Use of psychotropic drugs in elderly nursing home residents with and without dementia in Helsinki, Finland

OBJECTIVE: Use of psychotropic medication is very common in nursing home residents. Our objective was to describe the use of psychotropic drugs in all long-term nursing home residents > or =65 years of age with and without dementia in Helsinki, Finland. METHOD: The study was a cross-sectional assessment of the nursing home population. The residents' health status was assessed and data on their demographic factors, health and medication use were collected from medical charts in February 2003. RESULTS: Of all nursing home residents in Helsinki, 82% (n = 1987) participated in the study. The nursing home residents' mean age was 83.7 (SD 7.7) years, 80.7% were female, and 69.5% were diagnosed with dementia. The mean number of drugs [corrected] given regularly was 7.9 (SD 3.6) per day per resident[corrected] Of the participants, 79.7% were regularly taking psychotropic medication. Conventional antipsychotics were administered to 18.9% of residents and atypical antipsychotics to 27.0%. Of the residents, 26.7% were on selective serotonin reuptake inhibitors (SSRIs), 3.1% on tricyclic antidepressants and 17.6% on other antidepressants. Altogether, 44.6% of residents were taking one or more antidepressant. More than a quarter (26.3%) were taking at least one anxiolytic drug. Hypnotics were used by 27.5%. However, only moderate dosages of psychotropic drugs were being taken. Only 10.4% of individuals with dementia were regularly taking cholinesterase inhibitors and four residents were taking memantine. CONCLUSIONS: Use of psychotropic drugs is very common in nursing homes in Helsinki, Finland, with four of five nursing home residents regularly receiving psychotropic drugs. Only one in ten residents were receiving cholinesterase inhibitors. Physicians caring for nursing home residents require further education on the benefits and adverse effects of psychotropic drugs in frail elderly people.     

Medication use and risk of falls among nursing home residents: a retrospective cohort study

Background Geriatric falls are leading causes of hospital trauma admissions and injury-related deaths. Medication use is a crucial element among extrinsic risk factors for falls. To reduce fall risk and the prevalence of adverse drug reactions, potentially inappropriate medication (PIM) lists are widely used. Objective Our aim was to investigate the possible predictors of geriatric falls annualized over a 5-year-long period, as well as to evaluate the medication use of nursing home residents. Setting Nursing home residents were recruited from the same institution between 2010 and 2015 in Szeged, Hungary. Method A retrospective epidemiological study was performed. Patient data were analysed for the first 12 months of residency. Chi-squared test and Fisher’s-test were applied to compare the categorical variables, Student’s t test to compare the continuous variables between groups. Binary logistic regression analysis was carried out to determine the association of falls with other variables found significant in univariate analysis. Microsoft Excel, IBM SPSS Statistics (version 23) and R (3.2.2) programs were used for data analysis. Main outcome measure Falls affected by age, gender, number of chronic medications, polypharmacy, PIM meds. Results A total of 197 nursing home residents were included, 150 (76.2%) women and 47 (23.8%) men, 55 fallers (annual fall prevalence rate was 27.9%) and 142 non-fallers. Gender was not a predisposing factor for falls (prevalence in males: 23.4 vs 29.3% in females, p > 0.05). Fallers were older (mean years ± SD; 84.0 ± 7.0) than non-fallers (80.1 ± 9.3, p < 0.01). The age ≥80 years was a significant risk factor for falls (p < 0.001). The number of chronic medications was higher in male fallers (12.4 ± 4.0) than in non-fallers (6.9 ± 4.2, p < 0.001). Polypharmacy (taking four or more chronic medications) was a significant risk factor of falls (p < 0.01). Those PIMs carrying fall risk were taken by 70.9% of fallers and 75.3% of non-fallers (p > 0.05). Taking pantoprazole, vinpocetine or trimetazidine was a significant risk factor for falls. Conclusion Older age, polypharmacy and the independent use of pantoprazole, vinpocetine, and trimetazidine were found to be major risk factors for falls. Further real-life epidemiological studies are necessary to confirm the role of particular active agents, and to help professionals prescribe, evaluate and review geriatric medication use.     

Relationships between psychotropic drug dosage, plasma drug concentration, and prolactin levels in nursing home residents

This study aimed to characterize the relationships between administered dosages of psychotropic drugs, plasma drug concentration, and prolactin levels in a group of elderly nursing home residents. In a randomized, placebo-controlled, double-blind crossover design study, blood samples were drawn from 47 nursing home residents at least 6 hours after taking either haloperidol, thioridazine, or lorazepam. Correlations between drug dosage and plasma drug levels were significant for haloperidol and thioridazine, but not for lorazepam. Plasma drug levels were below the levels of detection for most of those taking haloperidol. Lorazepam was detected in the blood of 4 of the participants even after 3 weeks of downward titration to placebo and 6 weeks of placebo. Prolactin level was related to administered dosage only in those who were taking haloperidol. For those taking haloperidol or thioridazine, prolactin levels decreased when participants were on placebo. When an older person is taken off lorazepam, the possibility of residual drug in their bodies even 6 weeks after termination of drug use should be considered. Haloperidol may be clinically active in the brain despite no currently detectable plasma drug concentration.     

