- Email: [email protected]
Centrally active prescribing for nursing home residents - how are we doing?
European Geriatric Medicine 3 (2012) 304–307
Available online at
www.sciencedirect.com
Research paper
Centrally active prescribing for nursing home residents - how are we doing? L.D. Hughes a,*,b,c, J. Hanslip b, M.D. Witham c a
University of Dundee Medical School, Dundee, United Kingdom NHS Education for Scotland, Edinburgh, Scotland c University of Dundee, Dundee, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 March 2012 Accepted 30 April 2012 Available online 3 August 2012
Introduction: Older patients in nursing homes are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm. This clinical study reviewed all prescribed centrally active medications for residents in a nursing home in Dundee. Subsequent analysis was carried out to examine whether particular patient criteria are associated with an exposure to centrally acting drugs and to examine the adequacy of analgesia for care home residents. Methods: The study was carried out in a Dundee nursing home with two different units with varying admission criteria. The research team reviewed patient records establishing background patient characteristics and medical diagnoses where psychoactive prescribing may be appropriate. In addition, information on specific prescribed medications, patient pain scores (PAINAD system), quantified cognition (6CIT score) was gathered. The non-parametric Mann Whitney U test (P < 0.05) was used to compare exposure to CNS active medications between nursing home floors. Results: Patients with dementia in nursing homes are particularly likely to have bodily pain, insomnia and unipolar depression. Patients with more severe dementia were statistically more likely to be exposed to CNS active medications (P-value = 0.01). Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group may be undertreated for chronic pain. Conclusion: Centrally active prescribing in the community for geriatric patients remains high and may be associated with patient risk. Furthermore, despite this patients may be undertreated for pain syndromes. ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Community geriatrics Pain management Primary care Prescribing
1. Research in context Older patients are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm [1,2]. In addition, older patients are at a greater risk of adverse drug reactions (ADRs) in line with age-related reductions in hepatic metabolism and renal function and can often be more sensitive to the effects of medications than other age groups [3,4]. Older people are commonly prescribed medications with psychoactive properties [2]. Indeed, Guthrie et al. showed that patients with dementia in Tayside (Scotland) have a 17% chance of being prescribed one or more centrally active medications (including antipsychotics, antidepressants and hypnotic/anxiolytics) [5]. It is important to stress that the high levels of centrally active drug prescription are despite the well-documented health risks associated with these drugs, including an increased risk of worsening cardiovascular and cerebrovascular disease as well as cognitive decline [6,7]. Indeed, a Government funded review by
* Corresponding author. E-mail address: [email protected] (L.D. Hughes).
Prof. Sube Banerjee indicated that there could be up to 1800 avoidable patient deaths annually associated with such medications [8]. This clinical study reviewed all prescribed centrally active medications for residents in a nursing home in Dundee. Subsequent analysis was carried out to examine whether particular patient criteria are associated with an exposure to centrally acting drugs and to examine the adequacy of analgesia for care home residents. 2. Methods 2.1. Study location and patient background The study was undertaken in a purpose-built Dundee nursing home, in June 2010. The unit is specialized for patients with dementia, admitting patients with a confirmed diagnosis of dementia alongside appropriate social work assessment. Importantly, there are two floors (ground floor [GF] and first floor [FF]) with each floor having different admission criteria and run by a separate nursing and care team. An average patient on GF would have severe cognitive impairment, have the majority or all
1878-7649/$ – see front matter ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. http://dx.doi.org/10.1016/j.eurger.2012.04.008
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307 Table 1 Characteristics of patient cohort.
305
All residents (n = 50)
G F residents (n = 26)
FF residents (n = 24)
each CNS drug class prevalence comparing FF to GF using the nonparametric Wilson statistical method. The non-parametric Mann Whitney U test (P 0.05) was used to compare exposure to CNS active medications between nursing home floors.
