The impact of facility characteristics on the use of antipsychotic medications in nursing homes: a cross-sectional study

COVID-19 Factors Associated With Medication Changes Among Nursing Home Residents With Dementia

This study examined associations of COVID-19 mortality rates, staffing, and resident behavior with changes in antidementia and psychotropic medication initiation among nursing home (NH) residents with dementia. A nationally representative survey of Directors of Nursing was analyzed to assess changes in medication initiation at the peak of the pandemic. NHs with higher COVID-19 mortality rates were less likely to report increases in antidementia medication initiation. COVID-19 mortality rates were not associated with significant increases or decreases in psychotropic initiation. NH's that reported increased resident behavioral problems during the pandemic had higher odds of psychotropic initiation. In summary, NHs most affected by COVID-19 deaths were less likely than NHs with a milder pandemic experience to increase initiation of antidementia medications. Increased behavioral symptoms, possibly due to consequences of COVID-19, were associated with more psychotropic drug use. More research is needed to understand factors influencing prescribing practices during public health emergencies.

The impact of patient-facility language discordance on potentially inappropriate prescribing of antipsychotics in long-term care home in Ontario, Canada: a retrospective population health cohort study

BACKGROUND

Appropriate use of medication is a key indicator of the quality of care provided in long-term care (LTC). The objective of this study was to determine whether resident-facility language concordance/discordance is associated with the odds of potentially inappropriate prescribing of antipsychotics (PIP-AP) in LTC.

METHODS

We conducted a population-based, retrospective cohort study of LTC residents in Ontario, Canada from 2010 to 2019. We obtained resident language from standardized resident assessments, and derived facility language by determining the proportion of residents belonging to each linguistic group within individual LTC homes. Using linked administrative databases, we identified all instances of PIP-AP during a 1-year follow-up period. PIP-AP was defined using the STOPP-START criteria, which have previously been shown to predict adverse clinical events such as emergency department (ED) visits and hospitalizations. The association between linguistic factors and PIP-AP was assessed using adjusted multivariable logistic regression analysis.

RESULTS

We identified 198,729 LTC residents consisting of 162,814 Anglophones (81.9%), 6,230 Francophones (3.1%), and 29,685 Allophones (14.9%). The odds of PIP-AP of were higher for both Francophones (aOR 1.15, 95% CI 1.08-1.23) and Allophones (aOR 1.11, 95% CI 1.08-1.15) when compared to Anglophones. When compared to English LTC homes, French LTC homes had greater odds of PIP-AP (aOR 1.12, 95% CI 1.05-1.20), while Allophone homes had lower odds of PIP-AP (aOR 0.82, 95% CI 0.77-0.86). Residents living in language-discordant LTC homes had higher odds of PIP-AP when compared to LTC residents living in language-concordant LTC homes (aOR 1.07, 95% CI 1.04-1.10).

CONCLUSION

This study identified linguistic factors related to the odds of PIP-AP in LTC, suggesting that the linguistic environment may have an impact on the quality of care provided to residents.

Nursing Home Characteristics Associated with Antipsychotic Prescribing After Implementation of the National Antipsychotic Reduction Initiative (ARI)

OBJECTIVES

To describe nursing home (NH) characteristics associated with antipsychotic use and test whether associations changed after implementation of the National Partnership to Improve Dementia Care's antipsychotic reduction initiative (ARI).

METHODS

Longitudinal quasi-experimental design using data from multiple sources and piecewise linear mixed models were used for statistical analyses.

RESULTS

There was a significant decrease in monthly antipsychotic use across the study period (pre-ARI b = -0.0003, p <.001; post-ARI b = -0.0012, p <.001), which held after adjusting for NH characteristics. Registered nurse hours (b = -0.0026, p <.001), licensed practical nurse hours (b = -0.0019, p <.001), facility chain membership (b = -0.0013, p <.01), and health inspection ratings (b = -0.0003, p >.01) were associated with decreased antipsychotic use. Post-ARI changes in associations between NH characteristics and antipsychotic use were small and not statistically significant.

CONCLUSIONS

Decreases in antipsychotic use were associated with most NH characteristics, and associations persisted post-ARI. Further research is warranted to examine the interactions between ARI policy and NH characteristics on antipsychotic prescribing, as well as other NH factors, such as facility prescribing cultures and clinical specialty of staff.

CLINICAL IMPLICATIONS

Decreases in monthly antipsychotic use were observed following the ARI. The decreases in monthly antipsychotic use were associated with most NH characteristics, and these associations persisted during the post-ARI period.

Association Between Long-Term Care Facility Staffing Levels and Antipsychotic Use in US Long-Term Care Facilities

OBJECTIVES

Inappropriate use of antipsychotics is an indicator of quality of care in long-term care (LTC) facilities. There is evidence to suggest that staffing levels in LTC may be associated with the rates of inappropriate antipsychotic use. This study sought to examine the association between staffing and antipsychotic prescribing in LTC facilities.

DESIGN

Cross-sectional study investigated the association between reported staffing levels and the frequency of inappropriate antipsychotic prescribing at US LTC facilities between 2016 and 2018.

