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Antipsychotic drug use among elderly nursing home residents in the United States
P. Kamble et al.
The American Journal of Geriatric Pharmacotherapy
Antipsychotic Drug Use Among Elderly Nursing Home Residents in the United States Pravin Kamble, BPharm; Hua Chen, MD, PhD; Jeff Sherer, PharmD, MPH, BCPS, CGP; and Rajender R. Aparasu, MPharm, PhD Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, Texas
ABSTRACT Background: Antipsychotic utilization in elderly nursing home residents has increased substantially in recent years, primarily due to the use of atypical antipsychotic agents. However, few studies have examined antipsychotic utilization patterns in nursing home residents in the United States since the introduction of atypical agents in the 1990s. Objective: The goal of this study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States. Methods: This study involved a cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey (NNHS). The analysis focused on the use of 11 typical and 6 atypical antipsychotic agents among a nationally representative sample of elderly patients (aged ≥65 years). Descriptive weighted analysis was performed to examine antipsychotic prevalence patterns. Multiple logistic regression analysis within the conceptual framework of the Andersen behavioral model was used to examine the factors associated with antipsychotic drug use among the elderly nursing home residents. Results: According to the 2004 NNHS, 0.32 million elderly nursing home residents received antipsychotic medications, for an overall prevalence of 24.82%. Most received atypical agents (23.45%), while 1.90% received typical agents. Frequently reported diagnoses among the elderly using an antipsychotic agent were dementia (70%), depression (41%), and anxiety (18%). Among the predisposing characteristics, female gender and age (≥85 years) were negatively associated with antipsychotic drug use. Need factors such as increasing dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, history of falls, and bowel incontinence were positively associated with antipsychotic drug use. In addition to the use of antipsychotic agents in schizophrenia and bipolar mania, this study found high use in conditions such as dementia, anxiety, depression, and parkinsonism in the elderly. Conclusions: Nearly 1 in 4 elderly nursing home residents in the United States received antipsychotic agents. Predisposing and need factors played a vital role in determining the use of antipsychotic agents in these elderly patients. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in US nursing homes in light of recent efficacy and safety data on atypical agents. (Am J Geriatr Pharmacother. 2008;6:187–197) © 2008 Excerpta Medica Inc. Key words: antipsychotic, nursing home, elderly, atypical, typical. Accepted for publication July 25, 2008. ª&YDFSQUB.FEJDB*OD"MMSJHIUTSFTFSWFE
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INTRODUCTION Inappropriate use of antipsychotic medications in nursing homes has been a concern for many years.1 The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) was enacted to improve quality of care in nursing homes.2,3 Specifically, explicit criteria for potentially inappropriate antipsychotic use were included in the interpretative guidelines for nursing homes.2,3 Research has shown that antipsychotic drug use declined 30% to 36% among nursing home residents after the enforcement of the OBRA 87 regulations.3,4–8 However, studies have found the prevalence of antipsychotic medication use to be 15% to 27%, based on data from 1999 onward.9–11 These studies reported an increasing prevalence of antipsychotic drug use in nursing homes in recent years. Expenditures for atypical antipsychotic agents among Medicare beneficiaries increased from US $10 million in 1996 to US $151 million in 2002, a 15-fold increase in 6 years.12 The increase in antipsychotic prescribing and high drug expenditures have been attributed to greater use of atypical antipsychotic agents versus typical agents.11,12 Atypical antipsychotic agents, such as risperidone and olanzapine, are commonly used in the elderly for the management of various psychiatric disorders.9–11 Although the US Food and Drug Administration (FDA) has approved atypical agents for the treatment of schizophrenia and bipolar mania, they are extensively used (43%–70%) for off-label indications.13 In the elderly, atypical antipsychotic agents are often used (30%–37%) to manage the behavioral symptoms of dementia.14–16 However, the Agency for Healthcare Research and Quality (AHRQ) report found only a moderate level of evidence supporting the effectiveness of atypical agents in the treatment of behavioral symptoms of dementia based on data from published randomized clinical trials.17 The review also found that atypical agents are associated with an increase in risk of death and stroke, neurologic problems, and weight gain in patients with dementia.17,18 An FDA analysis of placebo-controlled trials conducted with olanzapine, aripiprazole, risperidone, and quetiapine also found an increase in mortality in the drug-treated group compared with the group receiving placebo.19 In 2005, the FDA issued warnings for all atypical agents due to the increased risk of mortality.19 The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) studies were funded by the National Institute of Mental Health to address the limited availability of effectiveness data comparing typical and atypical agents.20 The initial CATIE study was conducted in 1493 randomized patients aged 18 to 65 years
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with schizophrenia.20 The study found that time to discontinuation for any cause was longer for olanzapine (9.2 months) and perphenazine (5.6 months) but shorter for risperidone (4.8 months) and quetiapine (4.6 months). Time to discontinuation due to intolerable adverse effects was similar among patients receiving olanzapine, perphenazine, risperidone, and quetiapine. Patients were more likely (9%) to discontinue olanzapine due to metabolic adverse effects or weight gain and more likely (8%) to discontinue perphenazine due to extrapyramidal adverse effects. Another CATIE study investigated the effect of atypical antipsychotic agents in 421 patients with Alzheimer’s disease (mean [SD] age, 77.9 [7.5] years).21 This study found no significant differences among olanzapine, quetiapine, risperidone, or placebo with regard to time to discontinuation of treatment for any reason. Median time to discontinuation of treatment due to lack of efficacy was longer with risperidone and olanzapine compared with quetiapine and placebo. The study concluded that there was no advantage to using atypical antipsychotic agents over placebo due to the adverse effects experienced with antipsychotic agents in these patients with dementia. In light of recent efficacy and safety data on atypical agents,17–21 there is a need to examine antipsychotic drug use in elderly nursing home residents. A MEDLINE review (search terms: nursing homes, elderly, atypical, typical, antipsychotics; years searched: January 1990–June 2008) revealed that few studies have examined antipsychotic utilization patterns in US nursing home residents since the introduction of the atypical antipsychotic agents in the 1990s.10,11 Liperoti et al10 conducted a cross-sectional study to describe the pattern of atypical antipsychotic drug use among elderly nursing home residents by using computerized Minimum Data Set (MDS) assessment records from 1999 to 2000. This study, which was limited to 5 US states, found that the prevalence of antipsychotic drug use was 15.0% among 139,174 elderly residents from 1732 facilities. Another nationally representative, retrospective cross-sectional study was conducted by Briesacher et al,11 using the 2000–2001 Medicare Current Beneficiary Survey (MCBS) to examine the prevalence of antipsychotic drug use and its appropriateness among communitydwelling and institutionalized elderly. This study found a 27.6% prevalence of antipsychotic drug use among 2.5 million Medicare beneficiaries nationwide. Understanding prevalence patterns and factors associated with antipsychotic drug use based on more recent, nationally representative data can be instrumental in optimizing
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antipsychotic drug use and expenditures in this vulnerable population. Therefore, the aim of the current study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States.
