Reducing Antipsychotic Medication Use in Nursing Homes: A Qualitative Study of Nursing Staff Perceptions

Effects of Nursing Home Changes in Antipsychotic Use on Outcomes among Residents with Dementia

OBJECTIVES

Little information exists on whether nationwide efforts to reduce antipsychotic use among nursing home (NH) residents with Alzheimer's disease and related dementias improved mortality and hospitalization outcomes for residents. Our objective was to examine the effect of NH decreases in antipsychotic use on outcomes for residents with Alzheimer's disease and related dementias.

DESIGN

Observational nationwide study that emulated a series of cluster randomized trials.

SETTING AND PARTICIPANTS

Long-stay NH residents with Alzheimer's disease and related dementias in US NHs.

METHODS

The study used data from Medicare claims to emulate cluster randomized trials in which NHs were assigned to either decrease or maintain/increase antipsychotic use. Outcome ascertainment for the first trial began on April 1, 2012 (ie, following the announcement of the National Partnership to Improve Dementia Care in NHs). The last day of follow-up was December 31, 2017. Outcomes measured included 12-month all-cause mortality, all-cause hospitalization, and hospitalization for stroke, myocardial infarction, fracture, and psychiatric conditions. Use of other psychotropic medications was also evaluated. Inverse-probability-of-treatment-weighted pooled Poisson regression models estimated covariate-adjusted risk ratios (RRs).

RESULTS

The adjusted risks of death (RR, 1.01; 95% CLs, 1.00, 1.01), all-cause hospitalization (RR, 1.00; 95% CLs, 1.00, 1.01), and hospitalization for specific causes were similar between resident-trials in NHs that decreased vs maintained/increased antipsychotic use. Use of antidepressants, anxiolytic/sedative-hypnotics, anticonvulsant/mood stabilizers, and antidementia medications was slightly higher among resident-trials in NHs that decreased antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

Decreases in NH antipsychotic use do not appear to improve resident outcomes. Intensive initiatives focused predominantly on achieving a decrease in antipsychotic use may not be effective at improving mortality and hospitalization outcomes for residents with Alzheimer's disease and related dementias. These findings suggest the need for better strategies that incorporate safe and effective nonpharmacological or pharmacological alternatives for managing neuropsychiatric symptoms of dementia.

Detecting Agitated Behaviors in Nursing Home Residents With Dementia Using Electronic Medical Records

OBJECTIVES

Agitated behaviors (behaviors) are common in nursing home (NH) residents with Alzheimer's disease and related dementias (ADRD). Pragmatic trials of behavior management interventions rely on routinely collected Minimum Data Set (MDS) data to evaluate study outcomes, despite known underreporting. We describe a method to augment MDS-based behavioral measures with structured and unstructured data from NH electronic medical records (EMR).

DESIGN

Repeated cross-sectional analyses of EMR data from a single multistate NH corporation.

SETTING AND PARTICIPANTS

Long-stay residents (at least 90 days in NH) with ADRD from January 2020 through August 2022.

METHODS

Quarterly and annual assessments of NH residents with ADRD during the study period were identified. For MDS, any behavior was defined as a score of 1 or higher on the Agitated and Reactive Behavior Scale. For structured EMR data, any behavior was defined as increased resident agitation, verbal aggression, or physical aggression on the Interventions to Reduce Acute Care Transfers, Change in Condition form (INTERACT). For unstructured EMR data, any behavior was defined using keyword searches of free-text orders.

RESULTS

A total of 77,936 MDS assessments for 19,705 long-stay residents with ADRD in 322 NHs were identified; 14.8% (SD 35.6) of residents had behaviors per month using MDS alone, 16.2% (SD 36.9) using MDS and INTERACT, and 18.6% (SD 38.9) using MDS, INTERACT, and orders. Supplementing MDS with EMR data increased behavior identification by 3.8 percentage points (a 25.7% relative increase). Less than 0.5% had behaviors noted in all 3 sources consistently across study months.

CONCLUSIONS AND IMPLICATIONS

Using EMR data increased detectable behaviors vs the MDS alone. The 3 sources captured different types of behaviors and using them together may be a more comprehensive identification strategy. These results are important for better targeting of interventions and allocation of resources to improve the quality of life for NH residents with ADRD-related behaviors.

An integrative systematic review of nurses' involvement in medication deprescription in long-term healthcare settings for older people

Background

Deprescription of medications for older people in long-term care settings is crucial to enhance medication safety by reducing polypharmacy and minimizing related adverse events. Nurses as the member of the multidisciplinary healthcare team can support deprescription initiatives, but there is a gap in comprehensive knowledge about their roles.

