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Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents
JAMDA 13 (2012) 407.e7e407.e12
JAMDA journal homepage: www.jamda.com
Original Study
Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents Yves Rolland MD, PhD a, b, c, *, Sandrine Andrieu MD, PhD a, b, c, Anne Crochard PhD d, Sylvia Goni MD d, Christophe Hein MD b, Bruno Vellas MD, PhD a, b, c a
INSERM, Toulouse, France University of Toulouse III, Toulouse, France c Gerontopole, Toulouse University Hospital, Toulouse, France d Laboratoire Lundbeck SAS, Issy-les-Moulineaux, France b
a b s t r a c t Keywords: Nursing homes dementia care transitions psychotropic drugs
Objectives: To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis. Design: A descriptive, cross-sectional, noninterventional study. Setting: The setting included 300 NH in France. Participants: Participants included 2231 NH residents. Measurements: Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status. Results: The mean number of beds in participating NHs was 85.9 33.2 (mean occupation rate ¼ 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 8.5 and 11.2 4.3, respectively. Most admissions (direct admission 3.2 3.3 or readmission 6.4 6.0) and discharges (4.4 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents. Conclusion: Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
The proportion of older people residing in nursing homes (NHs) in France is approximately 0.8% of the overall population, and 12.0% of the population older than 75 years. The main reasons for institutionalization are related to disability and dementia. The prescription of psychotropic drugs to NH residents is frequent, notably for This study was initially funded by Laboratoire Lundbeck SAS (Issy-les-Moulineaux, France). As member of the scientific committee of the study, Y.R., S.A., C.H., and B.V. received consultancy fees from the funding source in the context of this study. A.C. and S.G. are employees of Laboratoire Lundbeck SAS, manufacturer of memantine, an antidementia medication discussed in this publication. * Address correspondence to Yves Rolland, MD, PhD, Gérontopôle de Toulouse, Pavillon Junod,170, avenue de Casselardit, TSA 40031, 31059 Toulouse Cedex 9, France. E-mail address: [email protected] (Y. Rolland).
antipsychotic drugs, which are used widely for the management of behavioral and psychological symptoms of dementia.1,2 Large nationwide surveys in the United States have revealed that nearly 1 NH resident in 3 is treated with antipsychotic drugs.3e5 Similar high rates have also been reported in surveys performed in Canada,6,7 Australia,8 Germany,9 and France.10 Psychotropic drug use is an important risk factor for falls,11 hip fracture,12 delirium, and functional decline,13 and their use has been associated with cerebrovascular morbidity and mortality.14e16 In addition, the evidence supporting their effectiveness in the treatment of behavioral and psychological symptoms of dementia is weak. For these reasons, current treatment guidelines discourage prescription of these drugs in geriatric populations unless absolutely justified by
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2011.12.056
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the psychopathology of the patients.17,18 During the past 5 years, the French health authorities, as in other countries, have launched a national program (AMI-Alzheimer program) aimed at reducing prescription of antipsychotics in patients with Alzheimer’s disease.19 In spite of this, the use of psychotropic drugs by the elderly is still extensive both in the community and in institutional settings, such as hospitals and NHs. In the French system, each registered NH is required to have a dedicated geriatrician on the staff, responsible for comprehensive evaluation of each resident and for coordination of care. Each resident is evaluated systematically on admission and discharge. Drug prescription remains under the responsibility of the resident’s community physician, usually a general practitioner, for the entire duration of the NH stay. Nonetheless, available information on psychotropic drug prescription for NH residents is limited and a more complete description of the relationship between psychotropic drug prescription and the health care trajectory of NH residents may allow a better understanding of the factors influencing such prescription. Such information may be useful for rationalizing and limiting the use of psychotropic drugs in elderly NH residents. For this reason, we have undertaken a large survey of NH residents in France. The objective of this study was to quantify transitions into or out of the NH and to describe the characteristics of the NH residents at admission and discharge with regard to dementia diagnosis and psychotropic drug prescription.
dementia at the time of last transit and at the time of the study was collected using the Mini Mental State Examination (MMSE),20 if available, the Katz Basic Activities of Daily Living,21 and the Neuropsychiatric Inventory.22 Falls in the previous week (yes or no), loss of weight in the previous 3 months (yes or no), and current use of physical restraints (chair or bed) were also documented. Regarding medication use, the NH coordinating geriatrician was asked to select items from a checklist featuring four antidementia drugs (donepezil, galantamine, rivastigmine, and memantine) and to document the prescription of any psychotropic drugs at the time of the study. The study was conducted according to the International Chamber of Commerce/ESOMAR International Code on Market and Social Practice, relevant current French and European legislation, and Good Epidemiological Practice guidelines. The CRO responsible for the study makes an annual declaration of all studies to the Commission Nationale de L’informatique et des Libertés, the French agency that ensures all medical information is kept confidential and anonymous. Quantitative values are reported as means SDs. When the number of residents per group was 30 or more, the association between psychotropic drug use, transfer rates into and out of NHs, and other variables of interest was assessed using the c2 test. All testing was 2-tailed and a probability threshold of .05 was taken to be statistically significant. Data analysis was performed using SAS software version 8.2 (SAS Institute, Cary, NC). Results