Gender (, or <)
69–92 (mean 76) 27 ,:23 <
72–92 (mean 77) 13 ,:13 <
69–84 (mean 73) 14 ,: 10 <
3. Results
Dementia Diagnosis Alzheimer’s disease Multi-infarct dementia Dementia with Lewy bodies Other
35 11 3 1
18 7 1 0
17 4 2 1
Cognition [6CIT] Normal (0–7) Mild (8–14) Moderate (15–21) Severe (22–28)
NA 6 29 15
NA 0 15 11
NA 6 20 4
19 5 21
5 1 9
14 4 12
10 13 27
1 9 16
9 4 11
Age (years)
Indications for CNS Drugs Insomnia Anxiety Unipolar depression Bodily pain* None/minimal (0–3) Mild (4–7) Moderate/severe (> 7)
GF: ground floor; FF: first floor; 6CIT: 6-item cognitive impairment test; CNS: central nervous system. * Scored using Pain Assessment in Advanced Dementia (PAINAD) Key.
personal and social care needs met by nursing staff and have very limited mobility. An average patient on FF would have good mobility (able to walk without staff assistance with or without the use of a walking aid), require limited support from nursing staff and display one or more signs of behavioural and psychological symptoms of dementia (BPSD). This provided a unique opportunity to draw comparisons between centrally active prescribing between the two groups of nursing home patients. Information regarding the characteristics of the patient cohort can be found in Table 1. Resident care plans on both floors were reviewed by L.H. Medical indications for centrally acting medications were recorded including diagnosed dementia syndrome (most likely diagnosis listed in notes by general practitioner), sleep problems/ insomnia, anxiety, and unipolar depression. All patients were examined by the research team for the presence of pain using the validated pain assessment tool, Pain Assessment in Advanced Dementia (PAINAD) [9,10]. The PAINAD assesses and ranks pain in five patient domains including breathing independent of vocalization, negative vocalization, facial expression, body language, consolability [9,10]. Patients are scored between 0 (no pain) –10 (maximal pain) [9,10]. Patient cognition was quantified using the Six Item Cognitive Impairment Test, validated for use in a nursing home setting (6CIT) [11]. Patients were graded using their mean 6CIT score into normal cognition (0–7 points on 6CIT), mild cognitive impairment (8–14 points on 6CIT), moderate cognitive impairment (15–21 points on 6CIT) and severe cognitive impairment (22–28 points on 6CIT). L.H. anonymously collected drug information from the residents Medication Administration Record (MAR) sheets. Information about all centrally active medications including drug class, drug dose, and drug forms were recorded. Centrally active medications were defined according to the recently developed central nervous system drug model, which includes benzodiazepine receptor agonists, antidepressants (all classes), antipsychotics (first and second generation) and opioid analgesia [3]. Ninety-five percent confidence intervals of a proportion were calculated for
At the time of the study there were 26 residents on the GF and 24 residents on the FF. There were four different groups of dementia syndromes in the patient group with 35/50 (70%) of the patients being diagnosed with Alzheimer’s dementia, 11/50 (22%) being diagnosed with multi-infarct (vascular) dementia and 4/50 (8%) being diagnosed with Lewy body dementia or other. Twentynine out of 50 (58%) patients had moderate cognitive impairment compared to 15/50 (30%) having severe cognitive impairment and 6/50 (12%) having mild cognitive impairment. There were several medical indications for centrally acting medications. The most common conditions included moderate/severe bodily pain (27/50), depression (21/50), and insomnia (19/50). Table 2 provides information on the prevalence of individual classes and overall CNS medication. The most commonly prescribed medicine classes were opioid analgesia (16/50) and antidepressants (13/50). At the time of the study, 58% of residents were exposed to one or more centrally acting medication. When the residents between nursing homes units were compared, a number of important observations were made. Firstly, 25/26 of patients in the higher dependency unit had a recorded PAINAD bodily pain score of 4 or greater compared to 15/24 in the lower dependency unit. However, despite the high levels of pain experienced by residents’ only 16 patients in the nursing home were prescribed opioid analgesia. Secondly, patients living on the FF had on average a higher baseline cognition level, but this was accompanied with significantly higher levels of insomnia and anxiety and unipolar depression. Table 3 provides information on the cumulative burden of psychoactive medications after CNS model calculation between patient groups. Of the 29 patients prescribed centrally active drugs, four were on the highest dose (> 3 standardized daily dose [SDD]), 13 on the moderate dose (1–3 SDD), and 12 were on the lowest dose use (< 1.0 SDD). GF floor residents were statistically more likely to be exposed to CNS active medications (P-value = 0.001). Table 2 Prevalence of individual classes and overall CNS medication. GF residents (n = 26) [95% confidence intervals]
FF residents (n = 24) [95% confidence intervals]
4
1 [0.007–0.189]
3 [0.043–0.31]
1 3
1 0
0 3
4
1 [0.007–0.189]
3 [0.043–0.31]
Antidepressants (combined) SSRIs TCAs SNRIs
13
9 [0.194–0.538]
4 [0.067–0.359]
6 0 3
2 0 2
Opioid analgesic use
16
14 [0.355–0.713]
2 [0.023–0.258]
Total number of patients on CNS drugs
29
17 [0.462–0.806]
12 [0.314–0.686]
CNS medication
Antipsychotics (combined) First generation Second generation Benzodiazepine receptor agonist
All residents (n = 50)
8 0 5
GF: ground floor; FF: first floor; SSRI: selective serotonin reuptake inhibitors; TCA: tricyclic antidepressant; SNRI: serotonin-norepinephrine reuptake inhibitor.