Objectives

To investigate the role and contribution of nurses in deprescribing medications within the multidisciplinary pharmaceutical care context of long-term healthcare for older people.

Design

A systematic review utilizing an integrative approach was performed.

Methods

Multiple databases were searched, including PubMed (covering MEDLINE), Scopus, CINAHL, ProQuest and Embase, focusing on studies published in English from 2014 to 2024. The preliminary search yielded 4872 studies, which were then refined to 32 qualitative and quantitative studies chosen for data analysis and narrative synthesis. Thematic comparisons and analysis led to the creation of meaningful categories integrating the studies' findings to meet the review's objective.

Results

The review findings were classified into categories: 'necessity and benefits of deprescribing', 'multidisciplinary collaboration for deprescribing', 'nurse role in deprescribing', 'identified challenges to deprescribing', 'involvement of older people and families in deprescribing'. They illustrated and exemplified various aspects of nurses' roles and contributions in deprescription initiatives within the multidisciplinary pharmaceutical care team, such as support for reducing doses, discontinuing medications or transitioning to safer alternatives, as well as factors influencing this process.

Conclusion

The main dimensions of nurses' roles and contributions in deprescription initiatives encompass monitoring, communicating and educating. Challenges to nurses' active participation in deprescribing, such as the need for increased knowledge, confidence and inclusion in team discussions, should be addressed through education, training and changing attitudes. These steps are essential for improving the safety of medication deprescribing in long-term care settings.

Trial registration

The review was registered under PROSPERO ID: CRD42023486484, and can be accessed at crd.york.ac.uk/PROSPERO/display_record.php?RecordID=486484.

Site-level factors affecting nursing home implementation of a personalized music intervention: Qualitative analyses from Music & Memory: A Pragmatic Trial for Nursing Home Residents with Alzheimer's Disease (METRIcAL)

BACKGROUND

Non-pharmacological interventions (NPIs) are preferred alternatives to using antipsychotic medications to manage disruptive behaviors in nursing home (NH) residents living with dementia. However, the implementation of these interventions is often complex in the NH environment. In this qualitative analysis of data from an embedded pragmatic clinical trial (ePCT) of a personalized music intervention, we describe NH-level implementation barriers and facilitators.

METHODS

In a 54-facility trial, we randomized 27 NHs from four US corporations to the personalized music intervention. In this qualitative analysis, we analyzed barriers and facilitators at 9 of the 27 intervention NHs, using (1) routinely collected data collector observations and (2) semi-structured interviews with NH staff. We iteratively developed codes to best describe these data and generated themes.

RESULTS

We found five qualitative themes related to the variation of intervention implementation across NHs: (1) turnover and institutional changes interfered with implementation; (2) consistent with pragmatic implementation, delivery strategies varied across NHs; (3) family members influenced residents' participation; (4) non-clinical program champions needed clinical buy-in, which was challenging and required demonstrating the intervention's clinical benefits; and (5) technological barriers among staff and residents impeded implementation.

CONCLUSIONS

Qualitative results from nine facilities participating in a NH ePCT of personalized music intervention highlight the importance of identifying an intervention's key components to ensure fidelity, while allowing the flexibility necessary for pragmatic implementation. Engaging family caregivers may improve the implementation of NPIs in the NH setting. Results may be helpful to other researchers implementing NPIs to manage neuropsychiatric symptoms for people living with dementia in NHs.

Highlights

This was a real-world trial of a personalized music for nursing home (NH) residents with dementia.Pragmatic adaptations to intervention delivery may have compromised fidelity.Family caregivers are important to the success of behavioral interventions in NHs.

Guideline Recommendations on Behavioral and Psychological Symptoms of Dementia: A Systematic Review

OBJECTIVE

To synthesize recommendations on assessing and managing behavioral and psychological symptoms of dementia (BPSDs) in existing clinical practice guidelines on dementia care to learn from and adapt recommendations to a Canadian context and language for describing BPSDs.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Moderate to high-quality clinical practice guidelines on dementia care that made 1 or more recommendations on BPSD assessment or management.

METHODS

We searched MEDLINE, Embase, JBI EBM, PsycINFO, AgeLine, and gray literature for clinical practice guidelines on dementia care making recommendations on BPSD, published between January 1, 2011, and October 13, 2022. Two independent reviewers conducted study screening and data abstraction. Four independent reviewers completed quality appraisal using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool; included guidelines had a mean overall AGREE II score ≥4.