MATERIALS AND METHODS
Data Source
The National Nursing Home Survey (NNHS) is conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention to provide national-level data on providers and recipients of care in US nursing homes. The NNHS is a nationally representative sample survey of US nursing homes, their services, their staff, and their residents. It is conducted periodically, and the latest survey available is from 2004.22 The current study involved the public use data files from the 2004 NNHS to examine the prevalence of antipsychotic drug use and to identify the factors associated with such use among elderly nursing home residents. The study was approved by the University of Houston’s Committee for the Protection of Human Subjects (Houston, Texas). The 2004 NNHS involved a stratified 2-stage probability design.22 The first stage was the selection of facilities, and the second stage was the selection of residents. The nursing homes that participated in the NNHS had ≥3 beds and were certified by either Medicare or Medicaid, or had a state license to operate as a nursing home. Nursing homes were then selected using systematic sampling with a probability proportional to their bed size. The second stage, sampling of current residents, was conducted by interviewers at the time of their visits to the facilities. A sample of ≤12 current residents per facility was selected for the final interview. The 2004 NNHS consisted of resident and prescription data from 13,507 residents residing in 1174 facilities, for an overall response rate of 78%. The 2004 NNHS was conducted using computerassisted personal interviews. It contained facility-level and resident-level modules. The facility-level module was completed by the interviewer before the residentlevel modules to confirm the eligibility of the facility for the survey. The resident’s health status was documented in the MDS assessment, and non-MDS assessments were collected by health-status module. Data on the residents of the facility were collected by trained interviewers through consultations with designated staff members familiar with the resident and his or her overall care. Residents were not contacted directly by the interviewers.
The American Journal of Geriatric Pharmacotherapy
Facility data contained provider characteristics such as facility size, ownership, Medicare/Medicaid certification, services provided, specialty programs offered, and charges. Recipient data contained demographic characteristics, health status, diagnoses, medications taken, services received, and sources of payment. Prescription data included ≤25 medications administered in the 24 hours before the interview and ≤15 medications taken by the resident on a regular basis for the last month before the interview but not taken in the last 24 hours. Prescribed medications were coded for the products, along with the generic ingredients, according to a unique classification scheme developed by the NCHS, and drug classes were categorized based on National Drug Code numbers.23 The resident file captured ≤34 diagnostic conditions— including 2 primary diagnostic conditions at the time of admission to the nursing home, 2 current primary diagnostic conditions, and 30 current secondary diagnostic conditions—by referring to the medical chart at the time of interview. All diagnostic conditions were coded based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Further details concerning the data collection systems, sampling scheme, and definitions used in the NNHS can be found in other sources.22,24
Study Sample and Analysis The study sample included a nationally representative sample of elderly nursing home residents aged ≥65 years from the 2004 NNHS. Antipsychotic drug use was defined as the use of an atypical or typical agent. Atypical antipsychotic agents were clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole.12 Typical antipsychotics were chlorpromazine, fluphenazine, haloperidol, loxapine, mesoridazine, perphenazine, promazine, thioridazine, thiothixene, trifluoperazine, and molidone.12 The resident and prescription files were merged to examine personal-level utilization data based on the unique identifier provided by the NCHS. Generic ingredient codes were used to identify typical and atypical antipsychotic agents for analysis. The 2004 NNHS data resulted in an unweighted sample of 11,939 elderly nursing home residents, and among them 2910 received an antipsychotic medication. The national estimates were derived for these records based on the inflation factor called sampling weight provided by the NCHS. The 2004 NNHS data are based on a complex probability survey design. The 2004 NNHS provided cluster and strata variables to account for design effects
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of stratification and the cluster. The survey design variables were incorporated in descriptive and multivariate analyses in SAS survey procedures (SAS Institute Inc., Cary, North Carolina) to accommodate the complex design of the NNHS. Survey procedures such as SURVEYFREQ and SURVEYMEANS were used for descriptive domain analysis. The Andersen behavioral model of health services was utilized to examine the factors associated with antipsychotic use in elderly nursing home residents.25 This model has been employed in other studies to determine medication use.26,27 According to the Andersen behavioral model, an individual’s use of health services is a function of 3 characteristics: predisposing, enabling, and need factors. Predisposing factors are characteristics of an individual that exist before illness and include demographic characteristics, social structure characteristics, and health beliefs. Enabling factors are those that give the individual the ability to secure the health services, such as income, health insurance, and availability of the service. Need factors represent either a subjective acknowledgment of need, such as a patient’s symptoms or the need for health care as perceived by the patient, or professional judgment, such as disease severity. Predisposing, enabling, and need factors were selected from the literature and the availability of the factors in the 2004 NNHS.10,28–33 Predisposing factors included demographic characteristics such as age, sex, ethnicity, and race. Source of payment and facility characteristics (ownership, bed size, and metropolitan area) were used as enabling factors. Behavioral characteristics (decisionmaking ability regarding tasks of daily life, depressed mood indicators, and behavioral symptoms), functional characteristics (activities of daily living [ADLs], bowel and bladder continence, bed mobility, and history of falls), diagnoses (schizophrenia, bipolar mania, dementia, anxiety, depression, diabetes mellitus [DM], parkinsonism, and cerebrovascular stroke), and total number of medications were included as need factors. The ICD-9-CM codes were used to group diagnoses such as schizophrenia (295.xx), bipolar mania (296.0x, 296.1x, 296.4x–295.8x), dementia (290.xx, 291.2, 294.xx, 331.xx, 046.1, 046.3), anxiety (300.02, 300.0x), depression (296.2–296.3x, 300.4x, 296.2x, 296.3x, 311), DM (250.xx, 357.2x, 362.01, 362.02, 366.41, 648.0x), parkinsonism (332.xx), and cerebrovascular stroke (430, 431, 434, 435, 436, 433). The ICD-9-CM definitions of these indications were identified through a comprehensive literature review and the ICD-9-CM database.34–38 Multiple logistic regression involving the SURVEYLOGISTIC procedure was used to identify factors as-
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sociated with antipsychotic drug use among elderly nursing home residents. The analytical sample size was 11,227 for multivariate analysis; data were missing for 712 cases. The dependent variable was the use of antipsychotic agents, and independent variables were various predisposing (age, sex, ethnicity, race), enabling (payment source and facility characteristics), and need (decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, ADLs, bowel and bladder continence, history of falls, bed mobility, total number of medications, and diagnoses [schizophrenia, bipolar mania, dementia, anxiety, depression, DM, parkinsonism, and cerebrovascular stroke]) factors. Subgroup multivariate analysis was performed by creating modified weight variables as recommended by the NCHS.39 The NCHS method involves the use of sampling weight for subpopulations of interest and an assignment of near zero weight to observations that do not belong to the subpopulation. Statistical significance was defined as 0.05.
RESULTS According to the 2004 NNHS, 1.32 (95% CI, 1.30– 1.33) million elderly individuals resided in US nursing homes. Most elderly nursing home residents were female (74%), aged >85 years (51%), non-Hispanic (97%), and white (87%). Most resided in nursing homes that were for-profit (60%), with a bed size of 100 to 199 (53%), and located in a metropolitan area (75%). Each elderly nursing home resident could perform a mean of 4.11 (95% CI, 4.09–4.14) ADLs and received a mean of 9.56 (95% CI, 9.36–9.77) prescription medications. Table I shows the prevalence of antipsychotic drug use among the elderly nursing home residents. Analysis of prescription data revealed that 0.32 million (95% CI, 0.31–0.33) elderly residents received antipsychotic medications, for an overall prevalence of 24.82% (95% CI, 23.90–25.74). Most (23.45%) received atypical agents rather than typical agents (1.90%), while <1.0% received both atypical and typical antipsychotics. Among atypical agents, olanzapine (8.29%) was the most commonly prescribed, followed by risperidone (7.89%) and quetiapine (6.46%). Among typical agents, haloperidol was most commonly prescribed (1.04%), while other typical agents were prescribed in <1.0% of elderly residents. Table II presents selected characteristics of elderly nursing home residents who were users and nonusers of antipsychotic agents. Most users of these agents were aged <85 years (56%), female (71%), non-Hispanic
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The American Journal of Geriatric Pharmacotherapy
Table I. Prevalence of antipsychotic drug use among elderly nursing home residents in the United States. "OUJQTZDIPUJD 5SFBUNFOU
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(96%), and white (90%). Frequently reported diagnoses among antipsychotic users were dementia (70%), depression (41%), and anxiety (18%). The elderly nursing home residents who were using antipsychotic medications could perform a mean of 4.10 (95% CI, 4.03–4.12) ADLs. Each elderly antipsychotic drug user received a mean of 9.56 (95% CI, 9.40–9.73) medications. Table III shows the results of a multiple logistic regression with crude and adjusted odds ratios along with 95% CIs for receiving antipsychotic medications. Among the predisposing characteristics, the likelihood of receiving antipsychotic agents was lower for women and those aged ≥85 years. Enabling factors such as payment source and facility characteristics were not significantly associated with antipsychotic drug use. Among the need factors, the likelihood of receiving antipsychotic agents increased with dependence in
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decision-making ability regarding tasks of daily life, indicators of depressed mood, behavioral symptoms, history of falls, and bowel incontinence. The likelihood of receiving antipsychotic agents decreased for the elderly with increased need of assistance for bed mobility. The odds of receiving antipsychotic treatment also increased with a diagnosis of schizophrenia, dementia, bipolar mania, anxiety, depression, or parkinsonism. The odds of receiving antipsychotic treatment decreased with a diagnosis of cerebrovascular stroke.