Study of anemia in long-term care (SALT): prevalence of anemia and its relationship with the risk of falls in nursing home residents

ABSTRACT

Objective: The objectives of the current study were twofold. First, this study examined the prevalence of anemia in nursing home residents in the USA and its relationship with key resident characteristics and medical conditions. Second, the study explored whether an association between anemia and falls is evident in this same population.

Research design and methods: Chart review was conducted in 40 nursing homes across the USA. Residents were randomly sampled and considered eligible if they: were ≥18 years of age; had ≥1 hemoglobin (Hb) level reported during the data uptake period of 1/1/04–2/1/05 (first occurrence defined as index Hb); had a recorded serum creatinine level; maintained residency in the facility; and did not receive dialysis during the 6-month post-index follow-up period. Resident demographics, laboratory values, comorbid conditions, medication regimens, falling events, physical functioning measures, and hospitalizations were obtained from chart data. The relationship between selected resident characteristics and comorbidities was explored with index Hb level, using multiple linear regression. Logistic regression was used to analyze the relationship between falling and recurrent falls with anemia (index Hb <13 g/dL and <12 g/dL in men and women ≥15 years, respectively) adjusting for selected variables presumed to be related to falls.

Limitations: Study limitations include the retrospective design and limited follow-up, potential for biased selection of relevant covariates, gaps in time between index Hb levels and falling events, non-random selection of nursing homes, limits to quality and detail in data extracted from residents’ medical charts, and confounding of anemia therapy with index hemoglobin level.

Results: A total of 564 sampled residents met the criteria for data completeness and were retained for analysis; of these, 70% were female. Mean age was 81 ± 12.3 years (±SD). Mean index Hb level was 11.9 ± 1.8 g/dL (12.2 ± 2.0 for males, 11.7 ± 1.6 for females). Of all residents studied, 56% were identified as anemic (64% males, 53% females) from index Hb level. In all, 53% of anemic residents were receiving an identified therapy, with 72% of these treated residents receiving iron. None received an erythropoietic-stimulating agent (ESA). For index Hb level, the regression coefficient was significant for female (p = 0.002), African-American race (p = 0.012), glomerular filtration rate (GFR) <60 mL/min/1.73 m² (p < 0.001), diabetes (p = 0.004), cancer (p < 0.001), asthma (p = 0.002), GI bleeding (p = 0.012), and inflammatory disease (p = 0.039). Except for asthma, these factors were associated with a decrease in Hb. In the regression model for the dependent variable of falling, anemia (OR = 2.26, p < 0.001), psychoactive medication use (OR = 2.18, p = 0.001), and age 85+ years (OR = 2.08, p = 0.016) were associated with more than twice the risk of falling.

Conclusions: Anemia in nursing home residents appears to be under-recognized. For residents over 70 years, the prevalence of anemia in both male and female residents was approximately four times the rate reported in a study of older community dwellers (Salive et al., 1992). Both anemia and the use of psychoactive medications are potentially modifiable factors strongly associated with falling. Since falls and related fractures are events associated with high morbidity and mortality, each of these factors deserves special consideration for potentially reducing the risk of such events in the nursing home.     

Exposure to potentially inappropriate drugs and drug-drug interactions in elderly nursing home residents in Helsinki, Finland: a cross-sectional study

BACKGROUND AND OBJECTIVE: Multiple drug use is common among old, frail nursing home residents who are, as a consequence, susceptible to adverse effects and drug interactions. This study uses the updated Beers criteria for potentially inappropriate drug (PID) use in older adults to determine the extent and nature of PIDs in older nursing home residents in Helsinki, Finland. The study also uses the Swedish, Finnish, INteraction X-referencing (SFINX) interaction database to assess the possibility of clinically significant class D ("clinically significant interaction, and the combination should be avoided") drug-drug interactions (DDIs) in the same population. METHODS: This study is a cross-sectional assessment of all nursing home residents aged > or = 65 years in Helsinki. The residents' demographic information and medical data were collected from medical charts in February 2003. RESULTS: Of all nursing home residents in Helsinki, 82% (n = 1987) were eligible for analysis. Their mean age was 83.7 (SD 7.7) years, 80.7% were female and 69.5% were diagnosed with dementia. The mean number of drugs given on a regular basis per resident was 7.9 (SD 3.6) per day. Of the study population, 34.9% regularly used at least one PID. Residents taking PIDs were more likely to be taking psychotropic medication and to be taking nine or more drugs daily, and less likely to have a diagnosis of dementia, than patients not taking PIDs. The three most prevalent PIDs were: (i) short-acting benzodiazepines in greater than recommended doses (13.9% of all residents), of which temazepam >15 mg/day was the most commonly used agent and, indeed, the most common PID (taken by 13.5% of all residents); (ii) hydroxyzine (7.1%); and (iii) nitrofurantoin (6.3%). Together, these three PIDs accounted for 76.9% of all PID use. Of all residents, 4.8% were susceptible to a clinically significant DDI. The most common potential DDIs were related to the use of potassium-sparing diuretics, carbamazepine and codeine. Compared with residents not exposed to potential DDIs, residents exposed to potential DDIs were more likely to be younger, to have a prior history of stroke, to be taking psychotropics, to be taking nine or more drugs daily and to be taking PIDs. CONCLUSION: Use of PIDs is very common among nursing home residents, and this increases the likelihood of DDIs. Monitoring patients for PID use and potential drug interactions could increase the quality of prescribing.     

