- Email: [email protected]
ARE CARE HOME RESIDENTS WITH UNDIAGNOSED DEMENTIA MORE AT RISK OF ANTIPSYCHOTIC OVERUSE?
P1240
Podium Presentations: Wednesday, July 19, 2017
Table 1 HR of becoming LTC-dependent, moving into a nursing home, and death by type of APD (reference group: not receiving the specific drug) LTC-dependency
Haloperidol Melperone Risperidone Quetiapine Other FGA Other SGA
Yes Yes Yes Yes Yes Yes
HR
p
95% CI
2.12 2.34 2.08 1.64 2.13 0.78
*** *** *** *** ***
1.78 2.13 1.87 1.35 1.87 0.54
2.52 2.58 2.32 1.98 2.42 1.13
Nursing home admission
Death
HR
p
95% CI
HR
p
95% CI
1.51 1.74 1.56 1.39 1.49 1.40
*** *** *** *** ***
1.28 1.58 1.38 1.15 1.31 0.97
1.56 1.43 1.28 0.91 1.26 1.09
*** *** ***
1.38 1.33 1.17 0.78 1.14 0.80
1.80 1.93 1.75 1.69 1.71 2.02
***
1.75 1.54 1.40 1.08 1.39 1.49
p0.05 * p0.01 ** p0.001 *** LTC-dependency: controlled for sex age comorbidities, polypharmacy, anti-dementia drug-use Nursing home admission: controlled for sex, age, comorbidities, polypharmacy, anti-dementia drug-use. LTC-dependency. Death: controlled for sex, age, comorbidities, polypharmacy, anti-dementia drug-use, LTC-dependency, residency.
morbidities in old age. Results: APD users generally faced a twofold increased risk of LTC relative to non-users. Quetiapine was the exception, showing a comparatively lower risk (HR¼1.64; CI¼1.35-1.98). The risk of moving into a NH was generally increased by about 50% among APD users relative to non-users. Risk of death was significantly higher for haloperidol-, melperone-, and risperidone- but not for quetiapine users (HR¼0.91; CI¼0.78-1.08). The excess mortality associated with haloperidol and melperone was greater among patients living in private households (haloperidol: HR¼1.96; CI¼1.67-2.30; melperone: HR¼1.70; CI¼1.53-1.88) than in NHs (haloperidol: HR¼1.24; CI¼1.04-1.48; melperone: HR¼1.19; CI¼1.07-1.33). Conclusions: In our study, APDs appeared to accelerate the frailty process of dementia patients. However, quetiapine may have a more favorable profile compared with haloperidol and melperone in this context. In the absence of alternative treatment options, haloperidol and melperone should be rather administered in the nursing home than in the private setting.
O4-05-05
ARE CARE HOME RESIDENTS WITH UNDIAGNOSED DEMENTIA MORE AT RISK OF ANTIPSYCHOTIC OVERUSE?