Methods We performed a descriptive cross-sectional study of NH residents in France in 2010. The investigators were nursing home coordinating geriatricians. Operational management of the study was delegated to a contract research organization (CRO; Kantar Health, Paris). NH coordinating geriatricians responsible for medical care in private NHs with at least 50 beds were eligible for this study. Information on the study and an invitation to participate was sent by post to all eligible NH coordinating geriatricians and in duplicate to the manager of the NH. Each NH coordinating geriatrician who agreed to participate was then contacted by telephone to confirm participation. During an arranged face-to-face meeting, a representative of the CRO collected and validated the completed questionnaires from the NH coordinating geriatrician. Each participating NH coordinating geriatrician was expected to first complete a NH questionnaire on transitions into or out of the NH and on the organization of the NH and, second, a resident questionnaire providing information on the last 8 residents entering or leaving the NH. The aim of the NH questionnaire was to describe the flow of residents through the NH. Information was collected on the number of residents admitted and discharged (or who died) over the previous 3 months, and on where these residents were admitted from and discharged to. Information on distance from the nearest hospital and emergency unit was also reported, as well as details on NH organization, including facilities for day care, the presence of a nurse during the night, and the proportion of time spent by the coordinating geriatrician in the NH. The aim of the resident questionnaire was to describe individual residents moving into or out of the NH. To be eligible, the residents had to have been admitted to the NH for the first time or following a hospitalization, or had to have been temporarily or permanently discharged from the NH in the previous 3 months. In cases where an individual resident had transited into or out of the NH more than once during the 3-month period, only the last transit was taken into consideration. Residents who died were counted but not described. Data were obtained retrospectively from the records. For all residents, data were collected on demographics and place of residence before admission. The status of residents with
Of 2665 French NHs invited to participate in the study, 300 (11.0%) agreed to participate. The mean number of beds was 85.9 33.2 (median: 79.5 beds). There were 132 (44%) that had a special care unit (SCU) dedicated to Alzheimer’s disease residents, and 45 (15%) had a nurse present during the night. The NH coordinating geriatrician spent on average 2.0 1.1 days a week in the NH. The mean distance separating the NH from the nearest hospital with an emergency service was 10.0 11.5 km. All NHs accepted residents with dementia and the mean number of residents with dementia per NH was 42.9 23.7. Of the 25,772 beds in participating NHs, 24,899 (96.6%) were occupied at the time of the study (mean: 83.0 32.2 per NH). In the 3 months before completion of the study questionnaires, 5986 had been admitted or discharged. In addition, 1507 patients had died. The mean number of residents admitted to or discharged from participating NHs is presented in Figure 1. The mean duration of residence in the NH at the time of discharge was 27.2 36.1 months (median: 11.9 months; interquartile range: 1.9e35.5 months). For the patients who were readmitted to the NH after a hospitalization, the mean duration of residence was 39.9 46.2 months (median: 23.5 months; range: 1e377 months). The mean length of hospital stay was 12.4 12.3 days for the admitted residents and 12.9 13.6 days for the discharged residents. More than half of the residents who were hospitalized were directly admitted to the emergency room (522/905; 57.7%), then transferred to other departments (425/522; 81.4%). Only 7.7% were sent directly from the NH to a geriatric department. Questionnaires were completed for a total of 2231 residents, corresponding to 7.4 resident questionnaires per NH. Of these, 1859 (83.3%) related to admissions and 372 (16.7%) to discharges. Information on demographics, disability, and dementia-related variables are presented according to admission or discharge status in Table 1. Characteristics of dependency according to admission or discharge status are reported in Figure 2. Most residents (82%) presented at least 1 of the behavioral items on the Neuropsychiatric Inventory (mean of 2.8 2.3 items). The frequency of reported behavioral disturbances is presented in Figure 3.
Y. Rolland et al. / JAMDA 13 (2012) 407.e7e407.e12
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Fig. 1. Flow of residents into and out of the NH over the last 3 months. Data are presented as the mean number of transitions per participating NH. These NHs had a mean number of occupied beds of 83.0%. Numbers are means SD.
Overall, 1005 residents (45.0%) among the 2231 residents were diagnosed with dementia. Of the residents diagnosed with dementia, 54.2% were diagnosed with Alzheimer’s disease; 16.0% with vascular dementia; and 11.0% with Lewy body, parkinsonian, or frontotemporal dementia. In the remaining cases, the exact diagnosis was not specified. The MMSE score was documented in the records for 590 residents (58.7% of residents with dementia). For these residents, the mean MMSE score was 13.3 7.4 (median: 14.1; interquartile range: 7.3e17.9). The contribution of residents with dementia to the different admission and discharge status subgroups was fairly uniform (Table 1), with the exception of discharges back home, which were infrequent for patients with dementia. The characteristics of the residents with a diagnosis of dementia are reported in Table 2. Psychotropic drugs (antidepressants, hypnotics, antipsychotics, and anxiolytics) were frequently prescribed in the NH residents, whatever their admission or discharge status (Table 1). These different drugs, with the exception of hypnotics, were prescribed significantly more often to residents with dementia than to residents
who did not have dementia (Table 2). In particular, antipsychotic drugs were prescribed to more than twice as many residents in the dementia group than in the no dementia group (28.0% versus 11.8%). Antipsychotic drugs were also prescribed more frequently to younger residents, being prescribed to 25.9% (255/983) of residents younger than 86 years versus 13.6% (168/1233) of residents 86 years or older (P < .01), and to those who presented productive behavioral symptoms, such as agitation, irritability, or sleep disturbances (28.3% of patients with these symptoms versus 5.9% of those without). The use of antidementia drugs is reported in Table 2; these were prescribed to 53.7% of patients with dementia (24.2% of all patients). The most frequently prescribed antidementia drug in the residents with dementia was memantine, followed by donepezil, rivastigmine, and galantamine. The extent of psychotropic drug prescription was essentially similar in residents admitted (1305/1859; 70.2%) and residents discharged (251/372; 67.5%), irrespective of where they had been admitted from and where they were discharged to. An exception to
Table 1 Characteristics of Residents Admitted To or Discharged From a Nursing Home (n ¼ 2231) Characteristics
Total Population
First Admission From Home
First Admission From Hospital
Discharge to Hospital
Readmission From Hospital
Discharge Home
Admission From or Discharge to Other NH
n Age, mean SD Gender, n (% female) Diagnosis of dementia, n (%) Other characteristics, n (%) Fall in past week Weight loss in past 3 mo Physical restraint Antidementia* drug, n (%) At least 1 psychotropic drug, n (%) Antidepressant, n (%) Hypnotic, n (%) Antipsychotic, n (%) Anxiolytic, n (%)
2231 85.7 7.4 1560 (69.9) 1005 (45.0)
502 85.4 6.8 356 (70.9) 230 (45.8)
461 84.7 7.6 325 (70.5) 221 (47.9)
170 86.3 7.1 108 (63.5) 68 (40.0)
721 86.7 7.5 505 (70.0) 317 (44.0)
104 84.5 7.1 62 (59.6) 28 (26.9)
262 85.1 7.5 198 (75.6) 135 (51.5)
274 548 356 540 1556 880 674 426 776
49 57 44 145 351 196 141 75 172
48 118 70 116 319 182 154 97 155
31 64 39 31 122 63 51 42 63
108 242 162 159 511 287 223 138 258
7 12 9 14 65 33 24 14 36
32 55 33 71 178 113 75 60 88
(12.3) (24.6) (16.0) (24.2) (69.7) (39.4) (30.2) (19.1) (34.8)
(9.8) (11.4) (8.8) (28.9) (69.9) (39.0) (28.1) (14.9) (34.3)
NH, nursing home. *Antidementia drugs include acetylcholinesterase inhibitors and memantine.
