Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

DEprescribing and Care to reduce Antipsychotics in DEmentia (DECADE)-A Hybrid Effectiveness-Implementation Pilot Study

OBJECTIVES

The aim of DEprescribing and Care to reduce Antipsychotics in Dementia (DECADE) was to evaluate a multifaceted intervention to reduce antipsychotic use among nursing home residents with dementia without medication shifts (increase in the use of other psychotropic medications) or worsening Behavioral and Psychological Symptoms of Dementia (BPSD).

METHODS

From June 2022 to January 2024, a type 2 hybrid effectiveness-implementation pilot study was conducted across six Danish nursing homes. The intervention included education for general practitioners and healthcare professionals, medication reviews, and individualized care plans for 40 residents with dementia using antipsychotic medications. The data collection focused on implementation, antipsychotic use, psychotropic medication use, and BPSD. Implementation was assessed through fidelity analysis and surveys assessing providers' perceptions of the models' acceptability, appropriateness, feasibility, and healthcare providers' self-reported knowledge and competence. Changes in antipsychotic use, medication shifts, and BPSD scores measured effectiveness.

RESULTS

Fidelity was generally high, but participation in education was low. About half of the respondents considered the model appropriate and feasible. The intervention led to a significant reduction in antipsychotic use among the 40 included residents, with a decrease of 97.6 mg in olanzapine equivalents corresponding to a daily mean use of 5.9 mg olanzapine equivalents at baseline to a daily mean use of 4.8 mg, at study end (averaged reduction of 1.1 mg/day). In total, 36% of the residents achieved ≥50% reductions, and without an increase in the use of other psychotropic drugs or worsening of BPSD.

CONCLUSIONS

DECADE reduced antipsychotic use without worsening BPSD, highlighting its potential for broader applications. Multidisciplinary collaboration and ongoing education regarding antipsychotic use in dementia care are essential.

Non-pharmacological management of wandering in persons with dementia: an integrative review

BACKGROUND

Wandering behaviour affects a significant portion of dementia patients, ranging from 15% to 80%, presenting a serious safety concern and adding to caregivers' burden. Recent studies emphasise the effectiveness of non-pharmacological interventions over pharmacological ones due to their minimal side effects. Consequently, in current literature there has been a surge of interest in exploring non-pharmacological methods for managing wandering.

PURPOSE

This integrative literature review aims to deepen comprehension of wandering behaviour, presents recent studies on non-pharmacological approaches, and inspires further research in this field.

METHODS

Electronic data collection spanned from 2019 to 2024, sourcing 20 relevant articles from PubMed and Scopus databases using search terms such as 'dementia', 'Alzheimer's disease', 'wandering', and 'management'. A thematic analysis methodology was employed to identify non-pharmacological treatment themes for managing wandering. This approach involves scrutinising and synthesising themes within the dataset. Qualitative data analysis focused on significant phrases and keywords, grouping them to derive relevant themes.

RESULTS

Recent literature extensively explores non-pharmacological methods for managing wandering. These include understanding behaviours, identifying and targeting high-risk groups, facilitating safe wandering, addressing environmental factors, promoting exercise and activity, and offering caregiver support.

CONCLUSIONS

This study significantly advances understanding of wandering behaviour and highlights recent research on non-pharmacological interventions. The findings suggest the potential for providing safe and effective treatment to wandering dementia patients, thereby alleviating stress for both patients and caregivers.

Protocol for DEprescribing and Care to reduce Antipsychotics in Dementia (DECADE)-A hybrid effectiveness-implementation pilot study

INTRODUCTION

Behavioural and psychological symptoms of dementia (BPSD) should only rarely and briefly be treated with antipsychotics. Despite recommendations to the contrary, the use of antipsychotics in nursing home residents with dementia is widespread and followed by serious adverse effects. Intervention studies on methods to reduce the use of antipsychotics in persons with dementia are few and needed. The aim of this protocol is to describe the rationale and content of the intervention DEprescribing and Care to reduce Antipsychotics in DEmentia (DECADE)-a hybrid effectiveness-implementation pilot study.

MATERIALS AND METHODS

This is a protocol of a prospective hybrid effectiveness-implementation pilot study. The primary aim of DECADE is to reduce the use of antipsychotic drugs by 50% in 50% of nursing home residents with dementia while maintaining or improving BPSD. The intervention is implemented in six nursing homes including approximately 190 residents with dementia and consists of Academic Detailing, medication review, education of nursing home staff, and care plans. The evaluation of feasibility and potential effectiveness is an overall assessment of all clinical and process outcomes. Logistic regression analyses will be used to investigate factors characterizing situations with prescription of antipsychotics. BPSD is analysed with a before- and after design using self-controlled case series methods and the use of antipsychotics is analysed as interrupted time series.

DISCUSSION

This protocol describes a study that will provide an indication of DECADE effectiveness and a model for upscaling and further evaluation in a controlled design.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.

Medication Costs and Use of Older Americans in Assisted Living Settings: a Nationally Representative Cross-Sectional Study

BACKGROUND

Assisted-living (AL) settings are an important residential care option for old and disabled Americans, but there are no national data characterizing medication use in AL.

OBJECTIVE

To investigate medication costs and use of older adults living in the AL settings compared to those in the community, independent living, and nursing home settings.

DESIGN

2015 National Health and Aging Trends Study; nationally representative cross-sectional study.

PATICIPANTS

Respondents ≥ 65 years with Medicare Part D prescription drug coverage (n = 5980, representing 32.34 million older adults).

