Anticholinergic and sedative medication use in older patients with cognitive concerns

BACKGROUND

Anticholinergic (AC) and sedative medications are a risk factor for cognitive impairment. This study sought to characterize AC and sedative use in older patients seen for outpatient neuropsychological evaluation and evaluate their associations with different cognitive domains. We hypothesized that AC and sedative use would be associated with worse attention/processing speed (AP), executive functioning (EF), and memory.

METHODS

We conducted a cross-sectional chart review of 392 patients (mean [M] age = 72 ± 7.7 years, range = 54-91). Medications were characterized by number of AC medications (≥1 on the Anticholinergic Cognitive Burden Scale [ACB]), number of sedative medications, and polypharmacy (≥5 daily medications). Demographically adjusted composites were calculated for AP, EF, and memory. Bivariate Pearson correlations assessed relationships between medication use and cognition. Multivariate linear regressions evaluated significant medication-cognition associations, controlling for total medications, medical comorbidities, and estimated premorbid cognitive functioning.

RESULTS

Polypharmacy was common (80%; n = 314). Most patients (70%; n = 275) used ≥1 sedative medications (range = 0-9). Over half (63%; n = 248) used ≥1 AC drugs (range = 0-7), yet ACB scores were ≤2 in 74% of patients. Sedative use was negatively correlated with AP (r = -0.134, p = 0.008) and EF (r = -0.105, p = 0.04). ACB scores were negatively correlated with AP (r = -0.106, p = 0.037). Sedatives and a priori covariates significantly predicted AP performance (R2 = 0.127, p < 0.001); using more sedative medications was uniquely associated with worse AP (β = -0.426, p = 0.049). No significant associations were found with memory.

CONCLUSION

AC and sedative medications and polypharmacy were prevalent in this sample of older patients. Though both drug classes had negative relationships with AP and EF, sedatives had a particularly negative association with AP. Contrary to our hypotheses, memory was not associated with medication use; however, anticholinergic burden was low within the sample, and AP and EF deficits may masquerade as memory problems.

Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia

OBJECTIVES

Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups.

DESIGN

Retrospective, cross-sectional trends study.

SETTING AND PARTICIPANTS

National long-stay nursing home residents with dementia from 2011 to 2017.

METHODS

We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015).

RESULTS

Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents.

CONCLUSIONS AND IMPLICATIONS

We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.

Abstract TMP58: Rest-Activity Patterns In Post-Stroke Delirium: A Pilot Study

Background: Delirium is an acute cognitive disturbance frequently characterized by abnormal levels of motor activity and sleep-wake cycle disruption. However, the degree to which delirium affects activity patterns in the acute period after stroke is unclear. We aimed to examine these patterns in a cohort of patients with intracerebral hemorrhage (ICH).

Methods: We enrolled 40 patients with supratentorial ICH and hemiparesis who had daily delirium assessments performed by expert clinicians. Continuous measurements of activity were captured using bilateral wrist actigraphs for the duration of each patient’s admission. Activity data were collected in 1-minute intervals, with “rest” intervals defined as periods with zero activity recorded. We compared differences in activity based on delirium status across multiple time intervals using linear regression models adjusted for age, ICH severity, and mechanical ventilation.

Results: There were 312 total days of actigraphy monitoring, of which 233 (75%) were rated as days with delirium; 85% of patients (34/40) experienced delirium during their hospitalization. In multivariable analyses, delirium days were associated with 66.3 (95% CI 9.4-123.2) fewer total minutes of rest, including 6.1% (95% CI 2.3-9.9%) fewer minutes of rest during daytime periods (06:00-21:59) and 9.2% (95% CI 3.3-15.0%) fewer minutes of rest during nocturnal periods (22:00-5:59). In separate analyses for individual hourly intervals, delirium days were associated with significantly higher levels of activity across multiple consecutive time intervals, including 05:00-09:00 and 17:00-03:00. In subgroup analyses, hyperactive or mixed delirium was associated with fewer total daily minutes of rest compared to hypoactive delirium, along with lower proportions of time at rest during both daytime and nocturnal periods (4.3% [95% CI 0.5-8.0%] and 6.5% [95% CI 0.9-12.1%] lower, respectively).

Conclusion: Post-stroke delirium is associated with less rest and higher overall levels of activity, especially during nocturnal periods and in patients with hyperactive or mixed delirium.