(10.4) (25.6) (15.2) (25.2) (69.2) (39.5) (33.4) (21.0) (33.6)
(18.2) (37.6) (22.9) (18.2) (71.8) (37.1) (30.0) (24.7) (37.1)
(15.0) (33.6) (22.5) (22.1) (70.9) (39.8) (30.9) (19.1) (35.8)
(6.7) (11.5) (8.7) (13.5) (62.5) (31.7) (23.1) (13.5) (34.6)
(12.2) (21.0) (12.6) (27.1) (67.9) (43.1) (28.6) (22.9) (33.6)
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Fig. 2. Level of disability of 2231 residents admitted to or discharged from an NH.
this was antipsychotic drug use, which was significantly lower in residents admitted from home (75/502; 14.9%) than in the other groups of residents (P < .01) (Table 1). No differences were observed in the extent of prescription of psychotropic drugs with respect to the size of the NH (number of beds), status (for-profit or not-for-profit), distance from a hospital emergency department, the time the coordinating geriatrician spends in the NH, geographic region, or presence of an SCU (data not shown). The only NH characteristic to be associated with the extent of psychotropic drug prescription was the presence of a nurse during the night. A higher proportion of residents were prescribed these drugs in NHs having a night-duty nurse (292/ 364; 80.2%) than in those without (1264/1867; 67.7%; P < .0001; c2 test). NHs with night nurses have a higher proportion of residents with Alzheimer’s disease (data not shown), which may account for this difference in prescribing patterns.
Delusions/paranoia Hallucinations Agitation/aggression Elation/euphoria Disinhibition Irritability/lability Motor disturbance
Discussion Our findings highlight the high rate of transition of individuals into and out of NHs in France, especially with the emergency department. More than one resident in four had either entered or left the NH in the previous 3 months. About one-half of these moves represented natural turnover, with first-time admissions replacing residents who had died or been definitively discharged either back home or to another NH. This probably reflects the relative paucity of NH places relative to the demand, where there is a long waiting list for NH places and rate of admissions is principally determined by the death of previous residents. The proportion of residents who were discharged back home was very low (approximately 5%). The other half of the transitions represented patients who were hospitalized or readmitted after a hospital stay. Approximately four residents in 10 had been hospitalized in the previous 3 months. Such high rates of hospitalization of NH residents, mainly to the emergency department, have been observed in previous studies,23 and may be associated with a reduction in the quality of care during the transition.24,25 For this reason, and because many of these transitions may be avoidable, interest has focused on developing resident-centered care in the NH to reduce the need for hospitalization.24,26 Studies such as PLEIAD may be useful in formulating national health policies aimed at reducing the number and consequences of NH transitions for the elderly.27,28 Overall, the rate of use of psychotropic drugs was very high, with approximately 70% of the sample being prescribed at least one such drug. Interestingly, the overall prescription rate between residents admitted or discharged from the NH was very similar, suggesting that initiation of psychotropic drug prescription does not happen in the NH itself, but rather in community care or in hospital before the individual arrives in the NH.
Nighttime behaviors Depressed mood/dysphoria Anxiety Apathy/indifference Appetite/eating 0
10
20
30
40
50
60
Proportion of patients (%)
Fig. 3. Behavioral disturbances in 2231 residents admitted to or discharged from an NH.
In contrast, the rate of prescription of antidementia drugs was relatively low, with only about half of residents with dementia (54.7%) receiving a specific treatment for dementia. The prescription rate for antidementia drugs was highest in individuals admitted
Y. Rolland et al. / JAMDA 13 (2012) 407.e7e407.e12 Table 2 Characteristics of Patients With a Dementia Diagnosis or No Dementia Diagnosis Characteristics
Dementia
No Dementia
P
n Age, mean SD Gender, n (% female) MMSE* score (n ¼ 590), mean SE Not disabled for ADL, n (%) Bathing Dressing Toileting Transferring Continent Feeding Neuropsychiatric inventory, n (%) Agitation/aggression Irritability Sleep disorders Apathy Fall during the past week, n (%) Weight loss in past 3 months, n (%) Physical restraints, n (%) Treatments, n (%) Antidepressant Hypnotic Antipsychotic Anxiolytic At least 1 psychotropic drug above Three or more of the above None of the above Antidementia drugy Any psychotropic or antidementia drug
1005 85.3 6.8 720 (71.6) 13.3 7.4
1212 86.0 7.8 833 (68.7) d
d <.05 NS
53 94 253 398 210 429
(5.3) (9.4) (25.2) (39.6) (20.9) (42.7)
236 359 534 539 537 812
(19.5) (29.6) (44.1) (44.5) (44.3) (67.0)
<.01 <.01 <.01 <.05 <.01 <.01
361 374 404 351 161 280 216
(35.9) (37.2) (40.2) (34.9) (16.0) (27.9) (21.5)
127 226 377 171 111 266 141
(10.5) (18.6) (31.1) (14.1) (9.2) (21.9) (11.6)
<.01 <.01 <.01 <.01 <.01 <.01 <.01
447 294 281 374 766 191 128 540 877
(44.5) (29.3) (28.0) (37.2) (76.2) (19.0) (12.7) (53.7) (87.3)
428 (35.3) 375 (30.9) 143 (11.8) 398 (32.8) 779 (64.3) 166 (13.7) 428 (35.3) None 781 (64.4)
<.05 NS <.05 <.05 <.05 <.05 <.05 d <.05
d, not available; ADL, activity of daily living; NS, not significant. *MMSE (Mini Mental Status Exam) was collected if available in residents with a diagnosis of dementia. y Antidementia drugs include acetylcholinesterase inhibitors and memantine.
