in 47% of the situations, staff reported no observable outcome from changes, suggesting that the changes had been appropriate. Finally, medical staff claimed in the follow-up survey that their knowledge about drug therapy had increased; they expressed an overall positive attitude toward this interactive collaboration.

CONCLUSIONS

Regular intervention conducted by a multidisciplinary team incorporating a pharmacist can effectively improve prescribing practices, increase staff knowledge about appropriate drug therapy in the elderly, and result in improved quality of care for nursing home residents.

The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes

OBJECTIVE

To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes.

DESIGN

A randomized controlled trial.

SETTING

A sample of 33 nursing homes: 15 experimental homes and 18 control homes representing 5% of all Swedish nursing homes.

PARTICIPANTS

The sample consisted of 1854 long-term care residents with an average age of 83 years. Seventy percent of the residents were women, and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder, and 7% had a diagnosis of depression.

INTERVENTION

Experimental homes participated in an outreach program that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses' assistants. Multidisciplinary team meetings were held on a regular basis throughout the 12-month study period.

MEASUREMENTS

Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12-month intervention. Measures included the proportion of residents with any psychotropic drug, polymedicine, and therapeutic duplication and proportion of residents with nonrecommended and acceptable drugs in each psychotropic drug class, as defined by current Swedish guidelines.

RESULTS

Baseline results show extensive psychotropic drug prescribing, with the most commonly prescribed drugs being hypnotics (40%), anxiolytics (40%), and antipsychotics (38%). After 12 months of team meetings in the experimental homes, there was a significant decrease in the prescribing of psychotics (-19%), benzodiazepine hypnotics (-37%), and antidepressants (-59%). Orders for more acceptable antidepressants also increased in the experimental homes. In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes.

CONCLUSIONS

There is excessive prescription of psychotropic drugs in Swedish nursing homes. Improved teamwork among caregivers can improve prescribing as defined by clinical guidelines.

Reliability and validity of the Overt Agitation Severity Scale in adult psychiatric inpatients

An instrument, that validly and reliably identifies and measures agitation is required to evaluate environmental modifications, interpersonal strategies, psychopharmacological interventions, directed toward managing these commonly occurring and highly-disabling emotions and behavior. The conceptualization of agitation on a continuum from anxiety to aggression provides a practical framework for guiding clinical practice toward the early identification and intervention of agitation. The results of this study established the reliability and validity of the Overt Agitation Severity Scale (OASS) in measuring agitation severity in young adult psychiatric inpatients based on objectifiable vocalizations and motoric upper and lower body behaviors. The OASS differs from other agitation scales in its ability to capture both the intensity and frequency of observable behavioral manifestations of agitation, as opposed to subjective interpretations and a diffuse range of symptoms and problem behaviors.

An open trial of valproate for agitation in geriatric neuropsychiatric disorders

The authors assessed the efficacy, tolerability and safety of open valproate administration in a group of elderly patients with agitation and neuropsychiatric disorders (N = 13), most of whom had dementia (n = 12). Dosing was individualized according to the response of target symptoms and side effects. Clinical Global Impression of Change (vs. baseline) measured efficacy. This open treatment suggested that valproate reduced agitated behaviors in some patients, and is well tolerated; thus, results warrant a larger, randomized, placebo-controlled study.

Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes

OBJECTIVES

To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

METHODS

A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre- and 6 months' post-intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subjects as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis.

RESULTS

While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA-approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home.

CONCLUSIONS

Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.

Inappropriate medication prescribing for the elderly by office-based physicians

OBJECTIVE

To estimate the prevalence of inappropriate medications prescribed by office-based physicians for patients 65 years or older.

DESIGN

A nationwide cross-sectional survey of office visits by the elderly.

SETTING

The National Ambulatory Medical Care Survey (NAMCS) 1992, a national probability sample survey of office visits by ambulatory patients within the continental US.

SUBJECTS

A national probability sample of patients 65 years or older visiting office-based physicians. National estimates are based on the National Center for Health Statistics weighting procedure for the NAMCS sample.

MAIN OUTCOME MEASURES

Prevalence of 20 inappropriate medications that should be entirely avoided in the elderly, using criteria developed by a panel of national experts in geriatric medicine and geriatric pharmacology.

RESULTS

In the US during 1992, an estimated 8.47 million (95% CI 7.66 million to 9.28 million) office visits by the elderly indicated prescribing of at least 1 of the 20 inappropriate medications. Approximately 7.75 million (95% CI 6.98 million to 8.52 million) visits by the elderly involved 1 inappropriate medication and 0.72 million (95% CI 0.51 million to 0.93 million) visits included 2 inappropriate medications. According to the NAMCS, office-based physicians prescribed at least 1 inappropriate medication to 7.58% of the elderly who received prescriptions. The most frequently prescribed inappropriate medications were propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide. Elderly patients rarely received prescriptions from office-based physicians for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and carisoprodol. Furthermore, office-based physicians did not prescribe cyclandelate, pentobarbital, or phenylbutazone for the elderly.

CONCLUSIONS

The prescribing of inappropriate medications by office-based physicians raises concerns regarding the quality of care for the elderly in ambulatory settings. The crux of improving patient care in ambulatory settings rests with collaborative efforts between physicians and pharmacists.

Inappropriate drug prescriptions for elderly residents of board and care facilities

OBJECTIVES

Using 1993 data, this study examines the prevalence of presumptively inappropriate prescriptions among residents, aged 65 and older, of board and care homes.

METHODS

Inappropriate drug prescriptions were identified through the use of established criteria developed for application to older nursing home residents and to community-dwelling elderly. This research used a sample of 2054 elderly residents from 410 facilities in 10 states. Weighted analyses were performed with SUDAAN, which accounted for the complex, multistage sampling design.

RESULTS

Depending on the criterion applied, between 20% and 25% of residents had at least one inappropriate prescription. Propoxyphene, long-acting benzodiazepines, dipyridamole, and amitriptyline were prescribed most frequently. Residents with inappropriate drug prescriptions had more complex drug regimens prescribed on a routine basis.

CONCLUSIONS

The results are a conservative estimate of the extent of inappropriate drug prescribing and utilization in board and care facilities. Increased involvement by pharmacists and physicians in systematic drug utilization review is warranted.