DISCUSSION According to the 2004 NNHS, nearly 25% of elderly nursing home residents received antipsychotic medications, with most receiving atypical agents. Compared with the prevalence (15.0%) reported by Liperoti et al10 based on data from 1999–2000, the current study
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The American Journal of Geriatric Pharmacotherapy
Table III. Factors significantly associated with antipsychotic drug use in elderly nursing home residents in the United States. $IBSBDUFSJTUJD †
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found higher use of antipsychotic drugs among the elderly nursing home residents. However, our study findings are consistent when compared with results from the national study (27.6%) conducted by Briesacher et al11 based on the 2000–2001 MCBS. Increasing use of antipsychotic agents in the elderly in recent years suggests the need to monitor the use of such drugs in nursing homes for efficacy and safety reasons.17–21 The current study found a high use of atypical antipsychotic agents; 23.45% of the elderly nursing home residents received an atypical antipsychotic agent. In addition, the ratio of typical to atypical antipsychotic drug use was 1:12.7. Previous studies have found a much lower ratio.10,11 Liperoti et al10 found a 1:1.5 ratio of typical to atypical antipsychotic utilization using 1999– 2000 computerized MDS assessment records. Briesacher et al11 found a ratio of 1:5.5 based on the 2000– 2001 MCBS. The findings suggest that atypical agents are replacing typical agents, which is consistent with the trend reported in community settings.40 This may be because of a better adverse-effect profile of the atypical agents, an increase in off-label use of atypical agents, or increased access to atypical agents.12,13,17 This study found that several predisposing and need factors were associated with antipsychotic drug use among the elderly nursing home residents. Multivariate analysis revealed that predisposing characteristics such as female gender and age (≥85 years) were negatively associated with antipsychotic drug use. Unlike research involving other psychotropic agents,41 this study revealed that elderly women were less likely to receive an-
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tipsychotic medications than elderly men. This may be attributed to gender-based behavioral symptoms. Consistent with a previous study,33 our study found those aged ≥85 years were less likely to receive antipsychotic agents compared with residents aged 65 to 74 years. Need factors such as dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, bowel incontinence, history of falls, and bed mobility were associated with antipsychotic drug use. These findings are consistent with the cross-sectional study conducted by Lindesay et al,33 which used data from 2 censuses in 1990 (4528 residents) and 1997 (4226 residents) involving elderly patients from nursing homes in Leicestershire, United Kingdom. Elderly residents with depressed mood indicators and behavioral symptoms were more likely to receive antipsychotic medications than those without these symptoms. Elderly residents who had severely impaired decision-making ability regarding tasks of daily life were also more likely to receive antipsychotic medications than those who were independent in their decision making. Those with bowel incontinence were more likely to receive antipsychotic medication than those who were continent. As dependence on others for bed mobility increased, the odds of receiving antipsychotic agents decreased. The findings of this study suggest a strong association between behavioral/ functional characteristics and antipsychotic use among elderly nursing home residents. Although the study did not address clinical appropriateness of antipsychotic use due to limited clinical data, the study findings suggest
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the importance of behavioral characteristics in the use of antipsychotic agents in the elderly and the frailty of those elderly receiving these potent medications. Our study found that residents with a history of falls were 16% more likely to receive antipsychotic agents compared with residents without a history of falls. However, Lindesay et al33 found that elderly residents with falls were 6% less likely to receive antipsychotic treatment based on 1997 data. This inconsistent finding may be attributed to increased use of antipsychotic agents, especially atypical agents; the previous study was based on data involving typical agents. The use of antipsychotics in the elderly with a history of falls is a concern, as antipsychotic agents can cause sedation, postural hypotension, dizziness, and extrapyramidal adverse effects that can lead to falls or fractures, especially in older patients.42,43 The study findings suggest the need to monitor use of antipsychotic agents among elderly residents with a history of falls. Multivariate analysis found that those diagnosed with schizophrenia, dementia, bipolar mania, anxiety, depression, or parkinsonism were more likely to receive antipsychotic agents than those without these disorders. The study found high use of antipsychotic drugs in off-label conditions such as dementia, anxiety, depression, and parkinsonism. Previous research found that up to 70% of atypical antipsychotics are used in disorders other than schizophrenia.13 The evidence base for use of antipsychotic agents, especially atypical agents, for the treatment of psychiatric disorders other than schizophrenia and bipolar mania is limited, according to the AHRQ report.17 Current analysis also revealed that elderly residents diagnosed with cerebrovascular stroke were less likely to receive antipsychotic treatment. This may be because of the warning about an increased risk of stroke and transient ischemic attack among elderly patients with dementia being treated with risperidone and olanzapine.44,45 This study suggests a need to monitor indication-based use of antipsychotic agents in the elderly in light of these efficacy and safety data. Our study does have some limitations. The findings are limited to the definitions and data source used in the original survey. The analysis focused on all antipsychotic agents and not on a specific class such as the atypical agents. The sample was limited to elderly nursing home residents in 2004 and cannot be generalized to other settings or years. Various predisposing, enabling, and need factors used in the logistic regression analysis were limited to those available from the data source. Variables such as belief constructs (patient per-
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ception) of the Andersen behavioral model, prescriber characteristics (specialty), and local area characteristics (region) were not incorporated due to limitations of the data source. The cross-sectional multivariate analysis examined only the association between the factors and antipsychotic drug use and did not address any cause-and-effect relationship. The inherent disadvantages of using secondary data—such as difficulty in assessing accuracy due to errors in data collection, editing, and imputation—were also limitations of this study. The research findings could be affected by both sampling error and sources of nonsampling error, respondent reporting errors, and interviewer effects. Also, the national estimates based on small subsamples could affect the confidence level of estimates and thereby influence their reliability.
CONCLUSIONS The study found that nearly 1 in 4 elderly nursing home residents in the United States used antipsychotic agents, with a 1:12.7 ratio of typical to atypical antipsychotic use. The most frequently used atypical agents were olanzapine, risperidone, and quetiapine. This study found that both predisposing and need factors played a vital role in determining the use of antipsychotic agents in elderly nursing home residents. In addition to their approved use in schizophrenia and bipolar mania, antipsychotic agents were extensively used in off-label conditions (eg, dementia, anxiety, depression, parkinsonism). Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by the elderly in US nursing homes in light of recent efficacy and safety data on atypical agents.