directly from home, even though there was no major difference in the proportion of residents with dementia between newly admitted, readmitted, and discharged residents. This may reflect in part a reluctance to prescribe such drugs in NHs, but probably also to discontinuation of acetylcholinesterase inhibitors as the dementia becomes more severe, when such drugs are no longer indicated. All classes of psychotropic drugs were prescribed more frequently to residents with dementia than those without, but this difference was particularly striking for antipsychotic drugs, prescribed to 28% of residents with dementia compared with 12% of residents who did not have dementia. Antipsychotic drugs are widely used to manage behavioral and psychological symptoms of dementia, which are believed to affect about 80% of NH residents with dementia.29 In our study, these drugs were particularly used in patients with productive behavioral symptoms, such as agitation, irritability, or sleep disturbances. The proportion of patients who do not have dementia, who do not necessarily present these behavioral disturbances, and who receive antipsychotics (12%) is also high, and unlikely to be justified by mental disorders for which these drugs are indicated (schizophrenia and bipolar disorders). Nonetheless, the risks associated with the use of antipsychotic drugs may well outweigh their benefits.30,31 The use of these drugs should be rare for treatment of elderly patients with dementia32 and they are contraindicated in this patient population in the United States.15 In our study, we observed a higher rate of falls in residents prescribed antipsychotic drugs (18% had experienced a fall in the previous week), although it is not possible to conclude that this is independent from the increased risk of falls associated with dementia. The proportion of residents receiving antipsychotic drugs in our survey is similar to that reported in recent surveys in Canada (20.4% in 2004),7 but are lower than the latest prescription rates reported from the United States (29.1% in 2006),3 Germany (28.4% in 2006),9 and particularly Austria (45.9%).33 The high use of psychotropic
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drugs in general, and of antipsychotic medication in particular, is likely to be a consequence of inadequate time, knowledge, and resources for implementing other nonpharmacological interventions for behavioral and psychological symptoms of dementia. Although the latter are effective, and do not carry the risks of side effects associated with drug therapy, they are time-consuming for staff to implement in routine practice in NHs. Time constraints are clearly relevant to the choice of therapeutic strategy. In addition, a large NH survey performed in the United States reported that more physician presence in the NH was associated with fewer psychotropic drug prescriptions.34 Decisions on NH staffing thus have an impact on psychotropic drug use and may thereby indirectly influence risk exposure of residents. Educational programs directed at medical and nursing staff in NHs focusing on the risk-benefit assessment of antipsychotic drug treatments may be effective in reducing the level of inappropriate antipsychotic prescribing. Policies aimed at achieving this, however, such as the French AMI-Alzheimer initiative,19 need to take into account the fact that much of this prescription is initiated before the resident is admitted to the NH, and the primary care physician remains responsible for drug prescription for NH residents after admission. For this reason, educational programs should first and foremost target primary care physicians. With respect to resource allocation in NHs, access to training in nonpharmacological interventions for NH staff and, above all, time allocated to such interventions, could be particularly useful in reducing unnecessary recourse to psychotropic drugs. Finally, better coordination between the primary care physician and the NH geriatrician may facilitate more rational use of psychotropic drugs. This study has several strengths. These include the large number of NH residents evaluated from a national sample of NHs in France. In addition, the study addressed the flow of patients in and out of the NH and compared characteristics and treatment of residents with respect to where they were admitted from and where they were discharged to. This represents a novel feature of the study, which has not been addressed extensively in previous studies, and reveals unanticipated relationships between dementia status, psychotropic drug treatment, and admission status. The study also presents a number of limitations, for example the cross-sectional nature of the survey, which precludes evaluation of how psychotropic drug use evolves following admission to the NH and in case of subsequent dementia diagnosis. The relatively low participation rate (11% of all NHs in France) also raises the issue of representativity. It is possible that this study attracted participants more interested in research or more alert to public health issues, whose standards of care may be higher than those of the average NH in France. In addition, no information was collected on reasons for prescription of psychotropic drugs or on other psychiatric diagnoses. It is likely that a minority of residents will also have been diagnosed with mental illnesses for which prescription of antipsychotic drugs is justified. It should also be noted that some of our findings may reflect specificities of the French health system, such as prescription of medication to residents being the responsibility of the community physician, and may not be transposable elsewhere. This study evaluated only individuals moving into and out of the NH in a 3-month period, and it is possible, especially given that approximately half of these cases concerned transfers to and from hospital, that frailer, more medicated residents are overrepresented, compared with those residents who were not transferred during the study period and who are not evaluated. The proportion of individuals in our study with dementia is similar to that reported in a previous study of NH residents in France10 (43.5%), however, and the reported use of antipsychotic medication is actually lower than in the previous study (27.4%).10 This may reflect the affect of public health campaigns aimed at limiting antipsychotic prescription to the elderly.
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Conclusion This large study conducted in France demonstrates, first, that movement of residents into and out of NHs and between NH and hospital is extensive. Second, prescription rates for psychotropic drugs in general and antipsychotic drugs in particular remain high, especially in residents with dementia. Even when admitted to an NH for the first time, residents are highly medicated. This indicates that several groups of health care providers, including general practitioners in the community, hospital physicians, physicians in emergency departments, and physicians in the NH, have responsibility for potentially inappropriate prescription of psychotropic drugs and should be targeted by educational measures to improve the quality of prescription of these drugs.