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307
306
Table 3 Comparison of cumulative burden between patient groups. Cumulative CNS Burden Score
All residents (n = 50)
GF residents (n = 26)
FF residents (n = 24)
No exposure Lowest dose use (< 1.0 SDD) Moderate dose use (1–3 SDD) Highest dose use (> 3 SDD)
21 12 13 4
9 8 8 1
12 4 5 3
may be similarly efficacious in this patient population [12,21]. Therefore, in future work we would use a combination of observational scales and a self-report scale. However, despite these limitations the authors feel that this small centre projects is able to reflect some of the real life challenges of prescribing medication for nursing home residents. 5. Conclusion
GF: ground floor; FF: first floor; SDD: standardized daily.
4. Discussion 4.1. Patient characteristics This study has noted the high prevalence of pain in this nursing home with 80% of the 50 residents having a recorded PAINAD bodily pain score of 4 or greater. It is known that chronic pain is a frequent health problem in the elderly [12]. Indeed, chronic pain is associated with a reduced quality of life, with prevalence levels ranging between 45% and 80% in line with age-related increases in patient comorbidity [12,13]. Importantly, a 2011 BMJ study by Rosenberg et al. noted that a systematic pain management protocol was associated with improvements in BPSD [14]. Rates of unipolar depression and insomnia/sleeping disturbances were both significant (42% and 38% of nursing home residents respectively) but in line with rates for this patient group noted in current literature [15,16]. 4.2. Drug prescribing In this nursing home the most commonly prescribed medicine classes were opioid analgesic receptor agonists and antidepressants. At the time of the study, an overall 58% was exposed to one or more centrally acting medication. Interestingly, each nursing home unit had significant variation in the nature of drugs prescribed. Residents on the GF were prescribed the vast majority of opioid analgesia with antidepressants being the second most commonly prescribed. Drugs with more potent sedative potential (antipsychotics and benzodiazepines) were limited to one resident on the GF. In contrast, three quarters of antipsychotics were prescribed on the on FF, where patients have higher levels of mobility and BPSD. However, just under 10% of these patients received opioid receptor analgesia despite only having slightly reduced levels of pain compared to residents on GF. This review notes that secondary care and community prescribers clearly have tailored prescribing to the patient needs with the notable exception of pain relief. It appears that patients on the FF who have higher levels of BPSD, anxiety, and insomnia appear to be undertreated for pain. Other papers have documented the under treatment of chronic pain in elderly patients, particularly those with comorbid psychiatric disturbance [17,18]. 4.3. Limitations There are numerous limitations for this research project. Firstly, the study is limited by the single centre nature of the study and subsequent small sample size. In addition, the population in this nursing home is relatively homogeneous, with the vast majority of residents being White Scottish/British. Another important limitation was the study used only a direct observational pain assessment tool (PAINAD). The PAINAD was selected in line with the significant communication deficits of the nursing home residents on both floors [19,20] and staff were already familiar with the scale. However, there is work that suggests that selfreporting scales, the gold standard measure of pain assessment,
This community project reinforces previous work that centrally active prescribing in the community for geriatric patients remains high [5]. The authors have noted that patients with dementia in nursing homes are particularly likely to have bodily pain, insomnia and unipolar depression. In addition, the authors note that patients with more severe dementia were statistically more likely to be exposed to CNS active medications (P-value = 0.001). Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group there may be undertreated for chronic pain. It is hoped that this study will stimulate further research into this important area of community geriatrics in Scotland. Keypoints Older patients are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm. Psychoactive prescribing in the community for nursing home patients remains high despite the documented risks associated with these drugs. Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group there may be undertreated for chronic pain.