ACKNOWLEDGMENT The authors thank Sham Chaudhari, MS, College of Pharmacy, University of Houston, Houston, Texas, for assistance with data coding and extraction.
REFERENCES 1. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: Epidemiologic evidence suggesting misuse. Am J Public Health. 1980;70: 485–491. 2. Omnibus Budget Reconciliation Act of 1987 (OBRA 87). Public Law 100–203, Title V, Subtitle C: Nursing Home Reform. Washington, DC; December 22, 1987. 3. Hughes CM, Lapane KL. Administrative initiatives for reducing inappropriate prescribing of psychotropic drugs in nursing homes: How successful have they been? Drugs Aging. 2005;22:339–351.
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4. Rovner BW, Edelman BA, Cox MP, Shmuely Y. The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes. Am J Psychiatry. 1992;149:1390–1392. 5. Semla TP, Palla K, Poddig B, Brauner DJ. Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents. J Am Geriatr Soc. 1994;42:648–652. 6. Shorr RI, Fought RL, Ray WA. Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations. JAMA. 1994;271:358–362. 7. Garrard J, Chen V, Dowd B. The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes. Am J Public Health. 1995;85: 771–776. 8. Siegler EL, Capezuti E, Maislin G, et al. Effects of a restraint reduction intervention and OBRA ’87 regulations on psychotropic drug use in nursing homes. J Am Geriatr Soc. 1997;45:791–796. 9. Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care. 2000;38:1164–1173. 10. Liperoti R, Mor V, Lapane KL, et al. The use of atypical antipsychotics in nursing homes. J Clin Psychiatry. 2003; 64:1106–1112. 11. Briesacher BA, Limcangco MR, Simoni-Wastila L, et al. The quality of antipsychotic drug prescribing in nursing homes. Arch Intern Med. 2005;165:1280–1285. 12. Zuvekas SH. Prescription drugs and the changing patterns of treatment for mental disorders, 1996–2001. Health Aff (Millwood). 2005;24:195–205. 13. Glick ID, Murray SR, Vasudevan P, et al. Treatment with atypical antipsychotics: New indications and new populations. J Psychiatr Res. 2001;35:187–191. 14. Verma SD, Davidoff DA, Kambhampati KK. Management of the agitated elderly patients in the nursing home: The role of the atypical antipsychotics. J Clin Psychiatry. 1998;59(Suppl 19):50–55. 15. Daniel DG. Antipsychotic treatment of psychosis and agitation in the elderly. J Clin Psychiatry. 2000;61(Suppl 14):49–52. 16. Lee PE, Gill SS, Freedman M, et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: Systematic review. BMJ. 2004; 329:75. 17. Efficacy and comparative effectiveness of off-label use of atypical antipsychotics. Rockville, Md: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 07-EHC003-EF. 18. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-
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19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934–1943. Deaths with antipsychotics in elderly patients with behavioral disturbances [FDA public health advisory]. http:// www.fda.gov/Cder/drug/advisory/antipsychotics.htm. Accessed July 18, 2008. Lieberman JA, Stroup TS, McEvoy JP, et al, for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353:1209–1223. Schneider LS, Tariot PN, Dagerman KS, et al, for the CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525–1538. National Nursing Home Survey Documentation. ftp:// ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_ Documentation/NNHS/nnhs04/. Accessed July 18, 2008. Koch H, Campbell W. The collection and processing of drug information: National Ambulatory Medical Care Survey—United States, 1980. Vital Health Stat 2. 1982;1–90. National Nursing Home Survey: Public-use data files. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Datasets/NNHS/nnhs04/. Accessed July 18, 2008. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51:95– 124. Gray SL, Hanlon JT, Fillenbaum GG, et al. Predictors of nutritional supplement use by the elderly. Pharmacotherapy. 1996;16:715–720. Aparasu RR, Mort JR, Brandt H. Psychotropic prescription use by community-dwelling elderly in the United States. J Am Geriatr Soc. 2003;51:671–677. Liperoti R, Gambassi G, Lapane KL, et al. Cerebrovascular events among elderly nursing home patients treated with conventional or atypical antipsychotics. J Clin Psychiatry. 2005;66:1090–1096. Sørensen L, Foldspang A, Gulmann NC, Munk-Jørgensen P. Determinants for the use of psychotropics among nursing home residents. Int J Geriatr Psychiatry. 2001; 16:147–154. Hien le TT, Cumming RG, Cameron ID, et al. Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc. 2005;53:1290– 1295. Frenchman IB. Atypical antipsychotics for nursing home patients: A retrospective chart review. Drugs Aging. 2005;22:257–264.
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32. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med. 2007;167:676–683. 33. Lindesay J, Matthews R, Jagger C. Factors associated with antipsychotic drug use in residential care: Changes between 1990 and 1997. Int J Geriatr Psychiatry. 2003; 18:511–519. 34. Chen H, Reeves JH, Fincham JE, et al. Off-label use of antidepressant, anticonvulsant, and antipsychotic medications among Georgia Medicaid enrollees in 2001. J Clin Psychiatry. 2006;67:972–982. 35. Gruber-Baldini AL, Stuart B, Zuckerman IH, et al. Treatment of dementia in community-dwelling and institutionalized Medicare beneficiaries [published correction appears in J Am Geriatr Soc. 2007;55:1697]. J Am Geriatr Soc. 2007;55:1508–1516. 36. Sclar DA, Robison LM, Gavrun C, Skaer TL. Hospital length of stay for children and adolescents diagnosed with depression: Is primary payer an influencing factor? Gen Hosp Psychiatry. 2008;30:73–76. 37. McLaughlin T, Geissler EC, Wan GJ. Comorbidities and associated treatment charges in patients with anxiety disorders. Pharmacotherapy. 2003;23:1251–1256. 38. Touré JT, Brandt NJ, Limcangco MR, Briesacher BA. Impact of second-generation antipsychotics on the use of antiparkinson agents in nursing homes and assisted-living facilities. Am J Geriatr Pharmacother. 2006;4:25–35.
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39. Continuous NHANES Web Tutorial: Logistic Regression. http://www.cdc.gov/nchs/tutorials/NHANES/ NHANESAnalyses/LogisticRegression/logistic_regression_ intro.htm. Accessed July 18, 2008. 40. Jano E, Johnson M, Chen H, Aparasu RR. Determinants of atypical antipsychotic use among antipsychotic users in community-dwelling elderly, 1996–2004. Curr Med Res Opin. 2008;24:709–716. 41. Aparasu RR, Mort JR. Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly. Am J Geriatr Pharmacother. 2004;2:102–111. 42. Ballard CG, Margallo-Lana ML. The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. J Clin Psychiatr. 2004;65(Suppl 11): 23–28. 43. Jackson-Siegal JM, Schneider LS, Baskys A, Haupt DW. Recognizing and responding to atypical antipsychotic side effects. J Am Med Dir Assoc. 2004;5(Suppl 4):H7– H10. 44. Wooltorton E. Risperidone (Risperidal): Increased rate of cerebrovascular events in dementia trials. CMAJ. 2002; 167:1269–1270. 45. Wooltorton E. Olanzapine (Zyprexa): Increased incidence of cerebrovascular events in dementia trials. CMAJ. 2004;170:1395.