References 1. Liperoti R, Mor V, Lapane KL, et al. The use of atypical antipsychotics in nursing homes. J Clin Psychiatry 2003;64:1106e1112. 2. Tolson D, Rolland Y, Andrieu S, et al. International Association of Gerontology and Geriatrics: A global agenda for clinical research and quality of care in nursing homes. J Am Med Dir Assoc 2011;12:184e189. 3. Chen Y, Briesacher BA, Field TS, et al. Unexplained variation across US nursing homes in antipsychotic prescribing rates. Arch Intern Med 2011;170:89e95. 4. Kamble P, Chen H, Sherer JT, et al. Use of antipsychotics among elderly nursing home residents with dementia in the US: An analysis of National Survey Data. Drugs Aging 2009;26:483e492. 5. Tjia J, Rothman MR, Kiely DK, et al. Daily medication use in nursing home residents with advanced dementia. J Am Geriatr Soc 2010;58:880e888. 6. Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med 2007;167:676e683. 7. Bronskill SE, Rochon PA, Gill SS, et al. The relationship between variations in antipsychotic prescribing across nursing homes and short-term mortality: Quality of care implications. Med Care 2009;47:1000e1008. 8. Snowdon J, Day S, Baker W. Why and how antipsychotic drugs are used in 40 Sydney nursing homes. Int J Geriatr Psychiatry 2005;20:1146e1152. 9. Richter T, Mann E, Meyer G, et al. Prevalence of psychotropic medication use among German and Austrian nursing home residents: A comparison of 3 cohorts. J Am Med Dir Assoc 2012;13:187. 10. Rolland Y, Abellan van Kan G, Hermabessiere S, et al. Descriptive study of nursing home residents from the REHPA network. J Nutr Health Aging 2009; 13:679e683. 11. Bloch F, Thibaud M, Dugue B, et al. Psychotropic drugs and falls in the elderly people: Updated literature review and meta-analysis. J Aging Health 2011;23: 329e346. 12. Jalbert JJ, Eaton CB, Miller SC, et al. Antipsychotic use and the risk of hip fracture among older adults afflicted with dementia. J Am Med Dir Assoc 2010; 11:120e127. 13. Cabrera MA, Dellaroza MS, Trelha CS, et al. Psychoactive drugs as risk factors for functional decline among noninstitutionalized dependent elderly people. J Am Med Dir Assoc 2010;11:519e522. 14. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934e1943.
15. US Food and Drug Administration. FDA Public Health Advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances. 2005. Available at: http://www.fda.gov/cder/drug/advisory/antipsychotics.htm. Accessed May 25, 2011. 16. Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007;146:775e786. 17. National Institute for Health and Clinical Excellence. Dementia. Supporting people with dementia and their carers in health and social care. Issue date 2006 (amended March 2011). Available at: http://www.nice.org.uk/nicemedia/ live/10998/30318/30318.pdf. Accessed January 9, 2012. 18. Doody RS, Stevens JC, Beck C, et al. Practice parameter: Management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56:1154e1166. 19. Haute Autorité de Santé. Programme AMI-Alzheimer: Alerte et Maitrise de la Iatrogénie des Neuroleptiques dans la Maladie d’Alzheimer 2007. Available at: http://www.has-sante.fr/portail/jcms/c_891528/programme-ami-alerte-maitriseiatrogenie-alzheimer. Accessed May 25, 2011. 20. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189e198. 21. Katz S, Downs TD, Cash HR, et al. Progress in development of the index of ADL. Gerontologist 1970;10:20e30. 22. Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology 1994; 44:2308e2314. 23. Mor V, Intrator O, Feng Z, et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood) 2010;29:57e64. 24. Murray LM, Laditka SB. Care transitions by older adults from nursing homes to hospitals: Implications for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc 2010;11:231e238. 25. McCloskey RM. A qualitative study on the transfer of residents between a nursing home and an emergency department. J Am Geriatr Soc 2011;59: 717e724. 26. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. J Am Geriatr Soc 2011;59:745e753. 27. Gimbert V, Godot C, Centre d’analyse stratégique. July 2010. [Live together longer] (Vivre ensemble plus longtemps. Enjeux et opportunités pour l’action publique du vieillissement de la population française). Available at: http:// www.strategie.gouv.fr/content/seminaire-quelle-organisation-de-l%E2%80%99 offre-de-sante-dans-20-ans. Accessed January 9, 2012. 28. Haut Conseil pour l’avenir de l’assurance maladie. November 2010. Annual Report 2010 [Rapport annuel 2010. L’assurance maladie face à la crise : Eléments d’analyse]. Available at: http://www.securite-sociale.fr/IMG/pdf/ hcaam_rapport2010.pdf. Accessed January 9, 2012. 29. Margallo-Lana M, Swann A, O’Brien J, et al. Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments. Int J Geriatr Psychiatry 2001;16:39e44. 30. Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 2006;355: 1525e1538. 31. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 2005;293:596e608. 32. Ballard C, Corbett A. Management of neuropsychiatric symptoms in people with dementia. CNS Drugs 2010;24:729e739. 33. Mann E, Kopke S, Haastert B, et al. Psychotropic medication use among nursing home residents in Austria: A cross-sectional study. BMC Geriatr 2009;9:18. 34. Hanlon JT, Handler SM, Castle NG. Antidepressant prescribing in US nursing homes between 1996 and 2006 and its relationship to staffing patterns and use of other psychotropic medications. J Am Med Dir Assoc 2010;11:320e324.