Association Between Bisphosphonates and Hospitalized Clostridioides difficile Infection Among Frail Older Adults

OBJECTIVES

Clostridioides difficile infection is a major source of morbidity and mortality among frail older adults, especially those in nursing homes (NHs). Safety reports have signaled that bisphosphonate use may be a contributing cause. We therefore evaluated the risk of C difficile hospitalization associated with oral bisphosphonate use in the NH.

DESIGN

Observational, retrospective new-user cohort study.

SETTING

The cohort included US NH residents aged ≥65 years who became a long-stay resident (>100 days in the NH) between January 1, 2008 and December 31, 2009.

METHODS

We conducted a study of NH residents using linked Medicare claims and Minimum Data Set records. Residents were new users of an oral bisphosphonate 1:1 matched to new calcitonin users ("active" comparator) on propensity scores controlling for more than 100 covariates. The outcome was risk of hospitalization for C difficile infection in a Cox proportional hazards model adjusted for previous antibiotic and proton pump inhibitor use.

RESULTS

Our final analytical cohort included 17,753 bisphosphonate and 5348 calcitonin users. In the matched cohort, 84/5209 (1.6%) vs 71/5209 (1.4%) C difficile-related hospitalizations occurred in bisphosphonate and calcitonin users, respectively. We observed no significant difference in the risk of hospitalization among bisphosphonate users (hazard ratio: 1.11, 95% confidence interval: 0.80-1.51). Antibiotic and proton pump inhibitor exposure before and after osteoporosis treatment was also similar between bisphosphonate and calcitonin users.

CONCLUSIONS AND IMPLICATIONS

C difficile infection should not be a consideration when prescribing bisphosphonates to frail older adults given the lack of a significant association.

Influenza Illness and Hip Fracture Hospitalizations in Nursing Home Residents: Are They Related?

Background

Influenza illness may impact the risk of falls and fractures during acute illness due to unsteady gait or dizziness. We evaluated the association between influenza and hip fracture hospitalizations in long-stay (LS) nursing home (NH) residents.

Methods

We analyzed weekly rates of hospitalization in a retrospective cohort of LS NH residents between January 1, 2000 to December 31, 2009. Hip fracture and influenza like illness (ILI) hospitalizations were identified with Medicare fee-for-service part A claims. We evaluated unadjusted and adjusted models with the primary exposures, weekly rate of influenza-like illness hospitalizations, city-wide mortality, and NH influenza vaccination rate and primary outcome of weekly rate of hip fracture hospitalizations.

Results

There were 9,237 incident hip fractures in the cohort. Facility wide ILI hospitalization rate was associated with the hip fracture hospitalization rate in the unadjusted (incidence rate ratio [IRR] 1.13, 95% confidence interval [CI]: 1.08, 1.17) and adjusted (IRR 1.13, 95% CI: 1.09, 1.18) analyses. City-wide influenza mortality was associated with hip fracture hospitalization rates for the unadjusted (IRR 1.03, 95% CI: 1.02, 1.04), and adjusted (IRR 1.02, 95% CI: 1.01, 1.03) analyses. NH influenza vaccination rates were not associated with changes in hip fracture hospitalization rates.

Conclusions

ILI hospitalizations are associated with a 13% average increase in hip fracture hospitalization risk. In a given NH week, an increase in the number ILI hospitalizations from none to two was associated with an approximate one percentage point increase in hip fracture hospitalization risk. Strategies to reduce influenza risk should be investigated to reduce hip fracture risk.

Fracture Risk Assessment in Long-term Care (FRAiL): Development and Validation of a Prediction Model

Background

Strategies used to predict fracture in community-dwellers may not be useful in the nursing home (NH). Our objective was to develop and validate a model (Fracture Risk Assessment in Long-term Care [FRAiL]) to predict the 2-year risk of hip fracture in NH residents using readily available clinical characteristics.

Methods

The derivation cohort consisted of 419,668 residents between May 1, 2007 and April 30, 2008 in fee-for service Medicare. Hip fractures were identified using Part A diagnostic codes. Resident characteristics were obtained using the Minimum Data Set and Part D claims. Multivariable competing risk regression was used to model 2-year risk of hip fracture. We validated the model in a remaining 1/3 sample (n = 209,834) and in a separate cohort in 2011 (n = 858,636).

Results

Mean age was 84 years (range 65-113 years) and 74.5% were female. During 1.8 years mean follow-up, 14,553 residents (3.5%) experienced a hip fracture. Fifteen characteristics in the final model were associated with an increased risk of hip fracture including dementia severity, ability to transfer and walk independently, prior falls, wandering, and diabetes. In the derivation sample, the concordance index was 0.69 in men and 0.71 in women. Calibration was excellent. Results were similar in the internal and external validation samples.