Address correspondence to: Rajender R. Aparasu, MPharm, PhD, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Texas Medical Center, 1441 Moursund Street, Houston, TX 77030. E-mail: [email protected]
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Antipsychotic Drug Use Among Elderly Nursing Home Residents in the United States Pravin Kamble, BPharm; Hua Chen, MD, PhD; Jeff Sherer, PharmD, MPH, BCPS, CGP; and Rajender R. Aparasu, MPharm, PhD Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Houston, Texas
ABSTRACT Background: Antipsychotic utilization in elderly nursing home residents has increased substantially in recent years, primarily due to the use of atypical antipsychotic agents. However, few studies have examined antipsychotic utilization patterns in nursing home residents in the United States since the introduction of atypical agents in the 1990s. Objective: The goal of this study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States. Methods: This study involved a cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey (NNHS). The analysis focused on the use of 11 typical and 6 atypical antipsychotic agents among a nationally representative sample of elderly patients (aged ≥65 years). Descriptive weighted analysis was performed to examine antipsychotic prevalence patterns. Multiple logistic regression analysis within the conceptual framework of the Andersen behavioral model was used to examine the factors associated with antipsychotic drug use among the elderly nursing home residents. Results: According to the 2004 NNHS, 0.32 million elderly nursing home residents received antipsychotic medications, for an overall prevalence of 24.82%. Most received atypical agents (23.45%), while 1.90% received typical agents. Frequently reported diagnoses among the elderly using an antipsychotic agent were dementia (70%), depression (41%), and anxiety (18%). Among the predisposing characteristics, female gender and age (≥85 years) were negatively associated with antipsychotic drug use. Need factors such as increasing dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, history of falls, and bowel incontinence were positively associated with antipsychotic drug use. In addition to the use of antipsychotic agents in schizophrenia and bipolar mania, this study found high use in conditions such as dementia, anxiety, depression, and parkinsonism in the elderly. Conclusions: Nearly 1 in 4 elderly nursing home residents in the United States received antipsychotic agents. Predisposing and need factors played a vital role in determining the use of antipsychotic agents in these elderly patients. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in US nursing homes in light of recent efficacy and safety data on atypical agents. (Am J Geriatr Pharmacother. 2008;6:187–197) © 2008 Excerpta Medica Inc. Key words: antipsychotic, nursing home, elderly, atypical, typical. Accepted for publication July 25, 2008. ª&YDFSQUB.FEJDB*OD"MMSJHIUTSFTFSWFE
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INTRODUCTION Inappropriate use of antipsychotic medications in nursing homes has been a concern for many years.1 The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) was enacted to improve quality of care in nursing homes.2,3 Specifically, explicit criteria for potentially inappropriate antipsychotic use were included in the interpretative guidelines for nursing homes.2,3 Research has shown that antipsychotic drug use declined 30% to 36% among nursing home residents after the enforcement of the OBRA 87 regulations.3,4–8 However, studies have found the prevalence of antipsychotic medication use to be 15% to 27%, based on data from 1999 onward.9–11 These studies reported an increasing prevalence of antipsychotic drug use in nursing homes in recent years. Expenditures for atypical antipsychotic agents among Medicare beneficiaries increased from US $10 million in 1996 to US $151 million in 2002, a 15-fold increase in 6 years.12 The increase in antipsychotic prescribing and high drug expenditures have been attributed to greater use of atypical antipsychotic agents versus typical agents.11,12 Atypical antipsychotic agents, such as risperidone and olanzapine, are commonly used in the elderly for the management of various psychiatric disorders.9–11 Although the US Food and Drug Administration (FDA) has approved atypical agents for the treatment of schizophrenia and bipolar mania, they are extensively used (43%–70%) for off-label indications.13 In the elderly, atypical antipsychotic agents are often used (30%–37%) to manage the behavioral symptoms of dementia.14–16 However, the Agency for Healthcare Research and Quality (AHRQ) report found only a moderate level of evidence supporting the effectiveness of atypical agents in the treatment of behavioral symptoms of dementia based on data from published randomized clinical trials.17 The review also found that atypical agents are associated with an increase in risk of death and stroke, neurologic problems, and weight gain in patients with dementia.17,18 An FDA analysis of placebo-controlled trials conducted with olanzapine, aripiprazole, risperidone, and quetiapine also found an increase in mortality in the drug-treated group compared with the group receiving placebo.19 In 2005, the FDA issued warnings for all atypical agents due to the increased risk of mortality.19 The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) studies were funded by the National Institute of Mental Health to address the limited availability of effectiveness data comparing typical and atypical agents.20 The initial CATIE study was conducted in 1493 randomized patients aged 18 to 65 years
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with schizophrenia.20 The study found that time to discontinuation for any cause was longer for olanzapine (9.2 months) and perphenazine (5.6 months) but shorter for risperidone (4.8 months) and quetiapine (4.6 months). Time to discontinuation due to intolerable adverse effects was similar among patients receiving olanzapine, perphenazine, risperidone, and quetiapine. Patients were more likely (9%) to discontinue olanzapine due to metabolic adverse effects or weight gain and more likely (8%) to discontinue perphenazine due to extrapyramidal adverse effects. Another CATIE study investigated the effect of atypical antipsychotic agents in 421 patients with Alzheimer’s disease (mean [SD] age, 77.9 [7.5] years).21 This study found no significant differences among olanzapine, quetiapine, risperidone, or placebo with regard to time to discontinuation of treatment for any reason. Median time to discontinuation of treatment due to lack of efficacy was longer with risperidone and olanzapine compared with quetiapine and placebo. The study concluded that there was no advantage to using atypical antipsychotic agents over placebo due to the adverse effects experienced with antipsychotic agents in these patients with dementia. In light of recent efficacy and safety data on atypical agents,17–21 there is a need to examine antipsychotic drug use in elderly nursing home residents. A MEDLINE review (search terms: nursing homes, elderly, atypical, typical, antipsychotics; years searched: January 1990–June 2008) revealed that few studies have examined antipsychotic utilization patterns in US nursing home residents since the introduction of the atypical antipsychotic agents in the 1990s.10,11 Liperoti et al10 conducted a cross-sectional study to describe the pattern of atypical antipsychotic drug use among elderly nursing home residents by using computerized Minimum Data Set (MDS) assessment records from 1999 to 2000. This study, which was limited to 5 US states, found that the prevalence of antipsychotic drug use was 15.0% among 139,174 elderly residents from 1732 facilities. Another nationally representative, retrospective cross-sectional study was conducted by Briesacher et al,11 using the 2000–2001 Medicare Current Beneficiary Survey (MCBS) to examine the prevalence of antipsychotic drug use and its appropriateness among communitydwelling and institutionalized elderly. This study found a 27.6% prevalence of antipsychotic drug use among 2.5 million Medicare beneficiaries nationwide. Understanding prevalence patterns and factors associated with antipsychotic drug use based on more recent, nationally representative data can be instrumental in optimizing
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antipsychotic drug use and expenditures in this vulnerable population. Therefore, the aim of the current study was to examine the prevalence of and the factors associated with antipsychotic drug use among elderly nursing home residents in the United States.
MATERIALS AND METHODS
Data Source
The National Nursing Home Survey (NNHS) is conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention to provide national-level data on providers and recipients of care in US nursing homes. The NNHS is a nationally representative sample survey of US nursing homes, their services, their staff, and their residents. It is conducted periodically, and the latest survey available is from 2004.22 The current study involved the public use data files from the 2004 NNHS to examine the prevalence of antipsychotic drug use and to identify the factors associated with such use among elderly nursing home residents. The study was approved by the University of Houston’s Committee for the Protection of Human Subjects (Houston, Texas). The 2004 NNHS involved a stratified 2-stage probability design.22 The first stage was the selection of facilities, and the second stage was the selection of residents. The nursing homes that participated in the NNHS had ≥3 beds and were certified by either Medicare or Medicaid, or had a state license to operate as a nursing home. Nursing homes were then selected using systematic sampling with a probability proportional to their bed size. The second stage, sampling of current residents, was conducted by interviewers at the time of their visits to the facilities. A sample of ≤12 current residents per facility was selected for the final interview. The 2004 NNHS consisted of resident and prescription data from 13,507 residents residing in 1174 facilities, for an overall response rate of 78%. The 2004 NNHS was conducted using computerassisted personal interviews. It contained facility-level and resident-level modules. The facility-level module was completed by the interviewer before the residentlevel modules to confirm the eligibility of the facility for the survey. The resident’s health status was documented in the MDS assessment, and non-MDS assessments were collected by health-status module. Data on the residents of the facility were collected by trained interviewers through consultations with designated staff members familiar with the resident and his or her overall care. Residents were not contacted directly by the interviewers.