RESULTS

Our systematic review identified 23 moderate to high-quality clinical practice guidelines (264 recommendations). The mean overall quality score on the AGREE II tool ranged from 4 to 6.5. Recommendations were clearly presented (mean clarity of presentation score 73.5%), but guideline applicability was not consistently addressed (mean applicability score 39.3%). BPSD was the most prevalent term describing neuropsychiatric symptoms (number of guidelines [n] = 14). People with lived experience contributed to 6 guidelines (26.1%). Ten guidelines (43.5%) described 1 or more health equity considerations. Guidelines made recommendations for assessing and managing agitation (n = 12), aggression (n = 10), psychosis (n = 11), depression (n = 9), anxiety (n = 5), apathy (n = 6), inappropriate sexual behavior (n = 3), nighttime behavior (n = 5), and eating disturbances (n = 3). There was substantial variability in recommendation statements, evidence quality assigned to each statement, and strength of recommendations.

CONCLUSIONS AND IMPLICATIONS

There are several moderate to high-quality clinical practice guidelines making recommendations on BPSD assessment and management, but variability in recommendation statements across guidelines and insufficient consideration of guideline applicability may hamper guideline dissemination and implementation in clinical practice.

Therapeutic dilemma's: antipsychotics use for neuropsychiatric symptoms of dementia, delirium and insomnia and risk of falling in older adults, a clinical review

PURPOSE

Because of the common and increasing use of antipsychotics in older adults, we aim to summarize the current knowledge on the causes of antipsychotic-related risk of falls in older adults. We also aim to provide information on the use of antipsychotics in dementia, delirium and insomnia, their adverse effects and an overview of the pharmacokinetic and pharmacodynamic mechanisms associated with antipsychotic use and falls. Finally, we aim to provide information to clinicians for weighing the benefits and harms of (de)prescribing.

METHODS

A literature search was executed in CINAHL, PubMed and Scopus in March 2022 to identify studies focusing on fall-related adverse effects of the antipsychotic use in older adults. We focused on the antipsychotic use for neuropsychiatric symptoms of dementia, insomnia, and delirium.

RESULTS

Antipsychotics increase the risk of falls through anticholinergic, orthostatic and extrapyramidal effects, sedation, and adverse effects on cardio- and cerebrovascular system. Practical resources and algorithms are available that guide and assist clinicians in deprescribing antipsychotics without current indication.

CONCLUSIONS

Deprescribing of antipsychotics should be considered and encouraged in older people at risk of falling, especially when prescribed for neuropsychiatric symptoms of dementia, delirium or insomnia. If antipsychotics are still needed, we recommend that the benefits and harms of antipsychotic use should be reassessed within two to four weeks of prescription. If the use of antipsychotic causes more harm than benefit, the deprescribing process should be started.

Comparative Risk of Harm Associated with Zopiclone or Trazodone Use in Nursing Home Residents: a Retrospective Cohort Study in Alberta, Canada

Background

There is growing evidence of harm associated with trazodone and nonbenzodiazepine sedative hypnotics (e.g., zopiclone); however, their comparative risk of harm is unknown.

Methods

We conducted a retrospective cohort study with linked health administrative data, which enrolled older (≥66 years old) nursing home residents living in Alberta, Canada, between December 1, 2009, and December 31, 2018; the last follow-up date was June 30, 2019. We compared the rate of injurious falls and major osteoporotic fractures (primary outcome) and all-cause mortality (secondary outcome) within 180 days of first prescription of zopiclone or trazodone with cause-specific hazard models and inverse probability of treatment weights to control for confounding; primary analysis was intention-to-treat and secondary analysis was per-protocol (i.e., residents censored if dispensed the other exposure drug).

Results

Our cohort included 1,403 residents newly dispensed trazodone and 1,599 residents newly dispensed zopiclone. At cohort entry, the mean resident age was 85.7 (standard deviation [SD] 7.4), 61.6% were female, and 81.2% had dementia. New zopiclone use was associated with similar rates of injurious falls and major osteoporotic fractures (intention-to-treat-weighted hazard ratio 1.15, 95% confidence interval [CI] 0.90-1.48; per-protocol-weighted hazard ratio 0.85, 95% CI 0.60-1.21) and all-cause mortality (intention-to-treat-weighted hazard ratio 0.96, 95% CI 0.79-1.16; per-protocol-weighted hazard ratio 0.90, 95% CI 0.66-1.23) compared to trazodone.

Conclusions

Zopiclone was associated with a similar rate of injurious falls, major osteoporotic fractures, and all-cause mortality compared to trazodone-suggesting one medication should not be used in lieu of the other. Appropriate prescribing initiatives should also target zopiclone and trazodone.