JAMDA journal homepage: www.jamda.com
Original Study
Psychotropic Drug Consumption at Admission and Discharge of Nursing Home Residents Yves Rolland MD, PhD a, b, c, *, Sandrine Andrieu MD, PhD a, b, c, Anne Crochard PhD d, Sylvia Goni MD d, Christophe Hein MD b, Bruno Vellas MD, PhD a, b, c a
INSERM, Toulouse, France University of Toulouse III, Toulouse, France c Gerontopole, Toulouse University Hospital, Toulouse, France d Laboratoire Lundbeck SAS, Issy-les-Moulineaux, France b
a b s t r a c t Keywords: Nursing homes dementia care transitions psychotropic drugs
Objectives: To quantify transitions of residents into or out of nursing homes (NHs) and to describe psychotropic drug prescription at admission and discharge and with regard to dementia diagnosis. Design: A descriptive, cross-sectional, noninterventional study. Setting: The setting included 300 NH in France. Participants: Participants included 2231 NH residents. Measurements: Participants reported the number, origin, and destination of residents transiting into or out of the NH in the previous 3 months and provided information on NH characteristics. For eight residents admitted or discharged by the NH, information was collected on medical characteristics, including psychotropic and antidementia drug prescription, and dementia status. Results: The mean number of beds in participating NHs was 85.9 33.2 (mean occupation rate ¼ 96.6%). The mean number of admissions and discharges in the previous 3 months was 13.7 8.5 and 11.2 4.3, respectively. Most admissions (direct admission 3.2 3.3 or readmission 6.4 6.0) and discharges (4.4 6.7) were from and to the hospital. Of the 2231 residents included, 1005 (45.0%) were diagnosed with dementia. At least one psychotropic drug (antidepressant, hypnotic, antipsychotic, or anxiolytic) was prescribed to 70.7% of residents and in particular an antipsychotic to 19.1% of residents. Psychotropic drugs, and in particular antipsychotic drugs, were significantly more prescribed to demented residents than to nondemented residents (76.2% vs 64.3% and 28.0% vs 11.8%, respectively). The extent of prescription (at least one psychotropic drug) was similar in residents admitted to (70.2%) and discharged from (67.5%) the NHs. Antidementia drugs (acetylcholinesterase inhibitors or NMDA receptor antagonists) were prescribed to 53.7% of demented residents. Conclusion: Movement of residents into and out of NHs and especially from and to the hospital is extensive and the prescription rate for psychotropic drugs is very high in this population, especially in residents with dementia. Multiple groups of health care providers should be targeted by educational measures to improve the quality of care for NH residents. Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.
The proportion of older people residing in nursing homes (NHs) in France is approximately 0.8% of the overall population, and 12.0% of the population older than 75 years. The main reasons for institutionalization are related to disability and dementia. The prescription of psychotropic drugs to NH residents is frequent, notably for This study was initially funded by Laboratoire Lundbeck SAS (Issy-les-Moulineaux, France). As member of the scientific committee of the study, Y.R., S.A., C.H., and B.V. received consultancy fees from the funding source in the context of this study. A.C. and S.G. are employees of Laboratoire Lundbeck SAS, manufacturer of memantine, an antidementia medication discussed in this publication. * Address correspondence to Yves Rolland, MD, PhD, Gérontopôle de Toulouse, Pavillon Junod,170, avenue de Casselardit, TSA 40031, 31059 Toulouse Cedex 9, France. E-mail address: [email protected] (Y. Rolland).
antipsychotic drugs, which are used widely for the management of behavioral and psychological symptoms of dementia.1,2 Large nationwide surveys in the United States have revealed that nearly 1 NH resident in 3 is treated with antipsychotic drugs.3e5 Similar high rates have also been reported in surveys performed in Canada,6,7 Australia,8 Germany,9 and France.10 Psychotropic drug use is an important risk factor for falls,11 hip fracture,12 delirium, and functional decline,13 and their use has been associated with cerebrovascular morbidity and mortality.14e16 In addition, the evidence supporting their effectiveness in the treatment of behavioral and psychological symptoms of dementia is weak. For these reasons, current treatment guidelines discourage prescription of these drugs in geriatric populations unless absolutely justified by
1525-8610/$ - see front matter Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc. doi:10.1016/j.jamda.2011.12.056
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the psychopathology of the patients.17,18 During the past 5 years, the French health authorities, as in other countries, have launched a national program (AMI-Alzheimer program) aimed at reducing prescription of antipsychotics in patients with Alzheimer’s disease.19 In spite of this, the use of psychotropic drugs by the elderly is still extensive both in the community and in institutional settings, such as hospitals and NHs. In the French system, each registered NH is required to have a dedicated geriatrician on the staff, responsible for comprehensive evaluation of each resident and for coordination of care. Each resident is evaluated systematically on admission and discharge. Drug prescription remains under the responsibility of the resident’s community physician, usually a general practitioner, for the entire duration of the NH stay. Nonetheless, available information on psychotropic drug prescription for NH residents is limited and a more complete description of the relationship between psychotropic drug prescription and the health care trajectory of NH residents may allow a better understanding of the factors influencing such prescription. Such information may be useful for rationalizing and limiting the use of psychotropic drugs in elderly NH residents. For this reason, we have undertaken a large survey of NH residents in France. The objective of this study was to quantify transitions into or out of the NH and to describe the characteristics of the NH residents at admission and discharge with regard to dementia diagnosis and psychotropic drug prescription.