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Facility data contained provider characteristics such as facility size, ownership, Medicare/Medicaid certification, services provided, specialty programs offered, and charges. Recipient data contained demographic characteristics, health status, diagnoses, medications taken, services received, and sources of payment. Prescription data included ≤25 medications administered in the 24 hours before the interview and ≤15 medications taken by the resident on a regular basis for the last month before the interview but not taken in the last 24 hours. Prescribed medications were coded for the products, along with the generic ingredients, according to a unique classification scheme developed by the NCHS, and drug classes were categorized based on National Drug Code numbers.23 The resident file captured ≤34 diagnostic conditions— including 2 primary diagnostic conditions at the time of admission to the nursing home, 2 current primary diagnostic conditions, and 30 current secondary diagnostic conditions—by referring to the medical chart at the time of interview. All diagnostic conditions were coded based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Further details concerning the data collection systems, sampling scheme, and definitions used in the NNHS can be found in other sources.22,24
Study Sample and Analysis The study sample included a nationally representative sample of elderly nursing home residents aged ≥65 years from the 2004 NNHS. Antipsychotic drug use was defined as the use of an atypical or typical agent. Atypical antipsychotic agents were clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole.12 Typical antipsychotics were chlorpromazine, fluphenazine, haloperidol, loxapine, mesoridazine, perphenazine, promazine, thioridazine, thiothixene, trifluoperazine, and molidone.12 The resident and prescription files were merged to examine personal-level utilization data based on the unique identifier provided by the NCHS. Generic ingredient codes were used to identify typical and atypical antipsychotic agents for analysis. The 2004 NNHS data resulted in an unweighted sample of 11,939 elderly nursing home residents, and among them 2910 received an antipsychotic medication. The national estimates were derived for these records based on the inflation factor called sampling weight provided by the NCHS. The 2004 NNHS data are based on a complex probability survey design. The 2004 NNHS provided cluster and strata variables to account for design effects
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of stratification and the cluster. The survey design variables were incorporated in descriptive and multivariate analyses in SAS survey procedures (SAS Institute Inc., Cary, North Carolina) to accommodate the complex design of the NNHS. Survey procedures such as SURVEYFREQ and SURVEYMEANS were used for descriptive domain analysis. The Andersen behavioral model of health services was utilized to examine the factors associated with antipsychotic use in elderly nursing home residents.25 This model has been employed in other studies to determine medication use.26,27 According to the Andersen behavioral model, an individual’s use of health services is a function of 3 characteristics: predisposing, enabling, and need factors. Predisposing factors are characteristics of an individual that exist before illness and include demographic characteristics, social structure characteristics, and health beliefs. Enabling factors are those that give the individual the ability to secure the health services, such as income, health insurance, and availability of the service. Need factors represent either a subjective acknowledgment of need, such as a patient’s symptoms or the need for health care as perceived by the patient, or professional judgment, such as disease severity. Predisposing, enabling, and need factors were selected from the literature and the availability of the factors in the 2004 NNHS.10,28–33 Predisposing factors included demographic characteristics such as age, sex, ethnicity, and race. Source of payment and facility characteristics (ownership, bed size, and metropolitan area) were used as enabling factors. Behavioral characteristics (decisionmaking ability regarding tasks of daily life, depressed mood indicators, and behavioral symptoms), functional characteristics (activities of daily living [ADLs], bowel and bladder continence, bed mobility, and history of falls), diagnoses (schizophrenia, bipolar mania, dementia, anxiety, depression, diabetes mellitus [DM], parkinsonism, and cerebrovascular stroke), and total number of medications were included as need factors. The ICD-9-CM codes were used to group diagnoses such as schizophrenia (295.xx), bipolar mania (296.0x, 296.1x, 296.4x–295.8x), dementia (290.xx, 291.2, 294.xx, 331.xx, 046.1, 046.3), anxiety (300.02, 300.0x), depression (296.2–296.3x, 300.4x, 296.2x, 296.3x, 311), DM (250.xx, 357.2x, 362.01, 362.02, 366.41, 648.0x), parkinsonism (332.xx), and cerebrovascular stroke (430, 431, 434, 435, 436, 433). The ICD-9-CM definitions of these indications were identified through a comprehensive literature review and the ICD-9-CM database.34–38 Multiple logistic regression involving the SURVEYLOGISTIC procedure was used to identify factors as-
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sociated with antipsychotic drug use among elderly nursing home residents. The analytical sample size was 11,227 for multivariate analysis; data were missing for 712 cases. The dependent variable was the use of antipsychotic agents, and independent variables were various predisposing (age, sex, ethnicity, race), enabling (payment source and facility characteristics), and need (decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, ADLs, bowel and bladder continence, history of falls, bed mobility, total number of medications, and diagnoses [schizophrenia, bipolar mania, dementia, anxiety, depression, DM, parkinsonism, and cerebrovascular stroke]) factors. Subgroup multivariate analysis was performed by creating modified weight variables as recommended by the NCHS.39 The NCHS method involves the use of sampling weight for subpopulations of interest and an assignment of near zero weight to observations that do not belong to the subpopulation. Statistical significance was defined as 0.05.
RESULTS According to the 2004 NNHS, 1.32 (95% CI, 1.30– 1.33) million elderly individuals resided in US nursing homes. Most elderly nursing home residents were female (74%), aged >85 years (51%), non-Hispanic (97%), and white (87%). Most resided in nursing homes that were for-profit (60%), with a bed size of 100 to 199 (53%), and located in a metropolitan area (75%). Each elderly nursing home resident could perform a mean of 4.11 (95% CI, 4.09–4.14) ADLs and received a mean of 9.56 (95% CI, 9.36–9.77) prescription medications. Table I shows the prevalence of antipsychotic drug use among the elderly nursing home residents. Analysis of prescription data revealed that 0.32 million (95% CI, 0.31–0.33) elderly residents received antipsychotic medications, for an overall prevalence of 24.82% (95% CI, 23.90–25.74). Most (23.45%) received atypical agents rather than typical agents (1.90%), while <1.0% received both atypical and typical antipsychotics. Among atypical agents, olanzapine (8.29%) was the most commonly prescribed, followed by risperidone (7.89%) and quetiapine (6.46%). Among typical agents, haloperidol was most commonly prescribed (1.04%), while other typical agents were prescribed in <1.0% of elderly residents. Table II presents selected characteristics of elderly nursing home residents who were users and nonusers of antipsychotic agents. Most users of these agents were aged <85 years (56%), female (71%), non-Hispanic
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Table I. Prevalence of antipsychotic drug use among elderly nursing home residents in the United States. "OUJQTZDIPUJD 5SFBUNFOU
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(96%), and white (90%). Frequently reported diagnoses among antipsychotic users were dementia (70%), depression (41%), and anxiety (18%). The elderly nursing home residents who were using antipsychotic medications could perform a mean of 4.10 (95% CI, 4.03–4.12) ADLs. Each elderly antipsychotic drug user received a mean of 9.56 (95% CI, 9.40–9.73) medications. Table III shows the results of a multiple logistic regression with crude and adjusted odds ratios along with 95% CIs for receiving antipsychotic medications. Among the predisposing characteristics, the likelihood of receiving antipsychotic agents was lower for women and those aged ≥85 years. Enabling factors such as payment source and facility characteristics were not significantly associated with antipsychotic drug use. Among the need factors, the likelihood of receiving antipsychotic agents increased with dependence in
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decision-making ability regarding tasks of daily life, indicators of depressed mood, behavioral symptoms, history of falls, and bowel incontinence. The likelihood of receiving antipsychotic agents decreased for the elderly with increased need of assistance for bed mobility. The odds of receiving antipsychotic treatment also increased with a diagnosis of schizophrenia, dementia, bipolar mania, anxiety, depression, or parkinsonism. The odds of receiving antipsychotic treatment decreased with a diagnosis of cerebrovascular stroke.