Did the COVID-19 Pandemic Affect the Use of Antipsychotics Among Nursing Home Residents With ADRD?

OBJECTIVE

To examine whether and how the COVID-19 pandemic affected the use of antipsychotics among residents with Alzheimer's disease and related dementias in nursing homes.

DESIGN

Observational study based on the Minimum Data Set and Medicare claims.

SETTING

Medicare- and/or Medicaid-certified nursing homes.

PARTICIPANTS

Nursing home residents diagnosed with Alzheimer's disease and related dementias between 2017 and 2020.

MEASUREMENTS

The main outcome variable was any antipsychotic use during a quarter. The secondary outcome was certified nursing assistants' staffing hours per bed per day in a quarter. We categorized nursing homes into quartiles based on the distribution of nursing home racial and/or ethnic composition. To explore the relationship between the COVID-19 pandemic and the frequency of antipsychotic use, we estimated a linear probability model with robust standard errors, individual and facility random effects. We used a similar model for certified nursing assistant hours.

RESULTS

About 23.7% of residents with ADRD had antipsychotic uses during the study period. The frequency of antipsychotic use declined from 23.7%-23.1% between the first quarter of 2017 (2017Q1) and the first quarter of 2020 (2020Q1) but increased to 24.8% by the last quarter of 2020 (2020Q4). Residents in all four racial and/or ethnic groups experienced an increase in antipsychotic use during the COVID-19 pandemic, but the extent of the increase varied by race and/or ethnicity. For example, while residents in the very-high minority nursing homes experienced a greater increase in antipsychotic use than did the residents of other nursing homes at the beginning of the pandemic, the increasing trend during the pandemic was smaller in the very-high minority nursing homes compared to the low-minority nursing homes (0.2 percentage points less, p<0.001, based on heteroskedasticity-robust t statistics, t = 3.67, df = 8,155,219). On average, the certified nursing assistant hours decreased from 1.8-1.7 hours per bed per day between 2017Q1 and 2020Q1, and further decreased to 1.5 hours per bed per day by 2020Q4. There was also a decreasing trend in staffing hours across all racial and/or ethnic groups during the pandemic.

CONCLUSIONS AND RELEVANCE

The COVID-19 pandemic was associated with an increase in the use of antipsychotics among nursing home residents with Alzheimer's disease and related dementias and decreased staffing of certified nursing assistants, especially among nursing homes with a high minority penetration. Future research is needed to explore means for reducing antipsychotic use, particularly in homes with a high penetration of minority residents.

Determinants of regulatory compliance in health and social care services: A systematic review using the Consolidated Framework for Implementation Research

BACKGROUND

The delivery of high quality care is a fundamental goal for health systems worldwide. One policy tool to ensure quality is the regulation of services by an independent public authority. This systematic review seeks to identify determinants of compliance with such regulation in health and social care services.

METHODS

Searches were carried out on five electronic databases and grey literature sources. Quantitative, qualitative and mixed methods studies were eligible for inclusion. Titles and abstracts were screened by two reviewers independently. Determinants were identified from the included studies, extracted and allocated to constructs in the Consolidated Framework for Implementation Research (CFIR). The quality of included studies was appraised by two reviewers independently. The results were synthesised in a narrative review using the constructs of the CFIR as grouping themes.

RESULTS

The search yielded 7,500 articles for screening, of which 157 were included. Most studies were quantitative designs in nursing home settings and were conducted in the United States. Determinants were largely structural in nature and allocated most frequently to the inner and outer setting domains of the CFIR. The following structural characteristics and compliance were found to be positively associated: smaller facilities (measured by bed capacity); higher nurse-staffing levels; and lower staff turnover. A facility's geographic location and compliance was also associated. It was difficult to make findings in respect of process determinants as qualitative studies were sparse, limiting investigation of the processes underlying regulatory compliance.

CONCLUSION

The literature in this field has focused to date on structural attributes of compliant providers, perhaps because these are easier to measure, and has neglected more complex processes around the implementation of regulatory standards. A number of gaps, particularly in terms of qualitative work, are evident in the literature and further research in this area is needed to provide a clearer picture.

Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland

INTRODUCTION

The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective.

METHODS

A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework.

RESULTS

Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process.

CONCLUSION

Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.

Identification of Potentially Inappropriate Medications in Frail Older Adults Residing in Long-Term Care: A Retrospective Chart Review Study

INTRODUCTION

Deprescribing is associated with positive health outcomes for older adults in long-term care (LTC), however deprescribing is not universally implemented.