Disclosure of interest LDH was a member of staff at the care home where the study took place for the duration of the study. MDW and JH have no conflict of interest to declare. References [1] Information Services Division NHS Scotland. Measuring long-term conditions in Scotland. Edinburgh: ISD Scotland. http://www.isdscotland.org/isd/5658. html, 2008. [2] Uijen A, Lisdonk E. Multimorbidity in primary care: prevalence and trend over the last 20 years. Eur J Gen Pract 2008;1:28–32. [3] Boss GR, Seegmiller JE. Age-related physiological changes and their clinical significance. West J Med 1981;135(6):434–40. [4] Taipale H, Hartikainen, Bell JS. A comparison of four methods to quantify with cumulative effect of taking multiple drugs with sedative properties. Am J Geriatr Pharmacol 2010;8(5):460–71. [5] Guthrie B, Clark SA, McCowan C. The burden of psychotropic drug prescribing in people with dementia: a population database study. Age Ageing 2010;39(5): 637–42. [6] EMedicine Website- Challoner KR, Newton E Toxicity, Neuroleptic Agents. (Cited 2012 Jan 25); Available from: http://emedicine.medscape.com/article/ 815881-overview. [7] McShane R, Keene J, Gedling K, Fairburn C, Jacoby R, Hope T. Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow-up. BMJ 1997;314:266–70. [8] Department of Health, Report for Minister of State for Care Services written by S. Banerjee (2009) The use of antipsychotic medication for people with dementia. [9] Warden V, Hurley AC, Volicer V. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc 2003;4:9–15 [Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA]. [10] Pain Assessment in Advanced Dementia (PAINAD) Scale. (Cited 2012 Jan 25); Available from: web.missouri.edu/proste/tool/cog/painad.pdf.
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307 [11] Brooke P, Bullock R. Validation of a 6-item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry 1999;14(11):936–40. [12] Ciampi de Andrade D, Vieira de Faria JW, Caramelli P, Alvarenga L, Galhardoni R, Siqueira SRD, et al. Assessment and management of pain in the demented and non-demented elderly patient. Arq Neuropsiquiatr 2011;69(no 2b):387–94. [13] Roy R, Michael T. A survey of chronic pain in the elderly population. Can Fam Physician 1986;32:513–6. [14] Rosenberg PB, Lyketsos CG. Treating agitation in dementia. BMJ 2011;343:d3913. [15] Robert PH, Verhey FR, Byrne EJ, Hurt C, De Deyn PP, Nobili F, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20(7):490–6.
307
[16] Omelan C. Approach to managing behavioural disturbances in dementia. Can Fam Physician 2006;52:191–9. [17] Mitchell C. Assessment and management of chronic pain in elderly people. Br J Nurs 2001;10(5):296–304. [18] Shives LR. Basic Concepts of Psychiatric-Mental Health Nursing’ 6th edn Lippincott Williams & Wilkins (2004) Chpt 30 pp. 573–602. [19] Passmore P, Wilson D, McGuiness B, Todd S. Recognition and management of pain in dementia. Geriatr Med 2010;41(9):499–507. [20] Hughes LD. Assessment and management of pain in older patients receiving palliative care. Nurs Older People 2012;24(6):23–9. [21] Lu DF, Herr K. Pain in dementia: recognition and treatment. J Gerontol Nurs 2012;38(2):8–13.