DISCUSSION According to the 2004 NNHS, nearly 25% of elderly nursing home residents received antipsychotic medications, with most receiving atypical agents. Compared with the prevalence (15.0%) reported by Liperoti et al10 based on data from 1999–2000, the current study
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found higher use of antipsychotic drugs among the elderly nursing home residents. However, our study findings are consistent when compared with results from the national study (27.6%) conducted by Briesacher et al11 based on the 2000–2001 MCBS. Increasing use of antipsychotic agents in the elderly in recent years suggests the need to monitor the use of such drugs in nursing homes for efficacy and safety reasons.17–21 The current study found a high use of atypical antipsychotic agents; 23.45% of the elderly nursing home residents received an atypical antipsychotic agent. In addition, the ratio of typical to atypical antipsychotic drug use was 1:12.7. Previous studies have found a much lower ratio.10,11 Liperoti et al10 found a 1:1.5 ratio of typical to atypical antipsychotic utilization using 1999– 2000 computerized MDS assessment records. Briesacher et al11 found a ratio of 1:5.5 based on the 2000– 2001 MCBS. The findings suggest that atypical agents are replacing typical agents, which is consistent with the trend reported in community settings.40 This may be because of a better adverse-effect profile of the atypical agents, an increase in off-label use of atypical agents, or increased access to atypical agents.12,13,17 This study found that several predisposing and need factors were associated with antipsychotic drug use among the elderly nursing home residents. Multivariate analysis revealed that predisposing characteristics such as female gender and age (≥85 years) were negatively associated with antipsychotic drug use. Unlike research involving other psychotropic agents,41 this study revealed that elderly women were less likely to receive an-
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tipsychotic medications than elderly men. This may be attributed to gender-based behavioral symptoms. Consistent with a previous study,33 our study found those aged ≥85 years were less likely to receive antipsychotic agents compared with residents aged 65 to 74 years. Need factors such as dependence in decision-making ability regarding tasks of daily life, depressed mood indicators, behavioral symptoms, bowel incontinence, history of falls, and bed mobility were associated with antipsychotic drug use. These findings are consistent with the cross-sectional study conducted by Lindesay et al,33 which used data from 2 censuses in 1990 (4528 residents) and 1997 (4226 residents) involving elderly patients from nursing homes in Leicestershire, United Kingdom. Elderly residents with depressed mood indicators and behavioral symptoms were more likely to receive antipsychotic medications than those without these symptoms. Elderly residents who had severely impaired decision-making ability regarding tasks of daily life were also more likely to receive antipsychotic medications than those who were independent in their decision making. Those with bowel incontinence were more likely to receive antipsychotic medication than those who were continent. As dependence on others for bed mobility increased, the odds of receiving antipsychotic agents decreased. The findings of this study suggest a strong association between behavioral/ functional characteristics and antipsychotic use among elderly nursing home residents. Although the study did not address clinical appropriateness of antipsychotic use due to limited clinical data, the study findings suggest
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the importance of behavioral characteristics in the use of antipsychotic agents in the elderly and the frailty of those elderly receiving these potent medications. Our study found that residents with a history of falls were 16% more likely to receive antipsychotic agents compared with residents without a history of falls. However, Lindesay et al33 found that elderly residents with falls were 6% less likely to receive antipsychotic treatment based on 1997 data. This inconsistent finding may be attributed to increased use of antipsychotic agents, especially atypical agents; the previous study was based on data involving typical agents. The use of antipsychotics in the elderly with a history of falls is a concern, as antipsychotic agents can cause sedation, postural hypotension, dizziness, and extrapyramidal adverse effects that can lead to falls or fractures, especially in older patients.42,43 The study findings suggest the need to monitor use of antipsychotic agents among elderly residents with a history of falls. Multivariate analysis found that those diagnosed with schizophrenia, dementia, bipolar mania, anxiety, depression, or parkinsonism were more likely to receive antipsychotic agents than those without these disorders. The study found high use of antipsychotic drugs in off-label conditions such as dementia, anxiety, depression, and parkinsonism. Previous research found that up to 70% of atypical antipsychotics are used in disorders other than schizophrenia.13 The evidence base for use of antipsychotic agents, especially atypical agents, for the treatment of psychiatric disorders other than schizophrenia and bipolar mania is limited, according to the AHRQ report.17 Current analysis also revealed that elderly residents diagnosed with cerebrovascular stroke were less likely to receive antipsychotic treatment. This may be because of the warning about an increased risk of stroke and transient ischemic attack among elderly patients with dementia being treated with risperidone and olanzapine.44,45 This study suggests a need to monitor indication-based use of antipsychotic agents in the elderly in light of these efficacy and safety data. Our study does have some limitations. The findings are limited to the definitions and data source used in the original survey. The analysis focused on all antipsychotic agents and not on a specific class such as the atypical agents. The sample was limited to elderly nursing home residents in 2004 and cannot be generalized to other settings or years. Various predisposing, enabling, and need factors used in the logistic regression analysis were limited to those available from the data source. Variables such as belief constructs (patient per-
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ception) of the Andersen behavioral model, prescriber characteristics (specialty), and local area characteristics (region) were not incorporated due to limitations of the data source. The cross-sectional multivariate analysis examined only the association between the factors and antipsychotic drug use and did not address any cause-and-effect relationship. The inherent disadvantages of using secondary data—such as difficulty in assessing accuracy due to errors in data collection, editing, and imputation—were also limitations of this study. The research findings could be affected by both sampling error and sources of nonsampling error, respondent reporting errors, and interviewer effects. Also, the national estimates based on small subsamples could affect the confidence level of estimates and thereby influence their reliability.
CONCLUSIONS The study found that nearly 1 in 4 elderly nursing home residents in the United States used antipsychotic agents, with a 1:12.7 ratio of typical to atypical antipsychotic use. The most frequently used atypical agents were olanzapine, risperidone, and quetiapine. This study found that both predisposing and need factors played a vital role in determining the use of antipsychotic agents in elderly nursing home residents. In addition to their approved use in schizophrenia and bipolar mania, antipsychotic agents were extensively used in off-label conditions (eg, dementia, anxiety, depression, parkinsonism). Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by the elderly in US nursing homes in light of recent efficacy and safety data on atypical agents.
ACKNOWLEDGMENT The authors thank Sham Chaudhari, MS, College of Pharmacy, University of Houston, Houston, Texas, for assistance with data coding and extraction.