OBJECTIVE

The primary aim of this study was to estimate the prevalence of potentially inappropriate medications (PIMs) prescribed to frail older adults in Irish long-term care facilities (LTCFs), as identified by the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy, version 2 (STOPPFrail v2).

METHODS

A retrospective chart review was conducted in two publicly funded LTCFs in Ireland. Eligible participants were those (1) ≥ 65 years of age; (2) resident in a LTCF; (3) eligible as per the STOPPFrail v2 criteria by the site's Medical Officer; and (4) receiving regular medication. Data collected included age, sex, drug, dose, frequency, regular/pro re nata prescribing and indication/relevant diagnoses. Rates of polypharmacy (taking five or more medications) and excessive polypharmacy (taking 10 or more medications) were calculated. STOPPFrail v2 was used to identify PIMs; however, clinical measurements were not taken. Descriptive and association statistics were calculated.

RESULTS

Of the 103 residents, 89 were ≥ 65 years of age and categorised as frail and were therefore eligible for inclusion in the study. Of those eligible, 85 (95.5%) had polypharmacy and 57 (64%) experienced excessive polypharmacy. The mean number of regular medications was 10.8 (± 3.8), total medications 17.7 (± 5) and diagnoses 5.5 (± 2.5). The mean number of PIMs per resident was 4.8 (± 2.6). Of the eligible participants, 59.6% had at least one medicine without a documented indication, while 61.8%, 42.7% and 30.3% had at least one PIM from the vitamin D, antihypertensives and proton pump inhibitors drug classes, respectively.

CONCLUSION

Medication and PIM use was high among LTC residents, with inappropriate polypharmacy of concern. Lack of clear indication for prescribing medications appears to be an issue in LTC, potentially affecting healthcare professionals' engagement with deprescribing. The prevalence of PIMs may be overestimated in the antihypertensives/antidiabetic classes due to the lack of clinical measurements.

Perspectives of residents on shared decision making in medication management: A qualitative study

OBJECTIVES

Shared decision making is the process in which the person, their representative, and health care professional share information with each other, participate in the decision-making process, and agree on a course of action. At present, very little is known about shared decision making (SDM) in medication management from the perspective of long-term care facility residents. The objective of this study was to identify residents' beliefs, motivation, and aspects of the environment that facilitate or impede SDM.

DESIGN

A qualitative study was conducted using face-to-face semi-structured interviews, and data analysis was carried out using a thematic approach.

SETTING

Six long-term care facilities in Sydney, Australia.

PARTICIPANTS

Thirty-one residents.

RESULTS

Enablers to resident involvement in SDM were resident beliefs in exercising their right to take part in medication-related decisions, preference to maintain control over decisions, and motivation to raise concern about medication. Residents were not motivated to be involved in SDM if they believed they had no control over life circumstance, perceived that medications were necessary, or experienced no problems with their medications. Participation in SDM was hindered by limitations in opportunities for resident involvement, engagement with staff and primary care physician to discuss issues related to medications, and continuity of care with their regular physician.

CONCLUSION

This study highlights that the residents' beliefs in control over decisions and concerns about medication are a significant function of the SDM process. It is important that residents are given the choice to take part in SDM, their beliefs and values regarding SDM are understood, and the culture of the care facility respects residents' right to participate in SDM.

Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes

OBJECTIVE

The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA.

METHODS

The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018.

RESULTS

Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%.

CONCLUSIONS

Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia

OBJECTIVES

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.

DESIGN

A mixed-methods study was performed.

SETTING AND PARTICIPANTS

During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.

METHODS

Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.

RESULTS

Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

OBJECTIVE

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.

METHODS

The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.

RESULTS

The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.

CONCLUSION

Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Barriers and enablers to deprescribing in long-term care facilities: a 'best-fit' framework synthesis of the qualitative evidence

INTRODUCTION

older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers' (HCWs) engagement with deprescribing in LTCFs.

METHODS

the 'best-fit' framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers.

RESULTS

of 655 records identified, 14 met the inclusion criteria. The 'best-fit' framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an 'established hierarchy' within LTCFs, negatively affecting communication and insufficient resources which limited HCWs' engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients' condition to influence decisions.

DISCUSSION

this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.

Strengthening Resident, Proxy, and Staff Engagement in Injury Prevention in Skilled Nursing Facilities

BACKGROUND AND OBJECTIVES

Engaging residents, their proxies, and skilled nursing facility (SNF) staff through effective communication has potential for improving fall-related injury prevention. The purpose of this study was to understand how multiple stakeholders develop and communicate fall-related injury prevention plans to enhance sustained implementation.