Available online at
www.sciencedirect.com
Research paper
Centrally active prescribing for nursing home residents - how are we doing? L.D. Hughes a,*,b,c, J. Hanslip b, M.D. Witham c a
University of Dundee Medical School, Dundee, United Kingdom NHS Education for Scotland, Edinburgh, Scotland c University of Dundee, Dundee, United Kingdom b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 March 2012 Accepted 30 April 2012 Available online 3 August 2012
Introduction: Older patients in nursing homes are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm. This clinical study reviewed all prescribed centrally active medications for residents in a nursing home in Dundee. Subsequent analysis was carried out to examine whether particular patient criteria are associated with an exposure to centrally acting drugs and to examine the adequacy of analgesia for care home residents. Methods: The study was carried out in a Dundee nursing home with two different units with varying admission criteria. The research team reviewed patient records establishing background patient characteristics and medical diagnoses where psychoactive prescribing may be appropriate. In addition, information on specific prescribed medications, patient pain scores (PAINAD system), quantified cognition (6CIT score) was gathered. The non-parametric Mann Whitney U test (P < 0.05) was used to compare exposure to CNS active medications between nursing home floors. Results: Patients with dementia in nursing homes are particularly likely to have bodily pain, insomnia and unipolar depression. Patients with more severe dementia were statistically more likely to be exposed to CNS active medications (P-value = 0.01). Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group may be undertreated for chronic pain. Conclusion: Centrally active prescribing in the community for geriatric patients remains high and may be associated with patient risk. Furthermore, despite this patients may be undertreated for pain syndromes. ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Community geriatrics Pain management Primary care Prescribing
1. Research in context Older patients are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm [1,2]. In addition, older patients are at a greater risk of adverse drug reactions (ADRs) in line with age-related reductions in hepatic metabolism and renal function and can often be more sensitive to the effects of medications than other age groups [3,4]. Older people are commonly prescribed medications with psychoactive properties [2]. Indeed, Guthrie et al. showed that patients with dementia in Tayside (Scotland) have a 17% chance of being prescribed one or more centrally active medications (including antipsychotics, antidepressants and hypnotic/anxiolytics) [5]. It is important to stress that the high levels of centrally active drug prescription are despite the well-documented health risks associated with these drugs, including an increased risk of worsening cardiovascular and cerebrovascular disease as well as cognitive decline [6,7]. Indeed, a Government funded review by
* Corresponding author. E-mail address: [email protected] (L.D. Hughes).
Prof. Sube Banerjee indicated that there could be up to 1800 avoidable patient deaths annually associated with such medications [8]. This clinical study reviewed all prescribed centrally active medications for residents in a nursing home in Dundee. Subsequent analysis was carried out to examine whether particular patient criteria are associated with an exposure to centrally acting drugs and to examine the adequacy of analgesia for care home residents. 2. Methods 2.1. Study location and patient background The study was undertaken in a purpose-built Dundee nursing home, in June 2010. The unit is specialized for patients with dementia, admitting patients with a confirmed diagnosis of dementia alongside appropriate social work assessment. Importantly, there are two floors (ground floor [GF] and first floor [FF]) with each floor having different admission criteria and run by a separate nursing and care team. An average patient on GF would have severe cognitive impairment, have the majority or all
1878-7649/$ – see front matter ß 2012 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. http://dx.doi.org/10.1016/j.eurger.2012.04.008
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307 Table 1 Characteristics of patient cohort.
305
All residents (n = 50)
G F residents (n = 26)
FF residents (n = 24)
each CNS drug class prevalence comparing FF to GF using the nonparametric Wilson statistical method. The non-parametric Mann Whitney U test (P 0.05) was used to compare exposure to CNS active medications between nursing home floors.
Gender (, or <)
69–92 (mean 76) 27 ,:23 <
72–92 (mean 77) 13 ,:13 <
69–84 (mean 73) 14 ,: 10 <
3. Results
Dementia Diagnosis Alzheimer’s disease Multi-infarct dementia Dementia with Lewy bodies Other
35 11 3 1
18 7 1 0
17 4 2 1
Cognition [6CIT] Normal (0–7) Mild (8–14) Moderate (15–21) Severe (22–28)
NA 6 29 15
NA 0 15 11
NA 6 20 4
19 5 21
5 1 9
14 4 12
10 13 27
1 9 16
9 4 11
Age (years)
Indications for CNS Drugs Insomnia Anxiety Unipolar depression Bodily pain* None/minimal (0–3) Mild (4–7) Moderate/severe (> 7)
GF: ground floor; FF: first floor; 6CIT: 6-item cognitive impairment test; CNS: central nervous system. * Scored using Pain Assessment in Advanced Dementia (PAINAD) Key.