SETTING AND PARTICIPANTS

Data from the Nursing Home Compare and LTCFocus datasets were linked, which contain information from the Minimum Data Set database on facility characteristics and staffing measures from the Payroll-Based Journal system. A final sample set of 10,436 facilities was used.

METHODS

Descriptive statistics were calculated for all variables of interest. An unadjusted linear correlation analysis and linear regression were performed. Potential confounders were investigated by comparison across low-vs high-staffing facilities where adjusted for in regression analyses.

RESULTS

The mean staff level for the facilities was identified as 3.69 (SD = 0.67) staffing hours per patient per day, and the mean antipsychotic use rate across all facilities was 15.24% (SD = 8.62%). There was a 0.75% decrease in inappropriate antipsychotic prescribing per unit increase in overall staff-to-patient ratio. When looking at staffing types, a 3.09% decrease in inappropriate antipsychotic prescribing per unit increase in licensed staff hours. More specifically, we saw a 2.25% decrease per unit increase in RN staffing hours, a 1.83% decrease per unit increase in LPN staffing hours, and nursing aide staffing hours were not associated with antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

These findings provide support for policy-based interventions to decrease antipsychotic use in LTC facilities by improving staffing skill mix and staffing levels. The results may also inform nursing staff education and training on antipsychotic prescribing practices.

A Canadian Cohort Study to Evaluate the Outcomes Associated with a Multicenter Initiative to Reduce Antipsychotic Use in Long-Term Care Homes

OBJECTIVES

To evaluate the impact of a multicenter intervention to reduce potentially inappropriate antipsychotic use in Canadian nursing homes at the individual and facility levels.

DESIGN

Longitudinal, population-based cohort study to evaluate the Canadian Foundation for Healthcare Improvement's Spreading Healthcare Innovations Initiative to reduce potentially inappropriate antipsychotic use in 6 provinces/territories.

SETTING AND PARTICIPANTS

Adults in nursing homes in 6 provinces/territories in Canada between 2014 and 2016. The sample involved 4927 residents in 45 intervention homes and 122,570 residents in 1193 control homes in the first quarter of the study.

MEASURES

Assessment data based on the Resident Assessment Instrument 2.0 were used in both settings to track antipsychotic use and to obtain risk-adjusters for a quality indicator on potentially inappropriate use.

INTERVENTION

Quality improvement teams in participating organizations were provided with education, training, and support to implement localized strategies intended to reduce antipsychotic medication use in residents without diagnosis of psychosis.

RESULTS

At the resident level, we found that the odds of remaining on potentially inappropriate antipsychotics were 0.75 in intervention compared with control homes after adjusting for age, sex, aggressive behavior, and cognition. These findings were evident within the pooled Canadian data as well as within provinces. At the facility level, the intervention homes had greater improvements in risk-adjusted quality indicator performance than the control homes, and this was true for the worst, median, and best-performing homes at baseline. There was no major change in the quality indicator for worsening of behavior symptoms.

CONCLUSIONS/IMPLICATIONS

The Canadian Foundation for Healthcare Improvement intervention was associated with a reduction in potentially inappropriate antipsychotic use at both the individual and facility levels of analysis. This improvement in performance was independent of secular trends toward reduced antipsychotic use in participating provinces. This suggests that substantial improvements in medication use may be achieved through targeted, collaborative quality improvement initiatives in long-term care.

Use of Central Nervous System (CNS) Medicines in Aged Care Homes: A Systematic Review and Meta-Analysis

BACKGROUND

Both old age and institutionalization in aged care homes come with a significant risk of developing several long-term mental and neurological disorders, but there has been no definitive meta-analysis of data from studies to determine the pooled estimate of central nervous system (CNS) medicines use in aged care homes. We conducted this systematic review to summarize the use of CNS drugs among aged care homes residents.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and International Pharmaceutical Abstracts (IPA) databases were searched (between 1 January 2000 and 31 December 2018) to identify population-based studies that reported the use of CNS medicines in aged care homes. Pooled proportions (with 95% confidence interval), according to study location were calculated.

RESULTS

A total of 89 studies reported the use of CNS medicines use in aged care. The pooled estimate of CNS drugs use varied according to country (from 20.3% in Ireland to 49.0% in Belgium) and region (from 31.7% in North America to 42.5% in Scandinavia). The overall pooled estimate of psychotropic medicines use was highest in Europe (72.2%, 95% CI, 67.1-77.1%) and lowest in ANZ region (56.9%, 95% CI, 52.2-61.4%). The pooled estimate of benzodiazepines use varied widely from 18.9% in North America to 44.8% in Europe. The pooled estimate of antidepressants use from 47 studies was 38.3% (95% CI 35.1% to 41.6%) with highest proportion in North America (44.9%, 95% CI, 35.3-54.5%).

CONCLUSION

The overall use of CNS drugs varied among countries, with studies from Australia-New Zealand reported the lowest use of CNS drugs. The criteria for prescribing CNS drugs in clinical practice should be evidence-based. The criteria should be used not to prohibit the use of the listed medications but to support the clinical judgement as well as patient safety.