RESEARCH DESIGN AND METHODS

Descriptive qualitative study using framework analysis applied to open-ended semistructured interviews (n = 28) regarding experiences of communication regarding fall-related injury prevention, guided by the Patient and Family Engaged Care framework. Participants included residents at high risk of injury and their proxies, nursing assistants, nurses, and a nurse practitioner from 3 SNFs in the Eastern United States (Massachusetts and North Carolina).

RESULTS

Interdisciplinary teams were viewed as essential for injury prevention. However, the roles of the interdisciplinary team members were sometimes unclear. Communication structures were often hierarchical, which reduced engagement of nursing assistants and frustrated proxies. Practices that enhanced engagement included knowing the residents, active listening skills, and use of strategies for respecting autonomy. Engagement was inhibited by time constraints, lack of proactive communication among staff, and by challenges eliciting the perspectives of residents with dementia. Resident barriers included desire for autonomy, strong preferences, and language differences.

DISCUSSION AND IMPLICATIONS

Strengthening team meeting processes and cultivating open communication and collaboration could facilitate staff, resident, and proxy engagement in injury prevention planning and implementation. Skill building and targeting resources to improve communication can address barriers related to staff practices, resident characteristics, and time constraints.

What Makes Deprescription of Psychotropic Drugs in Nursing Home Residents with Dementia so Challenging? A Qualitative Systematic Review of Barriers and Facilitators

Background

Behavioral and psychological symptoms of dementia are frequently experienced in the nursing home setting and place a substantial burden on patients, relatives, and nursing home staff. Despite guidelines recommending non-pharmacological treatments, psychotropic drugs are often prescribed to address these symptoms. This is the case despite their effects being limited, and there being a risk of side effects and adverse events for the patient. Several studies have aimed to reduce the use of psychotropic drugs, with varying results. The reasons behind these variations are not well understood.

Objectives

The objective of this systematic review was to investigate which factors nursing home general practitioners and nursing home staff experience as barriers or facilitators when attempting to deprescribe psychotropic drugs in nursing home residents.

Methods

We searched PubMed, EMBASE, psycINFO, Web of Science, and CINAHL between April and September 2020. An inductive method using thematic analysis of the qualitative findings was applied for the derivation of themes. Quantitative studies were included but described descriptively and separately.

Results

Of 8204 unique records, 14 studies were included in the review. Of these, nine were interview or focus group studies and five were survey studies. Thematic analysis resulted in five major themes identified as either facilitators or barriers or both: (1) ‘Operationality and routines’; (2) ‘Lack of resources and qualifications’; (3) ‘Patient-related outcomes’, which points to a strong belief in negative patient-related outcomes of discontinuation and a downplay of side effects of the medication; (4) ‘Policies’, including support and buy-in from nursing home leadership; and (5) ‘Collaboration’ between physicians and nursing home staff. Themes 1 and 4 consist of facilitators. Theme 2 consists of barriers. Theme 3 and 5 consist of both facilitators and barriers. Evaluation of closed-ended questions from the surveys supported the findings.

Conclusions

Deprescribing psychotropic drugs used for behavioral and psychological symptoms of dementia in nursing home residents is challenging. Resources need to be in place for deprescribing, as well as there being a focus on the positive patient-related outcomes of doing so. Managerial support, staff routines, and interprofessional collaboration are some factors facilitating the process, in addition to there being routines and systematic procedures in place allowing for operationality and a common understanding. Addressing these barriers and facilitators is necessary to ensure that deprescribing can be understood as meaningful and pursued among healthcare professionals in the nursing home setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00875-1.

Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff

BACKGROUND

Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications.

OBJECTIVE

The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents.

METHODS

A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics.

RESULTS

A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression.

CONCLUSIONS

To successfully and sustainably optimise medication use in RACF residents, it is important to consider the variation in views of nurses and care staff.

Effect of a multimethod quality improvement intervention on antipsychotic medication use among residents of long-term care

BACKGROUND

Antipsychotic medications are used to address neuropsychiatric symptoms associated with dementia. Evidence suggests that among older adults with dementia, their harms outweigh their benefits. A quality improvement initiative was conducted to address inappropriate antipsychotic medication use in long-term care (LTC) in the province of Alberta.