dementia at the time of last transit and at the time of the study was collected using the Mini Mental State Examination (MMSE),20 if available, the Katz Basic Activities of Daily Living,21 and the Neuropsychiatric Inventory.22 Falls in the previous week (yes or no), loss of weight in the previous 3 months (yes or no), and current use of physical restraints (chair or bed) were also documented. Regarding medication use, the NH coordinating geriatrician was asked to select items from a checklist featuring four antidementia drugs (donepezil, galantamine, rivastigmine, and memantine) and to document the prescription of any psychotropic drugs at the time of the study. The study was conducted according to the International Chamber of Commerce/ESOMAR International Code on Market and Social Practice, relevant current French and European legislation, and Good Epidemiological Practice guidelines. The CRO responsible for the study makes an annual declaration of all studies to the Commission Nationale de L’informatique et des Libertés, the French agency that ensures all medical information is kept confidential and anonymous. Quantitative values are reported as means SDs. When the number of residents per group was 30 or more, the association between psychotropic drug use, transfer rates into and out of NHs, and other variables of interest was assessed using the c2 test. All testing was 2-tailed and a probability threshold of .05 was taken to be statistically significant. Data analysis was performed using SAS software version 8.2 (SAS Institute, Cary, NC). Results
Methods We performed a descriptive cross-sectional study of NH residents in France in 2010. The investigators were nursing home coordinating geriatricians. Operational management of the study was delegated to a contract research organization (CRO; Kantar Health, Paris). NH coordinating geriatricians responsible for medical care in private NHs with at least 50 beds were eligible for this study. Information on the study and an invitation to participate was sent by post to all eligible NH coordinating geriatricians and in duplicate to the manager of the NH. Each NH coordinating geriatrician who agreed to participate was then contacted by telephone to confirm participation. During an arranged face-to-face meeting, a representative of the CRO collected and validated the completed questionnaires from the NH coordinating geriatrician. Each participating NH coordinating geriatrician was expected to first complete a NH questionnaire on transitions into or out of the NH and on the organization of the NH and, second, a resident questionnaire providing information on the last 8 residents entering or leaving the NH. The aim of the NH questionnaire was to describe the flow of residents through the NH. Information was collected on the number of residents admitted and discharged (or who died) over the previous 3 months, and on where these residents were admitted from and discharged to. Information on distance from the nearest hospital and emergency unit was also reported, as well as details on NH organization, including facilities for day care, the presence of a nurse during the night, and the proportion of time spent by the coordinating geriatrician in the NH. The aim of the resident questionnaire was to describe individual residents moving into or out of the NH. To be eligible, the residents had to have been admitted to the NH for the first time or following a hospitalization, or had to have been temporarily or permanently discharged from the NH in the previous 3 months. In cases where an individual resident had transited into or out of the NH more than once during the 3-month period, only the last transit was taken into consideration. Residents who died were counted but not described. Data were obtained retrospectively from the records. For all residents, data were collected on demographics and place of residence before admission. The status of residents with
Of 2665 French NHs invited to participate in the study, 300 (11.0%) agreed to participate. The mean number of beds was 85.9 33.2 (median: 79.5 beds). There were 132 (44%) that had a special care unit (SCU) dedicated to Alzheimer’s disease residents, and 45 (15%) had a nurse present during the night. The NH coordinating geriatrician spent on average 2.0 1.1 days a week in the NH. The mean distance separating the NH from the nearest hospital with an emergency service was 10.0 11.5 km. All NHs accepted residents with dementia and the mean number of residents with dementia per NH was 42.9 23.7. Of the 25,772 beds in participating NHs, 24,899 (96.6%) were occupied at the time of the study (mean: 83.0 32.2 per NH). In the 3 months before completion of the study questionnaires, 5986 had been admitted or discharged. In addition, 1507 patients had died. The mean number of residents admitted to or discharged from participating NHs is presented in Figure 1. The mean duration of residence in the NH at the time of discharge was 27.2 36.1 months (median: 11.9 months; interquartile range: 1.9e35.5 months). For the patients who were readmitted to the NH after a hospitalization, the mean duration of residence was 39.9 46.2 months (median: 23.5 months; range: 1e377 months). The mean length of hospital stay was 12.4 12.3 days for the admitted residents and 12.9 13.6 days for the discharged residents. More than half of the residents who were hospitalized were directly admitted to the emergency room (522/905; 57.7%), then transferred to other departments (425/522; 81.4%). Only 7.7% were sent directly from the NH to a geriatric department. Questionnaires were completed for a total of 2231 residents, corresponding to 7.4 resident questionnaires per NH. Of these, 1859 (83.3%) related to admissions and 372 (16.7%) to discharges. Information on demographics, disability, and dementia-related variables are presented according to admission or discharge status in Table 1. Characteristics of dependency according to admission or discharge status are reported in Figure 2. Most residents (82%) presented at least 1 of the behavioral items on the Neuropsychiatric Inventory (mean of 2.8 2.3 items). The frequency of reported behavioral disturbances is presented in Figure 3.
Y. Rolland et al. / JAMDA 13 (2012) 407.e7e407.e12
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Fig. 1. Flow of residents into and out of the NH over the last 3 months. Data are presented as the mean number of transitions per participating NH. These NHs had a mean number of occupied beds of 83.0%. Numbers are means SD.
Overall, 1005 residents (45.0%) among the 2231 residents were diagnosed with dementia. Of the residents diagnosed with dementia, 54.2% were diagnosed with Alzheimer’s disease; 16.0% with vascular dementia; and 11.0% with Lewy body, parkinsonian, or frontotemporal dementia. In the remaining cases, the exact diagnosis was not specified. The MMSE score was documented in the records for 590 residents (58.7% of residents with dementia). For these residents, the mean MMSE score was 13.3 7.4 (median: 14.1; interquartile range: 7.3e17.9). The contribution of residents with dementia to the different admission and discharge status subgroups was fairly uniform (Table 1), with the exception of discharges back home, which were infrequent for patients with dementia. The characteristics of the residents with a diagnosis of dementia are reported in Table 2. Psychotropic drugs (antidepressants, hypnotics, antipsychotics, and anxiolytics) were frequently prescribed in the NH residents, whatever their admission or discharge status (Table 1). These different drugs, with the exception of hypnotics, were prescribed significantly more often to residents with dementia than to residents
who did not have dementia (Table 2). In particular, antipsychotic drugs were prescribed to more than twice as many residents in the dementia group than in the no dementia group (28.0% versus 11.8%). Antipsychotic drugs were also prescribed more frequently to younger residents, being prescribed to 25.9% (255/983) of residents younger than 86 years versus 13.6% (168/1233) of residents 86 years or older (P < .01), and to those who presented productive behavioral symptoms, such as agitation, irritability, or sleep disturbances (28.3% of patients with these symptoms versus 5.9% of those without). The use of antidementia drugs is reported in Table 2; these were prescribed to 53.7% of patients with dementia (24.2% of all patients). The most frequently prescribed antidementia drug in the residents with dementia was memantine, followed by donepezil, rivastigmine, and galantamine. The extent of psychotropic drug prescription was essentially similar in residents admitted (1305/1859; 70.2%) and residents discharged (251/372; 67.5%), irrespective of where they had been admitted from and where they were discharged to. An exception to
Table 1 Characteristics of Residents Admitted To or Discharged From a Nursing Home (n ¼ 2231) Characteristics
Total Population
First Admission From Home
First Admission From Hospital
Discharge to Hospital
Readmission From Hospital
Discharge Home
Admission From or Discharge to Other NH
n Age, mean SD Gender, n (% female) Diagnosis of dementia, n (%) Other characteristics, n (%) Fall in past week Weight loss in past 3 mo Physical restraint Antidementia* drug, n (%) At least 1 psychotropic drug, n (%) Antidepressant, n (%) Hypnotic, n (%) Antipsychotic, n (%) Anxiolytic, n (%)
2231 85.7 7.4 1560 (69.9) 1005 (45.0)
502 85.4 6.8 356 (70.9) 230 (45.8)
461 84.7 7.6 325 (70.5) 221 (47.9)
170 86.3 7.1 108 (63.5) 68 (40.0)
721 86.7 7.5 505 (70.0) 317 (44.0)
104 84.5 7.1 62 (59.6) 28 (26.9)
262 85.1 7.5 198 (75.6) 135 (51.5)
274 548 356 540 1556 880 674 426 776
49 57 44 145 351 196 141 75 172
48 118 70 116 319 182 154 97 155
31 64 39 31 122 63 51 42 63
108 242 162 159 511 287 223 138 258
7 12 9 14 65 33 24 14 36
32 55 33 71 178 113 75 60 88
(12.3) (24.6) (16.0) (24.2) (69.7) (39.4) (30.2) (19.1) (34.8)
(9.8) (11.4) (8.8) (28.9) (69.9) (39.0) (28.1) (14.9) (34.3)
NH, nursing home. *Antidementia drugs include acetylcholinesterase inhibitors and memantine.