personal and social care needs met by nursing staff and have very limited mobility. An average patient on FF would have good mobility (able to walk without staff assistance with or without the use of a walking aid), require limited support from nursing staff and display one or more signs of behavioural and psychological symptoms of dementia (BPSD). This provided a unique opportunity to draw comparisons between centrally active prescribing between the two groups of nursing home patients. Information regarding the characteristics of the patient cohort can be found in Table 1. Resident care plans on both floors were reviewed by L.H. Medical indications for centrally acting medications were recorded including diagnosed dementia syndrome (most likely diagnosis listed in notes by general practitioner), sleep problems/ insomnia, anxiety, and unipolar depression. All patients were examined by the research team for the presence of pain using the validated pain assessment tool, Pain Assessment in Advanced Dementia (PAINAD) [9,10]. The PAINAD assesses and ranks pain in five patient domains including breathing independent of vocalization, negative vocalization, facial expression, body language, consolability [9,10]. Patients are scored between 0 (no pain) –10 (maximal pain) [9,10]. Patient cognition was quantified using the Six Item Cognitive Impairment Test, validated for use in a nursing home setting (6CIT) [11]. Patients were graded using their mean 6CIT score into normal cognition (0–7 points on 6CIT), mild cognitive impairment (8–14 points on 6CIT), moderate cognitive impairment (15–21 points on 6CIT) and severe cognitive impairment (22–28 points on 6CIT). L.H. anonymously collected drug information from the residents Medication Administration Record (MAR) sheets. Information about all centrally active medications including drug class, drug dose, and drug forms were recorded. Centrally active medications were defined according to the recently developed central nervous system drug model, which includes benzodiazepine receptor agonists, antidepressants (all classes), antipsychotics (first and second generation) and opioid analgesia [3]. Ninety-five percent confidence intervals of a proportion were calculated for
At the time of the study there were 26 residents on the GF and 24 residents on the FF. There were four different groups of dementia syndromes in the patient group with 35/50 (70%) of the patients being diagnosed with Alzheimer’s dementia, 11/50 (22%) being diagnosed with multi-infarct (vascular) dementia and 4/50 (8%) being diagnosed with Lewy body dementia or other. Twentynine out of 50 (58%) patients had moderate cognitive impairment compared to 15/50 (30%) having severe cognitive impairment and 6/50 (12%) having mild cognitive impairment. There were several medical indications for centrally acting medications. The most common conditions included moderate/severe bodily pain (27/50), depression (21/50), and insomnia (19/50). Table 2 provides information on the prevalence of individual classes and overall CNS medication. The most commonly prescribed medicine classes were opioid analgesia (16/50) and antidepressants (13/50). At the time of the study, 58% of residents were exposed to one or more centrally acting medication. When the residents between nursing homes units were compared, a number of important observations were made. Firstly, 25/26 of patients in the higher dependency unit had a recorded PAINAD bodily pain score of 4 or greater compared to 15/24 in the lower dependency unit. However, despite the high levels of pain experienced by residents’ only 16 patients in the nursing home were prescribed opioid analgesia. Secondly, patients living on the FF had on average a higher baseline cognition level, but this was accompanied with significantly higher levels of insomnia and anxiety and unipolar depression. Table 3 provides information on the cumulative burden of psychoactive medications after CNS model calculation between patient groups. Of the 29 patients prescribed centrally active drugs, four were on the highest dose (> 3 standardized daily dose [SDD]), 13 on the moderate dose (1–3 SDD), and 12 were on the lowest dose use (< 1.0 SDD). GF floor residents were statistically more likely to be exposed to CNS active medications (P-value = 0.001). Table 2 Prevalence of individual classes and overall CNS medication. GF residents (n = 26) [95% confidence intervals]
FF residents (n = 24) [95% confidence intervals]
4
1 [0.007–0.189]
3 [0.043–0.31]
1 3
1 0
0 3
4
1 [0.007–0.189]
3 [0.043–0.31]
Antidepressants (combined) SSRIs TCAs SNRIs
13
9 [0.194–0.538]
4 [0.067–0.359]
6 0 3
2 0 2
Opioid analgesic use
16
14 [0.355–0.713]
2 [0.023–0.258]
Total number of patients on CNS drugs
29
17 [0.462–0.806]
12 [0.314–0.686]
CNS medication
Antipsychotics (combined) First generation Second generation Benzodiazepine receptor agonist
All residents (n = 50)
8 0 5
GF: ground floor; FF: first floor; SSRI: selective serotonin reuptake inhibitors; TCA: tricyclic antidepressant; SNRI: serotonin-norepinephrine reuptake inhibitor.