METHODS

We conducted a multimethod evaluation of the provincial implementation of the project in 170 LTC sites over a 3-year project period incorporating a quasi-experimental before-after design. Using a three-component intervention of education and audit and feedback delivered in a learning workshop innovation collaborative format, local LTC teams were supported to reduce the number of residents receiving antipsychotic medications in the absence of a documented indication. Project resources were preferentially allocated to supporting sites with the highest baseline antipsychotic medication use. Changes in antipsychotic medication use, associated clinical and economic outcomes, and the effects of the project on LTC staff, physicians, leaders and administrators, and family members of LTC residents were assessed at the conclusion of the implementation phase.

RESULTS

The province-wide initiative was delivered with a 75% implementation fidelity. Inappropriate antipsychotic medication use declined from 26.8% to 21.1%. The decrease was achieved without unintended consequences in other outcomes including physical restraint use or aggressive behaviours. The project was more expensive but resulted in less inappropriate use of antipsychotics than the pre-project period (incremental cost per inappropriate antipsychotic avoided of $5 678.71). Accounts from family, organisational leaders, and LTC staff were supportive of the project activities and outcomes.

CONCLUSION

This quality improvement initiative was successfully delivered across an entire delivery arm of the continuing care sector. Quality of care in LTC was improved.

Trends in antipsychotic prescribing among long-term care residents receiving hospice care

IMPORTANCE

The Centers for Medicare & Medicaid Services' (CMS) National Partnership to Improve Dementia Care in Nursing Homes ("CMS National Partnership") focuses on reducing antipsychotic prescribing to long-term care residents. Hospice enrollment is not an exclusionary condition for the antipsychotic quality measure reported by CMS. It is unclear how prescribing in hospice may have been impacted by the initiative.

OBJECTIVE

Estimate the association of the CMS National Partnership with trends in antipsychotic prescribing among long-term care residents in hospice.

DESIGN

Interrupted time-series analysis of a 100% Minimum Data Set sample with linked hospice claims from 2011 to 2017.

SETTING

Long-term care nursing facilities.

PARTICIPANTS

Older adults ≥65 residing in long-term care (n = 3,741,379) and limited to those enrolled in hospice (n = 821,610).

MAIN OUTCOME

Quarterly prevalence of antipsychotic and other psychotropic (antianxiety, hypnotic, antidepressant) use among long-term care residents; overall and among residents with dementia, stratified by hospice enrollment.

RESULTS

From 2011 to 2017, parallel declines in antipsychotic prescribing were observed among long-term care residents enrolled and not enrolled in hospice (hospice: decline from 26.8% to 18.7%; non-hospice: decline from 23.0% to 14.4%). Following the 2012 CMS National Partnership, quarterly rates of antipsychotic prescribing declined significantly for both residents enrolled and not enrolled in hospice care. Declines in antipsychotic prescribing were greater for residents with dementia, with similar rates among residents enrolled and not enrolled in hospice. Among residents with dementia enrolled in hospice, use of other psychotropic medication classes including antianxiety, antidepressant, and hypnotic use remained relatively stable over time.

CONCLUSIONS AND RELEVANCE

Declines in antipsychotic prescribing during the CMS National Partnership occurred among long-term care residents in hospice, where use may be deemed clinically appropriate. Nursing homes are an important location for the provision of dementia end-of-life care and the drivers of potentially unintended reductions in antipsychotic use merits further investigation.

A qualitative exploration of factors contributing to non-guideline adherent antipsychotic polypharmacy

BACKGROUND

Antipsychotic polypharmacy ("polypharmacy") involves the concurrent prescribing of two or more antipsychotics for managing schizophrenia. It occurs frequently despite there being limited clinical evidence for this practice and an increased risk of adverse events. Little is understood about why it occurs outside of treatment guidelines, highlighting a current research gap.

OBJECTIVE

To explore the factors contributing to non-evidence based polypharmacy practice and possible strategies for addressing these factors.

METHODS

Three focus groups were conducted between June and August 2018 with doctors and nurses employed at a mental health unit of a Western Australian public hospital. Participants were asked about their perceptions of polypharmacy, why it occurred and what could limit its prevalence. Thematic inductive analysis was mapped to the Theoretical Domains Framework to identify key underlying themes and to establish potential enablers and barriers for practice change.

RESULTS

Participants understood the risks of polypharmacy and perceived it to largely be perpetuated by external factors, out of which two key themes emerged: system-related issues (e.g.: communication failures whereby de-prescribing plans are not actioned); and patient-related issues (e.g.: misinformed views translating to medication-seeking behaviour). This led to the third theme: a disconnect between clinicians' knowledge and their practices (i.e.: being aware of Australian evidence-based guideline recommendations yet acknowledging polypharmacy still occurred due to the aforementioned issues). Strategies suggested to address these issues included developing medication management plans to bridge communication gaps and managing patients' medication expectations with education.

