Mental illness and psychotropic medication use in the nursing home

Antipsychotic Use in Dementia

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.

Determinants for the use of psychotropics among nursing home residents

PURPOSE

To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use.

METHODS

Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics.

RESULTS

Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age.

CONCLUSIONS

Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Medication use in nursing homes for elderly people

Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions for the treatment of behavioural disturbances have been significantly reduced and non-pharmacists have a role to play in the appropriate management of medicines in elderly residents; they can improve patient care and be cost-effective. Identification of methods by which to improve awareness of inappropriate medication prescription and to avoid certain types of drugs is required. This review critically evaluates medication use in this population with specific reference to psychotropics and aims to raise awareness of the issue.

Invisible residents: the chronically mentally ill elderly in nursing homes

This article presents results from a retrospective study of psychological assessments of elderly persons with chronic mental illness residing in nursing homes. All residents (N = 570) received this assessment as part of federally mandated screening for mentally ill persons residing in long-term care. The process, the Preadmission Screening and Resident Review, was mandated by the Omnibus Budget Reconciliation Act (OBRA 87). These assessments were the first stage in a process to determine if the nursing home was the most appropriate placement for each resident. If nursing home care was deemed appropriate, then a psychological treatment program was to be established within the nursing home setting. The sample ranged in age from 50 to 104 (mean of 70). The majority had a diagnosis of schizophrenia and a history of psychiatric hospitalization occurring early in their life. The assessments did not include any quantifiable data on activities of daily living, cognitive functioning, or level of psychiatric impairment. Therefore, the researchers coded the narrative data so that it could be interpreted. The majority functioned within the none-to-mild range of cognitive impairment, and very few were completely dependent in the need for physical care. The most recorded symptom was social withdrawal. Neuroleptic medications were administered to 64% of elderly persons with chronic mental illness. Importantly, there was no relationship between demographic or clinical information and treatment recommendations. Implications of these findings for psychiatric nurses are discussed.

The use of medicines with anticholinergic effects in older people: a population study in an urban area of Sweden

OBJECTIVE

To investigate the use of medicines with anticholinergic properties among older people in an urban population in Sweden.

DESIGN

A cross-sectional survey.

SETTING

Ordinary homes, sheltered accommodations, nursing homes, and geriatric departments.

PARTICIPANTS

All residents aged 75 and older in a district of Stockholm, Sweden.

MEASUREMENTS

Structured interviews with older persons, their relatives and/or health care personnel; prescription forms; medical records.

RESULTS

The overall use of medicines with anticholinergic effects was comparatively low. Doses of these medicines were also generally low. Concurrent use of several such medicines was uncommon. The most prevalent therapeutic/pharmacological group was neuroleptics. In contrast, antidepressants were used by few older people. The prevalence of medicines with anticholinergic effects was highest at institutions, where neuroleptics were frequent and use of low-potency neuroleptics was not uncommon.

CONCLUSION

Our results indicate that the risk of anticholinergic side effects may be quite low in the present population as a whole. However, there may be grounds for revising the therapy in institutions, where the use of neuroleptics was shown to be high and low-potency neuroleptics, known to have a higher incidence of anticholinergic side effects, were not avoided.