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307
306
Table 3 Comparison of cumulative burden between patient groups. Cumulative CNS Burden Score
All residents (n = 50)
GF residents (n = 26)
FF residents (n = 24)
No exposure Lowest dose use (< 1.0 SDD) Moderate dose use (1–3 SDD) Highest dose use (> 3 SDD)
21 12 13 4
9 8 8 1
12 4 5 3
may be similarly efficacious in this patient population [12,21]. Therefore, in future work we would use a combination of observational scales and a self-report scale. However, despite these limitations the authors feel that this small centre projects is able to reflect some of the real life challenges of prescribing medication for nursing home residents. 5. Conclusion
GF: ground floor; FF: first floor; SDD: standardized daily.
4. Discussion 4.1. Patient characteristics This study has noted the high prevalence of pain in this nursing home with 80% of the 50 residents having a recorded PAINAD bodily pain score of 4 or greater. It is known that chronic pain is a frequent health problem in the elderly [12]. Indeed, chronic pain is associated with a reduced quality of life, with prevalence levels ranging between 45% and 80% in line with age-related increases in patient comorbidity [12,13]. Importantly, a 2011 BMJ study by Rosenberg et al. noted that a systematic pain management protocol was associated with improvements in BPSD [14]. Rates of unipolar depression and insomnia/sleeping disturbances were both significant (42% and 38% of nursing home residents respectively) but in line with rates for this patient group noted in current literature [15,16]. 4.2. Drug prescribing In this nursing home the most commonly prescribed medicine classes were opioid analgesic receptor agonists and antidepressants. At the time of the study, an overall 58% was exposed to one or more centrally acting medication. Interestingly, each nursing home unit had significant variation in the nature of drugs prescribed. Residents on the GF were prescribed the vast majority of opioid analgesia with antidepressants being the second most commonly prescribed. Drugs with more potent sedative potential (antipsychotics and benzodiazepines) were limited to one resident on the GF. In contrast, three quarters of antipsychotics were prescribed on the on FF, where patients have higher levels of mobility and BPSD. However, just under 10% of these patients received opioid receptor analgesia despite only having slightly reduced levels of pain compared to residents on GF. This review notes that secondary care and community prescribers clearly have tailored prescribing to the patient needs with the notable exception of pain relief. It appears that patients on the FF who have higher levels of BPSD, anxiety, and insomnia appear to be undertreated for pain. Other papers have documented the under treatment of chronic pain in elderly patients, particularly those with comorbid psychiatric disturbance [17,18]. 4.3. Limitations There are numerous limitations for this research project. Firstly, the study is limited by the single centre nature of the study and subsequent small sample size. In addition, the population in this nursing home is relatively homogeneous, with the vast majority of residents being White Scottish/British. Another important limitation was the study used only a direct observational pain assessment tool (PAINAD). The PAINAD was selected in line with the significant communication deficits of the nursing home residents on both floors [19,20] and staff were already familiar with the scale. However, there is work that suggests that selfreporting scales, the gold standard measure of pain assessment,
This community project reinforces previous work that centrally active prescribing in the community for geriatric patients remains high [5]. The authors have noted that patients with dementia in nursing homes are particularly likely to have bodily pain, insomnia and unipolar depression. In addition, the authors note that patients with more severe dementia were statistically more likely to be exposed to CNS active medications (P-value = 0.001). Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group there may be undertreated for chronic pain. It is hoped that this study will stimulate further research into this important area of community geriatrics in Scotland. Keypoints Older patients are more likely to be prescribed multiple drugs than other age groups as multimorbidity is the norm. Psychoactive prescribing in the community for nursing home patients remains high despite the documented risks associated with these drugs. Importantly, despite being exposed to significant levels of psychoactive prescribing this patient group there may be undertreated for chronic pain.