CONCLUSIONS

Management of schizophrenia is complex, requiring consideration of many patient-related and systemic factors. Polypharmacy has a place in certain contexts, however, must be well considered and closely monitored to allow for early identification of opportunities to rationalise (i.e.: de-prescribe) therapy, where appropriate. Future research objectives will centre on implementing strategies identified from these focus groups to optimise patient outcomes.

Mental health professionals' views and experiences of antipsychotic reduction and discontinuation

BACKGROUND

The widely established treatment for psychosis is long-term antipsychotic medication. However, many people stop taking this treatment, and request other options. There are also growing concerns about adverse effects, but currently no professional guidelines to support reducing or stopping these drugs. The views and experiences of individual mental health professionals around reducing and stopping antipsychotics are therefore crucial in treatment decisions.

METHODS

We conducted 7 focus groups with prescribing psychiatrists and other members of community-based statutory mental health services in London. Participants discussed their views about, experiences, and processes of antipsychotic reduction and discontinuation. Data were analysed using thematic analysis.

RESULTS

Participants acknowledged that antipsychotics can have severe adverse effects. They were generally supportive of trying to reduce these drugs to the lowest effective dose, although stopping antipsychotics was less acceptable. Prior experiences of adverse events after reduction or discontinuation meant that both were approached with caution. Reduction was also reported to be hampered by organisational and knowledge barriers. Lack of resources, pressure to discharge, and poor continuity of care were seen as organisational barriers. Knowledge barriers included inadequate evidence about who might be best suited to reduction, and lack of guidance about how this could be done safely. This meant that reduction was often prompted by patients, and sometimes actively discouraged, and stability with maintenance treatment was often favoured.

CONCLUSIONS

Concerns about risk and other barriers means that clinicians are often reluctant to implement reduction or discontinuation of antipsychotic medication. In order to increase the treatment options available to service users, more research and guidance on how to minimise the risks of antipsychotic reduction and discontinuation is required to enable clinicians to engage more constructively with service users requests, offering people more choice and control in managing their mental health condition.

Nurses' and Care Workers' Perception of Care Quality in Japanese Long-Term Care Wards: A Qualitative Descriptive Study

Despite the growing importance of long-term care for older adults, there has been limited attention to its quality assurance issues in Japan. To start planning the initiation of continuous quality improvement in long-term care hospitals, we explored how nurses and care workers themselves perceived current approaches to quality assurance and improvement on their ward. We interviewed 16 licensed nurses and nine care workers, transcribed and analyzed data using qualitative content analysis techniques, and derived six categories: keeping clients alive is barely possible, the absence of a long-term care practice model, the lack of quality indicators, long-term care hospitals as places for castaways, client quality of life as a source of satisfaction, and conflict between staff and client well-being. To develop continuous quality improvement in Japanese long-term care hospitals, it may be first necessary to introduce a practice model of long-term care and mechanisms to evaluate quality.

Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool©. A development and content validation study

INTRODUCTION

Psychotropic medicines are often prescribed in nursing homes to manage behavioral and psychological symptoms of dementia despite marginal clinical effects alongside harmful adverse events. Organizational culture has been identified as a key factor that contributes to the high-level prescribing of psychotropic medicines in nursing homes. There are gaps in existing tools used to link organizational culture to the use of psychotropic medicines. The aim of this research was to develop and content validate a tool that evaluates organizational culture specific to the use of psychotropic medicines, named the Psychotropic medicines use in Residents And Culture: Influencing Clinical Excellence (PRACTICE) tool^©.

METHODS

Schein's theory of organizational culture was used to guide the development and content validation of the PRACTICE tool^©. The PRACTICE tool^© was developed based on a comprehensive systematic review, qualitative research and generated by the research team. Content validity was assessed using the CVI (Content Validity Index). The content relevance and importance of the PRACTICE tool^© items were rated by an expert panel with relevant knowledge and experience. Any modified or re-worded items were presented to the panel members in a subsequent survey for re-rating.

RESULTS

Across the two rounds, the PRACTICE tool^© had 68 items that assessed all aspects of culture according to Schein's theory. Sixty-two items out of 68 (91%) met predefined cut-off values (≥0.78) for the I -CVI. The remaining six items (9%) did not fully meet the cut-off values but were deemed important to be included in the tool based on the systematic review, qualitative research and discussions with the research team.

CONCLUSIONS

The PRACTICE tool^© is a step forward in validating an instrument that will help inform managers and policy makers to identify target areas for improvement to create a culture of appropriate psychotropic prescribing in nursing homes.