Pharmacologic management by clinical pharmacists of behavioral and psychological symptoms of dementia in nursing home residents: results from a pilot study

A pharmacist-based consulting service was developed for the pharmacologic management of behavioral and psychological symptoms of dementia (BPSD) in a nursing home setting. Patients were evaluated using the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale, and pharmacotherapy was selected using a structured approach. Eleven patients were evaluated and treated with various psychotropic drugs. The most commonly administered drug was trazodone at a mean dosage of 70 mg/day (range 50-100 mg/day). Nine of the patients demonstrated satisfactory treatment responses as shown by a decreased BEHAVE-AD score of 30% or more (average BEHAVE-AD scores at baseline and 1 month after treatment were 13 +/- 4 and 4 +/- 3, respectively), and no clinical side effects were observed. The service was well received by the facility staff and primary care providers. These preliminary results suggest that pharmacists can play an important role in the pharmacotherapy of BPSD with positive clinical outcomes.     

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study

Purpose

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.

Methods

In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.

Results

Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0 % were successful discontinuers, with the subjective PSQI component evolving favourably (p?=?0.013) and a decreasing number of midnight awakenings (p?=?0.041). In the relapse group (n?=?13), the quality of life decreased (p?=?0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.

Conclusion

Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.     

Pain in nursing home residents: management strategies

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.     

The relationship of an anticholinergic rating scale with serum anticholinergic activity in elderly nursing home residents

ndings support the validity of the CR-ACh-mod. However, unexplained variance in SAA suggests that the CR-ACh-mod could benefit from improvements. Future research will evaluate the effect of including factors such as dose and the relative anticholinergic burden from drugs at each of the rating levels. An alternative explanation for the variance which is supported by recent research is that nondrug factors contribute to SAA.     

Adverse events among nursing home residents with Alzheimer's disease and psychosis

PURPOSE: The objective of this study was to quantify rates of adverse events in a high-risk multi-morbid population of institutionalized patients with Alzheimer's disease (AD). METHODS: We conducted a retrospective cohort study among nursing home residents diagnosed with AD and psychosis during January 1998 to October 1999. Using the Medicare Minimum Data Set (MDS) and Medicare inpatient claims (ICD-9 codes), 7728 nursing home residents aged 55-95 years with AD and psychosis were identified for study. Potential adverse events of interest were identified from the MDS and Medicare inpatient claims (ICD-9 codes). We estimated the incidence rate (IR) and 95% confidence interval (CI) for each adverse event during a 2-year follow-up period. RESULTS: Of the 7728 residents studied, nearly 30% were considered 'dependent' by the activities of daily living (ADL) score and approximately 15% exhibited severe cognitive impairment at baseline. At least 90% had comorbid psychiatric disorders. The most common adverse event was accidental injury, occurring at a rate of 97.7 per 100 person-years (95%CI = 94.7-100.7). Other common adverse events were death (IR = 44.6/100 person-years; 95%CI = 42.9-46.4), infection (IR = 41.8/100 person-years; 95%CI = 39.7-43.8), pain (IR = 43.5/100 person-years; 95%CI = 41.2-45.9), anorexia (41.3/100 person-years; 95%CI = 39.1-43.6), and weight change (IR = 40.2/100 person-years; 95%CI = 38.7-41.7). CONCLUSIONS: This information on the occurrence of adverse outcomes among nursing home patients with AD and psychosis provides useful context for any safety event observed among patients treated for psychosis.     

Embryotoxicity of 25 psychotropic drugs: a study using CHEST.

Twenty five psychotropic drugs were ranked according to the embryotoxicity dose ranges estimated by the Chick Embryotoxicity Screening Test (CHEST). The chick results were compared with some data for common laboratory mammals. In 17 psychotropic drugs a deleterious dose-dependent effect upon the embryonic cardiovascular system was disclosed, terminating in immediate cardiac arrest.     

Orodispersible films as a personalized dosage form for nursing home residents,an exploratory study

International Journal of Clinical Pharmacy - Background A frequent problem in ageing patients, and thus in nursing home residents, is dysphagia, affecting the ability to swallow solid dosage forms....