Disclosure of interest LDH was a member of staff at the care home where the study took place for the duration of the study. MDW and JH have no conflict of interest to declare. References [1] Information Services Division NHS Scotland. Measuring long-term conditions in Scotland. Edinburgh: ISD Scotland. http://www.isdscotland.org/isd/5658. html, 2008. [2] Uijen A, Lisdonk E. Multimorbidity in primary care: prevalence and trend over the last 20 years. Eur J Gen Pract 2008;1:28–32. [3] Boss GR, Seegmiller JE. Age-related physiological changes and their clinical significance. West J Med 1981;135(6):434–40. [4] Taipale H, Hartikainen, Bell JS. A comparison of four methods to quantify with cumulative effect of taking multiple drugs with sedative properties. Am J Geriatr Pharmacol 2010;8(5):460–71. [5] Guthrie B, Clark SA, McCowan C. The burden of psychotropic drug prescribing in people with dementia: a population database study. Age Ageing 2010;39(5): 637–42. [6] EMedicine Website- Challoner KR, Newton E Toxicity, Neuroleptic Agents. (Cited 2012 Jan 25); Available from: http://emedicine.medscape.com/article/ 815881-overview. [7] McShane R, Keene J, Gedling K, Fairburn C, Jacoby R, Hope T. Do neuroleptic drugs hasten cognitive decline in dementia? Prospective study with necropsy follow-up. BMJ 1997;314:266–70. [8] Department of Health, Report for Minister of State for Care Services written by S. Banerjee (2009) The use of antipsychotic medication for people with dementia. [9] Warden V, Hurley AC, Volicer V. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. J Am Med Dir Assoc 2003;4:9–15 [Developed at the New England Geriatric Research Education & Clinical Center, Bedford VAMC, MA]. [10] Pain Assessment in Advanced Dementia (PAINAD) Scale. (Cited 2012 Jan 25); Available from: web.missouri.edu/proste/tool/cog/painad.pdf.
L.D. Hughes et al. / European Geriatric Medicine 3 (2012) 304–307 [11] Brooke P, Bullock R. Validation of a 6-item cognitive impairment test with a view to primary care usage. Int J Geriatr Psychiatry 1999;14(11):936–40. [12] Ciampi de Andrade D, Vieira de Faria JW, Caramelli P, Alvarenga L, Galhardoni R, Siqueira SRD, et al. Assessment and management of pain in the demented and non-demented elderly patient. Arq Neuropsiquiatr 2011;69(no 2b):387–94. [13] Roy R, Michael T. A survey of chronic pain in the elderly population. Can Fam Physician 1986;32:513–6. [14] Rosenberg PB, Lyketsos CG. Treating agitation in dementia. BMJ 2011;343:d3913. [15] Robert PH, Verhey FR, Byrne EJ, Hurt C, De Deyn PP, Nobili F, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry 2005;20(7):490–6.
307
[16] Omelan C. Approach to managing behavioural disturbances in dementia. Can Fam Physician 2006;52:191–9. [17] Mitchell C. Assessment and management of chronic pain in elderly people. Br J Nurs 2001;10(5):296–304. [18] Shives LR. Basic Concepts of Psychiatric-Mental Health Nursing’ 6th edn Lippincott Williams & Wilkins (2004) Chpt 30 pp. 573–602. [19] Passmore P, Wilson D, McGuiness B, Todd S. Recognition and management of pain in dementia. Geriatr Med 2010;41(9):499–507. [20] Hughes LD. Assessment and management of pain in older patients receiving palliative care. Nurs Older People 2012;24(6):23–9. [21] Lu DF, Herr K. Pain in dementia: recognition and treatment. J Gerontol Nurs 2012;38(2):8–13.