Conclusions

The FRAiL model was developed specifically to identify NH residents at greatest risk for hip fracture, and it identifies a different pattern of risk factors compared with community models. This practical model could be used to screen NH residents for fracture risk and to target intervention strategies.

Defining hip fracture with claims data: outpatient and provider claims matter

Medicare claims are commonly used to identify hip fractures, but there is no universally accepted definition. We found that a definition using inpatient claims identified fewer fractures than a definition including outpatient and provider claims. Few additional fractures were identified by including inconsistent diagnostic and procedural codes at contiguous sites.

INTRODUCTION

Medicare claims data is commonly used in research studies to identify hip fractures, but there is no universally accepted definition of fracture. Our purpose was to describe potential misclassification when hip fractures are defined using Medicare Part A (inpatient) claims without considering Part B (outpatient and provider) claims and when inconsistent diagnostic and procedural codes occur at contiguous fracture sites (e.g., femoral shaft or pelvic).

METHODS

Participants included all long-stay nursing home residents enrolled in Medicare Parts A and B fee-for-service between 1/1/2008 and 12/31/2009 with follow-up through 12/31/2011. We compared the number of hip fractures identified using only Part A claims to (1) Part A plus Part B claims and (2) Part A and Part B claims plus discordant codes at contiguous fracture sites.

RESULTS

Among 1,257,279 long-stay residents, 40,932 (3.2%) met the definition of hip fracture using Part A claims, and 41,687 residents (3.3%) met the definition using Part B claims. 4566 hip fractures identified using Part B claims would not have been captured using Part A claims. An additional 227 hip fractures were identified after considering contiguous fracture sites.

CONCLUSIONS

When ascertaining hip fractures, a definition using outpatient and provider claims identified 11% more fractures than a definition with only inpatient claims. Future studies should publish their definition of fracture and specify if diagnostic codes from contiguous fracture sites were used.

National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010

OBJECTIVE

Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.

DESIGN AND SETTING

Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.

PARTICIPANTS

A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.

MEASUREMENTS

Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.

RESULTS

We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).

CONCLUSIONS

Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.

Microdosing of scopolamine as a "cognitive stress test": rationale and test of a very low dose in an at-risk cohort of older adults

BACKGROUND

Abnormal β-amyloid (Aβ) is associated with deleterious changes in central acetylcholinergic tone in the very early stages of Alzheimer's disease (AD), which may be unmasked by a cholinergic antagonist. We aimed to establish an optimal "microdose" of scopolamine for the development of a "cognitive stress test."

METHODS

Healthy older adults (n = 26, aged 55-75 years) with two risk factors for AD, but with low cortical Aβ burden, completed the Groton Maze Learning Test (GMLT) at baseline and then received scopolamine (0.20 mg subcutaneously). Participants were reassessed at 1, 3, 5, 7, and 8 hours postinjection.

RESULTS

There were significant differences, of a moderate magnitude, in performance between baseline and 3 hours postinjection for total errors, rule break errors, and the GMLT composite (d ≈ 0.50) that were all unrelated to body mass.

CONCLUSIONS

A very low dose of scopolamine leads to reliable cognitive impairment at 3 hours postdose (Tmax) and full cognitive recovery within 5 hours, supporting its use as a prognostic test paradigm to identify individuals with potential preclinical AD. This paradigm is being implemented in a larger cohort of healthy adults, with high or low Aβ, to identify pharmacodynamic differences between groups.

Prescribing for older people in nursing homes: strategies to improve prescribing and medicines use in nursing homes

Interventions to improve prescribing in the nursing home environment are many and varied. The critical literature review presented in Paper 1 (Parsons et al., 2011, International Journal of Older People Nursing 6, 45-54) in this series discussed the main issues repeatedly identified as problematic, and this paper summarises the main approaches which have been used to attempt to improve prescribing. These include national legislation which demands documented justification for the prescribing of medicines, medication review, approaches to reducing medication errors, improving communication across care boundaries and assessment teams and alternative service models. It is difficult to make global recommendations as some of these approaches are country specific or have been delivered in different ways, involving different professionals. However, a series of prompt questions have been provided which may assist nursing home staff in deciding whether prescribing is optimal in a resident or if an intervention is required which may lead to an overall improvement in outcomes.