Fake bus stops for persons with dementia? On truth and benevolent lies in public health

Fake bus stops are one strategy to keep persons with dementia (PwD) from wandering. By setting up authentic looking shelters and benches in hallways or gardens, nursing homes create the illusion of bus stops, for the purpose of preventing wandering PwD from leaving the facility and getting lost. By attracting wandering PwD to sit down and wait for the bus, they can be supervised more easily by caregivers. However, concerns are expressed that the use of fake bus stops could cause more harm than good for PwD, due to their deceptive nature and the potential stigmatisation of individuals seated at a fake bus stop. This article discusses the ethical aspects of using fake bus stops and outlines considerations prior to setting up fake bus stops in nursing homes in keeping with good clinical practice in dementia care. Moreover, the article assesses whether or not fake bus stops can be ethically justifiable, and if so, how they can be ethically justified and implemented in Israeli and other facilities for PwD.

Prevalence and Variability in Medications Contributing to Polypharmacy in Long-Term Care Facilities

Background

Research into which medications contribute to polypharmacy and the variability in these medications across long-term care facilities (LTCFs) has been minimal.

Objective

Our objective was to investigate which medications were more prevalent among residents with polypharmacy and to determine the variability in prescribing of these medications across LTCFs.

Methods

This was a cross-sectional study of 27 LTCFs in regional and rural Victoria, Australia. An audit of the medication charts and medical records of 754 residents was performed in May 2015. Polypharmacy was defined as nine or more regular medications. Logistic regression was performed to determine the association between medications and resident characteristics with polypharmacy. Analyses were adjusted for age, sex and Charlson’s comorbidity index. Variability in the use of the ten most prevalent medication classes was explored using funnel plots. Characteristics of LTCFs with low (< 30%), moderate (30–49%) and high (≥ 50%) polypharmacy prevalence were compared.

Results

Polypharmacy was observed in 272 (36%) residents. In adjusted analyses, each of the top ten most prevalent medication classes, with the exception of antipsychotics, were associated with polypharmacy. Between 7 and 23% of LTCFs fell outside the 95% control limits for each of the ten most prevalent medications. LTCFs with ≥ 50% polypharmacy prevalence were predominately smaller.

Conclusion

Polypharmacy was associated with nine of the ten most prevalent medication classes. There was greater than fourfold variability in nine of the ten most prevalent medications across LTCFs. Further studies are needed to investigate the clinical appropriateness of the variability in polypharmacy.

Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden

BACKGROUND

Antipsychotics form a class of drugs that should be used with caution among elderly people because of a high risk of adverse events. Despite the risks and modest effects, their use is estimated to be high, especially in nursing homes.

OBJECTIVE

The aim was to explore the effects of medication reviews on antipsychotic drug use for elderly primary care patients and describe the extent of, and reasons for, the prescription of antipsychotics.

METHODS

In this cross-sectional study in primary care in Skåne, Sweden, patients aged ≥75 years living in nursing homes or in their own homes with home care were included. The effects of medication reviews were documented, as were the use of antipsychotics and the differences in characteristics between patients receiving or not receiving antipsychotics.

RESULTS

A total of 1683 patients aged 87.6 (±5.7) years were included in the analysis. Medication reviews reduced the use of antipsychotics by 23% (p < 0.001) in this study. Of the 206 patients using antipsychotics, 43% (n = 93) had an approved indication, while for 15% (n = 32) the indication was not given. Antipsychotic drug use was more common with increasing number of drugs (p = 0.001), and in nursing home residents (p < 0.01). It was also more frequent in patients with cognitive impairment, depressive symptoms or sleeping problems.

CONCLUSION

The use of antipsychotic drugs is high in elderly patients in nursing homes. They are often given for indications that are not officially approved or are poorly documented. Medication reviews appear to offer one useful strategy for reducing excessive use of these drugs.

Pragmatic trials may help to identify effective strategies to reduce nursing home antipsychotic medication use

Despite widespread agreement that nursing homes’ use of antipsychotic medications for residents without specific psychiatric diagnoses is a marker of poor quality of care, prevalence remains high. Additionally, variation suggests continued opportunity to improve care even in countries, like the United States, that have long-standing policies designed to decrease antipsychotic medication use. In a recent Israel Journal of Health Policy Research article, Frankenthal et al. presented results linking increased antipsychotic medication use prevalence in Tel Aviv nursing homes with facility characteristics, including some that “undermine quality of care,” and called for increased national focus on this area. While we agree with the authors that government focus can help to decrease antipsychotic medication use, experience in the United States shows that such efforts may not be sufficient: we present data showing significant variation among United States nursing homes’ antipsychotic medication use prevalence after more than ten years of national warnings and programs. This suggests that United States nursing home clinicians and caregivers continue to need effective non-pharmacologic interventions to substitute for antipsychotic medications. We suggest expanded use of cluster-randomized trials to test strategies to withdraw residents from antipsychotic medications and to implement alternate, non-pharmacological approaches for addressing the behavioral and psychological symptoms of dementia.