Francesca La Frenais1,2, Gill Livingston1, Claudia Cooper1, Louise Marston1, Victoria Vickerstaff2, Patrick Stone2, Elizabeth Sampson2, 1University College London, London, United Kingdom; 2Marie Curie Palliative Care Research Department, London, United Kingdom. Contact e-mail: [email protected] Background: Antipsychotics are often prescribed in response to agitation in dementia. There is government pressure to reduce use in people with dementia, particularly ‘off-label’ prescribing, due to negative side effects. Clinical guidelines recommend review every three months for people with diagnosed dementia, however there are many residents in care homes with undiagnosed dementia who may not receive regular review. Methods: We collected data from the largest prospective clustered cohort study of residents living with dementia or probable dementia in a representative sample of English care homes. Dementia diagnosis status, dementia severity (Clinical Dementia Rating) and agitation data (CohenMansfield Agitation Inventory [CMAI]) were collected during structured interviews. Medication data and PRN administration in the prior 2 weeks were extracted from care records: antipsychotics, anxiolytics, hypnotics, antidepressants, opioids (strong and weak), non-opioids, NSAIDs. Data collected four months after baseline reports length of prescription. Prevalence (95% CIs) of medication
prescribing were calculated. We will use regression models to identify factors associated with psychotropic and analgesic use, including agitation subtypes. Results: 86 care homes and 1483 residents were recruited. 13.6% of consented residents did not have a clinical dementia diagnosis but screened positively for probable dementia (Noticeable Problems Checklist). 55.6% (53.0-58.1%) residents were prescribed psychotropics, with 16.7% (14.8-18.7%) of residents prescribed antipsychotics. Of the 248 residents prescribed antipsychotics, 142 (57.3%) received prescriptions for drugs other than Risperidone, the only antipsychotic licensed for use in people with dementia. 40% of residents had clinically significant agitation (CMAI>45). Other drugs, such as antidepressants (prescribed for 39.6% residents) and strong opioids (10.8%) may be used for their sedative effect. Results, including PRN use, will be presented in full at conference. Conclusions: Antipsychotic point prevalence appears similar to national prescribing levels. Reductions in antipsychotic prescribing do not appear to have been sustained. Many residents are prescribed unlicensed antipsychotics to treat agitation. It is vital to understand what factors are associated with use of antipsychotics, and whether those with undiagnosed dementia are more likely to receive antipsychotics, and for a longer, and potentially unsafe, duration.
O4-05-06
HOW IS A PERSON WITH ADVANCED DEMENTIA EXPERIENCING THEIR CARE ENVIRONMENT: A FRAMEWORK FOR OBSERVATION
Alison M. Campbell, Flinders University, Adelaide, Australia. Contact e-mail: [email protected] Background: People with advanced dementia encounter particular
challenges in communicating their experiences of care provided or how the environment impacts on them. Similarly, residential care staff encounter challenges in understanding what is being communicated by people with advanced dementia. PIECE-dem, is an observational framework that was developed in the UK for use by researchers, which focuses on the experience of people with significant cognitive impairment living in residential aged care. PIECE-dem, provides a process and framework for structuring observations to capture residents interaction and engagement (or lack thereof) and their agency within their care environment. This paper will discuss results from an exploratory study done on the utility of PIECE-dem as a tool for practitioners. Methods: A mixed method study design was used, with predominant
Podium Presentations: Wednesday, July 19, 2017
Table 1 HR of becoming LTC-dependent, moving into a nursing home, and death by type of APD (reference group: not receiving the specific drug) LTC-dependency
Haloperidol Melperone Risperidone Quetiapine Other FGA Other SGA
Yes Yes Yes Yes Yes Yes
HR
p
95% CI
2.12 2.34 2.08 1.64 2.13 0.78
*** *** *** *** ***
1.78 2.13 1.87 1.35 1.87 0.54
2.52 2.58 2.32 1.98 2.42 1.13
Nursing home admission
Death
HR
p
95% CI
HR
p
95% CI
1.51 1.74 1.56 1.39 1.49 1.40
*** *** *** *** ***
1.28 1.58 1.38 1.15 1.31 0.97
1.56 1.43 1.28 0.91 1.26 1.09
*** *** ***
1.38 1.33 1.17 0.78 1.14 0.80
1.80 1.93 1.75 1.69 1.71 2.02
***
1.75 1.54 1.40 1.08 1.39 1.49
p0.05 * p0.01 ** p0.001 *** LTC-dependency: controlled for sex age comorbidities, polypharmacy, anti-dementia drug-use Nursing home admission: controlled for sex, age, comorbidities, polypharmacy, anti-dementia drug-use. LTC-dependency. Death: controlled for sex, age, comorbidities, polypharmacy, anti-dementia drug-use, LTC-dependency, residency.
morbidities in old age. Results: APD users generally faced a twofold increased risk of LTC relative to non-users. Quetiapine was the exception, showing a comparatively lower risk (HR¼1.64; CI¼1.35-1.98). The risk of moving into a NH was generally increased by about 50% among APD users relative to non-users. Risk of death was significantly higher for haloperidol-, melperone-, and risperidone- but not for quetiapine users (HR¼0.91; CI¼0.78-1.08). The excess mortality associated with haloperidol and melperone was greater among patients living in private households (haloperidol: HR¼1.96; CI¼1.67-2.30; melperone: HR¼1.70; CI¼1.53-1.88) than in NHs (haloperidol: HR¼1.24; CI¼1.04-1.48; melperone: HR¼1.19; CI¼1.07-1.33). Conclusions: In our study, APDs appeared to accelerate the frailty process of dementia patients. However, quetiapine may have a more favorable profile compared with haloperidol and melperone in this context. In the absence of alternative treatment options, haloperidol and melperone should be rather administered in the nursing home than in the private setting.