MEASURES

Total Part D medication costs; number of 30-day prescription fills; binary indicators for overall polypharmacy (≥ 5 and ≥ 10 concurrent medications), prescription fills of opioid and psychotropic medications including antipsychotics, benzodiazepines, gabapentinoids, antidepressants, and central nervous system-active (CNS-active) polypharmacy.

RESULTS

Adjusting for demographics, the annual medication costs among AL residents, at $3890, were twice as high as those of their community-dwelling counterparts ($1932; p < .01). All medication outcomes except opioids were higher for older adults in AL compared to community settings. While the adjusted number of 30-day prescription fills among AL residents was slightly lower than that of nursing home residents (89.5 vs. 106.2; p < .05), AL residents experienced equivalent rates of overall polypharmacy ≥ 10 medications (30.2% vs. 23.5%), antipsychotics (30.8% vs. 27.8%), benzodiazepines (30.7% vs. 32.6%), gabapentinoids (21.2% vs. 16.1%), and CNS-active polypharmacy (26.0% vs. 36.9%; p > .05 for all). Patterns of use across settings were consistent when limited to older adults with dementia.

CONCLUSIONS

Older Americans in AL experience a prescription medication burden similar to those in nursing homes. AL settings have an important opportunity to ensure their medication-related clinical services and supports match the needs of their residents.

Treatment patterns and clinical outcomes among Medicare beneficiaries using antipsychotic medications for FDA-approved indications before and after transitioning from the community to a nursing home

OBJECTIVES

This study examines the relationships between changes in antipsychotic medication (AP) use and acute clinical events (identified with administrative claims data) for patients with FDA-approved indications for APs following transition from the community (e.g. home) to a nursing home (NH) in a Medicare population.

METHODS

A retrospective analysis was conducted using 100% Medicare fee-for-service (FFS) research identifiable files (RIF) claims data (2016-2018). Medicare beneficiaries with a condition for which APs are approved by the FDA were examined using logistic regression models to determine whether changes in AP use following transition from community to NHs were correlated with the likelihood of experiencing acute clinical events.

RESULTS

We identified 38,448 Medicare FFS beneficiaries meeting our study criteria. A change in AP use after transition to a NH did not have a statistically significant association with acute skeletal events, coronary artery events, or cerebrovascular events (p = .55, p = .69, and p = .59, respectively).

CONCLUSIONS

Between 2016 and 2018, Medicare FFS patients with approved-use indications for APs had lower average AP use following transition to a NH. Changes in the use of other medications of interest largely followed a similar pattern, indicating that these medications did not tend to be used as substitutions for APs. No clear relationship exists between increases or decreases in AP use and adverse events among NH residents who used APs and had FDA-approved conditions in the community setting.

Implications of Adverse Outcomes Associated with Antipsychotics in Older Patients with Dementia: A 2011-2022 Update

Neuropsychiatric symptoms affect most patients with dementia over the course of the disease. They include a wide variety of symptoms from apathy and depression to psychosis, irritability, impulsivity and agitation. These symptoms are associated with significant distress to the patient and caregivers, as well as more rapid progression of dementia, institutionalisation and higher mortality. The first-line management of the neuropsychiatric symptoms of dementia should be non-pharmacological. If medications are required, antipsychotics are commonly chosen. Second-generation antipsychotics such as risperidone, olanzapine, quetiapine and aripiprazole are prescribed more often than first-generation antipsychotics, such as haloperidol. The aim of this review is to provide an update on findings on adverse outcomes and clinical implications of antipsychotic use in dementia. These medications may increase mortality and can be associated with adverse events including pneumonia, cerebrovascular events, parkinsonian symptoms or higher rates of venous thromboembolism. Risks related to antipsychotic use in dementia are moderated by a number of modifiable and non-modifiable factors such as co-prescribing of other medications, medical and psychiatric co-morbidities, and demographics such as age and sex, making individualised treatment decisions challenging. Antipsychotics have further been associated with an increased risk of reliance on long-term care and institutionalisation, and they might not be cost-effective for healthcare systems. Many of these risks can potentially be mitigated by close physical health monitoring of antipsychotic treatment, as well as early withdrawal of pharmacotherapy when clinically possible.

Non-Pharmacological Interventions for Wandering/Aberrant Motor Behaviour in Patients with Dementia

Background: Aberrant motor behaviour or wandering refers to aimless movement without a specific purpose. Wandering is common in patients with dementia and leads to early institutionalization and caregivers’ burden. Non-pharmacological interventions should be also considered as a first-line solution for the wandering because current pharmacological treatment has serious side-effects. Methods: A cross-over randomised controlled trial (RCT) with 60 participants of all stages and different types of dementia was conducted in Greece. The sample was randomly assigned in 6 different groups of 10 participants each. Every intervention lasted for 5 days, and there were 2 days as a wash-out period. There was no drop-out rate. The measurements used were the Mini Mental State Examination (MMSE), Addenbrooke’s Cognitive Examination Revised (ACE-R), Geriatric Depression Scale (GDS), Functional Rating Scale for Symptoms in Dementia (FRSSD), and Neuropsychiatric Inventory (NPI). The interventions that were evaluated were reminiscence therapy (RT), music therapy (MT), and physical exercise (PE). Results: NPI scores were reduced in the group receiving PE (p = 0.006). When MT (p = 0.018) follows PE, wandering symptoms are reduced further. RT should follow MT in order to reduce wandering more (p = 0.034). The same combination was effective for the caregivers’ burden as well; PE (p = 0.004), MT (p = 0.036), RT (p = 0.039). Conclusions: An effective combination that can reduce wandering symptoms in all stages and types of dementia was found: The best order was PH-MT-RT. The same combination in the same order reduced caregivers’ burden.