REFERENCES 1. Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: Epidemiologic evidence suggesting misuse. Am J Public Health. 1980;70: 485–491. 2. Omnibus Budget Reconciliation Act of 1987 (OBRA 87). Public Law 100–203, Title V, Subtitle C: Nursing Home Reform. Washington, DC; December 22, 1987. 3. Hughes CM, Lapane KL. Administrative initiatives for reducing inappropriate prescribing of psychotropic drugs in nursing homes: How successful have they been? Drugs Aging. 2005;22:339–351.
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P. Kamble et al.
4. Rovner BW, Edelman BA, Cox MP, Shmuely Y. The impact of antipsychotic drug regulations on psychotropic prescribing practices in nursing homes. Am J Psychiatry. 1992;149:1390–1392. 5. Semla TP, Palla K, Poddig B, Brauner DJ. Effect of the Omnibus Reconciliation Act 1987 on antipsychotic prescribing in nursing home residents. J Am Geriatr Soc. 1994;42:648–652. 6. Shorr RI, Fought RL, Ray WA. Changes in antipsychotic drug use in nursing homes during implementation of the OBRA-87 regulations. JAMA. 1994;271:358–362. 7. Garrard J, Chen V, Dowd B. The impact of the 1987 federal regulations on the use of psychotropic drugs in Minnesota nursing homes. Am J Public Health. 1995;85: 771–776. 8. Siegler EL, Capezuti E, Maislin G, et al. Effects of a restraint reduction intervention and OBRA ’87 regulations on psychotropic drug use in nursing homes. J Am Geriatr Soc. 1997;45:791–796. 9. Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care. 2000;38:1164–1173. 10. Liperoti R, Mor V, Lapane KL, et al. The use of atypical antipsychotics in nursing homes. J Clin Psychiatry. 2003; 64:1106–1112. 11. Briesacher BA, Limcangco MR, Simoni-Wastila L, et al. The quality of antipsychotic drug prescribing in nursing homes. Arch Intern Med. 2005;165:1280–1285. 12. Zuvekas SH. Prescription drugs and the changing patterns of treatment for mental disorders, 1996–2001. Health Aff (Millwood). 2005;24:195–205. 13. Glick ID, Murray SR, Vasudevan P, et al. Treatment with atypical antipsychotics: New indications and new populations. J Psychiatr Res. 2001;35:187–191. 14. Verma SD, Davidoff DA, Kambhampati KK. Management of the agitated elderly patients in the nursing home: The role of the atypical antipsychotics. J Clin Psychiatry. 1998;59(Suppl 19):50–55. 15. Daniel DG. Antipsychotic treatment of psychosis and agitation in the elderly. J Clin Psychiatry. 2000;61(Suppl 14):49–52. 16. Lee PE, Gill SS, Freedman M, et al. Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: Systematic review. BMJ. 2004; 329:75. 17. Efficacy and comparative effectiveness of off-label use of atypical antipsychotics. Rockville, Md: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 07-EHC003-EF. 18. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-
196
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
analysis of randomized placebo-controlled trials. JAMA. 2005;294:1934–1943. Deaths with antipsychotics in elderly patients with behavioral disturbances [FDA public health advisory]. http:// www.fda.gov/Cder/drug/advisory/antipsychotics.htm. Accessed July 18, 2008. Lieberman JA, Stroup TS, McEvoy JP, et al, for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353:1209–1223. Schneider LS, Tariot PN, Dagerman KS, et al, for the CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525–1538. National Nursing Home Survey Documentation. ftp:// ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_ Documentation/NNHS/nnhs04/. Accessed July 18, 2008. Koch H, Campbell W. The collection and processing of drug information: National Ambulatory Medical Care Survey—United States, 1980. Vital Health Stat 2. 1982;1–90. National Nursing Home Survey: Public-use data files. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/ Datasets/NNHS/nnhs04/. Accessed July 18, 2008. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51:95– 124. Gray SL, Hanlon JT, Fillenbaum GG, et al. Predictors of nutritional supplement use by the elderly. Pharmacotherapy. 1996;16:715–720. Aparasu RR, Mort JR, Brandt H. Psychotropic prescription use by community-dwelling elderly in the United States. J Am Geriatr Soc. 2003;51:671–677. Liperoti R, Gambassi G, Lapane KL, et al. Cerebrovascular events among elderly nursing home patients treated with conventional or atypical antipsychotics. J Clin Psychiatry. 2005;66:1090–1096. Sørensen L, Foldspang A, Gulmann NC, Munk-Jørgensen P. Determinants for the use of psychotropics among nursing home residents. Int J Geriatr Psychiatry. 2001; 16:147–154. Hien le TT, Cumming RG, Cameron ID, et al. Atypical antipsychotic medications and risk of falls in residents of aged care facilities. J Am Geriatr Soc. 2005;53:1290– 1295. Frenchman IB. Atypical antipsychotics for nursing home patients: A retrospective chart review. Drugs Aging. 2005;22:257–264.
P. Kamble et al.
32. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med. 2007;167:676–683. 33. Lindesay J, Matthews R, Jagger C. Factors associated with antipsychotic drug use in residential care: Changes between 1990 and 1997. Int J Geriatr Psychiatry. 2003; 18:511–519. 34. Chen H, Reeves JH, Fincham JE, et al. Off-label use of antidepressant, anticonvulsant, and antipsychotic medications among Georgia Medicaid enrollees in 2001. J Clin Psychiatry. 2006;67:972–982. 35. Gruber-Baldini AL, Stuart B, Zuckerman IH, et al. Treatment of dementia in community-dwelling and institutionalized Medicare beneficiaries [published correction appears in J Am Geriatr Soc. 2007;55:1697]. J Am Geriatr Soc. 2007;55:1508–1516. 36. Sclar DA, Robison LM, Gavrun C, Skaer TL. Hospital length of stay for children and adolescents diagnosed with depression: Is primary payer an influencing factor? Gen Hosp Psychiatry. 2008;30:73–76. 37. McLaughlin T, Geissler EC, Wan GJ. Comorbidities and associated treatment charges in patients with anxiety disorders. Pharmacotherapy. 2003;23:1251–1256. 38. Touré JT, Brandt NJ, Limcangco MR, Briesacher BA. Impact of second-generation antipsychotics on the use of antiparkinson agents in nursing homes and assisted-living facilities. Am J Geriatr Pharmacother. 2006;4:25–35.
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39. Continuous NHANES Web Tutorial: Logistic Regression. http://www.cdc.gov/nchs/tutorials/NHANES/ NHANESAnalyses/LogisticRegression/logistic_regression_ intro.htm. Accessed July 18, 2008. 40. Jano E, Johnson M, Chen H, Aparasu RR. Determinants of atypical antipsychotic use among antipsychotic users in community-dwelling elderly, 1996–2004. Curr Med Res Opin. 2008;24:709–716. 41. Aparasu RR, Mort JR. Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly. Am J Geriatr Pharmacother. 2004;2:102–111. 42. Ballard CG, Margallo-Lana ML. The relationship between antipsychotic treatment and quality of life for patients with dementia living in residential and nursing home care facilities. J Clin Psychiatr. 2004;65(Suppl 11): 23–28. 43. Jackson-Siegal JM, Schneider LS, Baskys A, Haupt DW. Recognizing and responding to atypical antipsychotic side effects. J Am Med Dir Assoc. 2004;5(Suppl 4):H7– H10. 44. Wooltorton E. Risperidone (Risperidal): Increased rate of cerebrovascular events in dementia trials. CMAJ. 2002; 167:1269–1270. 45. Wooltorton E. Olanzapine (Zyprexa): Increased incidence of cerebrovascular events in dementia trials. CMAJ. 2004;170:1395.
Address correspondence to: Rajender R. Aparasu, MPharm, PhD, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, Texas Medical Center, 1441 Moursund Street, Houston, TX 77030. E-mail: [email protected]
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