O4-05-05
ARE CARE HOME RESIDENTS WITH UNDIAGNOSED DEMENTIA MORE AT RISK OF ANTIPSYCHOTIC OVERUSE?
Francesca La Frenais1,2, Gill Livingston1, Claudia Cooper1, Louise Marston1, Victoria Vickerstaff2, Patrick Stone2, Elizabeth Sampson2, 1University College London, London, United Kingdom; 2Marie Curie Palliative Care Research Department, London, United Kingdom. Contact e-mail: [email protected] Background: Antipsychotics are often prescribed in response to agitation in dementia. There is government pressure to reduce use in people with dementia, particularly ‘off-label’ prescribing, due to negative side effects. Clinical guidelines recommend review every three months for people with diagnosed dementia, however there are many residents in care homes with undiagnosed dementia who may not receive regular review. Methods: We collected data from the largest prospective clustered cohort study of residents living with dementia or probable dementia in a representative sample of English care homes. Dementia diagnosis status, dementia severity (Clinical Dementia Rating) and agitation data (CohenMansfield Agitation Inventory [CMAI]) were collected during structured interviews. Medication data and PRN administration in the prior 2 weeks were extracted from care records: antipsychotics, anxiolytics, hypnotics, antidepressants, opioids (strong and weak), non-opioids, NSAIDs. Data collected four months after baseline reports length of prescription. Prevalence (95% CIs) of medication
prescribing were calculated. We will use regression models to identify factors associated with psychotropic and analgesic use, including agitation subtypes. Results: 86 care homes and 1483 residents were recruited. 13.6% of consented residents did not have a clinical dementia diagnosis but screened positively for probable dementia (Noticeable Problems Checklist). 55.6% (53.0-58.1%) residents were prescribed psychotropics, with 16.7% (14.8-18.7%) of residents prescribed antipsychotics. Of the 248 residents prescribed antipsychotics, 142 (57.3%) received prescriptions for drugs other than Risperidone, the only antipsychotic licensed for use in people with dementia. 40% of residents had clinically significant agitation (CMAI>45). Other drugs, such as antidepressants (prescribed for 39.6% residents) and strong opioids (10.8%) may be used for their sedative effect. Results, including PRN use, will be presented in full at conference. Conclusions: Antipsychotic point prevalence appears similar to national prescribing levels. Reductions in antipsychotic prescribing do not appear to have been sustained. Many residents are prescribed unlicensed antipsychotics to treat agitation. It is vital to understand what factors are associated with use of antipsychotics, and whether those with undiagnosed dementia are more likely to receive antipsychotics, and for a longer, and potentially unsafe, duration.
O4-05-06
HOW IS A PERSON WITH ADVANCED DEMENTIA EXPERIENCING THEIR CARE ENVIRONMENT: A FRAMEWORK FOR OBSERVATION
Alison M. Campbell, Flinders University, Adelaide, Australia. Contact e-mail: [email protected] Background: People with advanced dementia encounter particular
challenges in communicating their experiences of care provided or how the environment impacts on them. Similarly, residential care staff encounter challenges in understanding what is being communicated by people with advanced dementia. PIECE-dem, is an observational framework that was developed in the UK for use by researchers, which focuses on the experience of people with significant cognitive impairment living in residential aged care. PIECE-dem, provides a process and framework for structuring observations to capture residents interaction and engagement (or lack thereof) and their agency within their care environment. This paper will discuss results from an exploratory study done on the utility of PIECE-dem as a tool for practitioners. Methods: A mixed method study design was used, with predominant