(10.4) (25.6) (15.2) (25.2) (69.2) (39.5) (33.4) (21.0) (33.6)
(18.2) (37.6) (22.9) (18.2) (71.8) (37.1) (30.0) (24.7) (37.1)
(15.0) (33.6) (22.5) (22.1) (70.9) (39.8) (30.9) (19.1) (35.8)
(6.7) (11.5) (8.7) (13.5) (62.5) (31.7) (23.1) (13.5) (34.6)
(12.2) (21.0) (12.6) (27.1) (67.9) (43.1) (28.6) (22.9) (33.6)
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Fig. 2. Level of disability of 2231 residents admitted to or discharged from an NH.
this was antipsychotic drug use, which was significantly lower in residents admitted from home (75/502; 14.9%) than in the other groups of residents (P < .01) (Table 1). No differences were observed in the extent of prescription of psychotropic drugs with respect to the size of the NH (number of beds), status (for-profit or not-for-profit), distance from a hospital emergency department, the time the coordinating geriatrician spends in the NH, geographic region, or presence of an SCU (data not shown). The only NH characteristic to be associated with the extent of psychotropic drug prescription was the presence of a nurse during the night. A higher proportion of residents were prescribed these drugs in NHs having a night-duty nurse (292/ 364; 80.2%) than in those without (1264/1867; 67.7%; P < .0001; c2 test). NHs with night nurses have a higher proportion of residents with Alzheimer’s disease (data not shown), which may account for this difference in prescribing patterns.
Delusions/paranoia Hallucinations Agitation/aggression Elation/euphoria Disinhibition Irritability/lability Motor disturbance
Discussion Our findings highlight the high rate of transition of individuals into and out of NHs in France, especially with the emergency department. More than one resident in four had either entered or left the NH in the previous 3 months. About one-half of these moves represented natural turnover, with first-time admissions replacing residents who had died or been definitively discharged either back home or to another NH. This probably reflects the relative paucity of NH places relative to the demand, where there is a long waiting list for NH places and rate of admissions is principally determined by the death of previous residents. The proportion of residents who were discharged back home was very low (approximately 5%). The other half of the transitions represented patients who were hospitalized or readmitted after a hospital stay. Approximately four residents in 10 had been hospitalized in the previous 3 months. Such high rates of hospitalization of NH residents, mainly to the emergency department, have been observed in previous studies,23 and may be associated with a reduction in the quality of care during the transition.24,25 For this reason, and because many of these transitions may be avoidable, interest has focused on developing resident-centered care in the NH to reduce the need for hospitalization.24,26 Studies such as PLEIAD may be useful in formulating national health policies aimed at reducing the number and consequences of NH transitions for the elderly.27,28 Overall, the rate of use of psychotropic drugs was very high, with approximately 70% of the sample being prescribed at least one such drug. Interestingly, the overall prescription rate between residents admitted or discharged from the NH was very similar, suggesting that initiation of psychotropic drug prescription does not happen in the NH itself, but rather in community care or in hospital before the individual arrives in the NH.
Nighttime behaviors Depressed mood/dysphoria Anxiety Apathy/indifference Appetite/eating 0
10
20
30
40
50
60
Proportion of patients (%)
Fig. 3. Behavioral disturbances in 2231 residents admitted to or discharged from an NH.
In contrast, the rate of prescription of antidementia drugs was relatively low, with only about half of residents with dementia (54.7%) receiving a specific treatment for dementia. The prescription rate for antidementia drugs was highest in individuals admitted
Y. Rolland et al. / JAMDA 13 (2012) 407.e7e407.e12 Table 2 Characteristics of Patients With a Dementia Diagnosis or No Dementia Diagnosis Characteristics
Dementia
No Dementia
P
n Age, mean SD Gender, n (% female) MMSE* score (n ¼ 590), mean SE Not disabled for ADL, n (%) Bathing Dressing Toileting Transferring Continent Feeding Neuropsychiatric inventory, n (%) Agitation/aggression Irritability Sleep disorders Apathy Fall during the past week, n (%) Weight loss in past 3 months, n (%) Physical restraints, n (%) Treatments, n (%) Antidepressant Hypnotic Antipsychotic Anxiolytic At least 1 psychotropic drug above Three or more of the above None of the above Antidementia drugy Any psychotropic or antidementia drug
1005 85.3 6.8 720 (71.6) 13.3 7.4
1212 86.0 7.8 833 (68.7) d
d <.05 NS
53 94 253 398 210 429
(5.3) (9.4) (25.2) (39.6) (20.9) (42.7)
236 359 534 539 537 812
(19.5) (29.6) (44.1) (44.5) (44.3) (67.0)
<.01 <.01 <.01 <.05 <.01 <.01
361 374 404 351 161 280 216
(35.9) (37.2) (40.2) (34.9) (16.0) (27.9) (21.5)
127 226 377 171 111 266 141
(10.5) (18.6) (31.1) (14.1) (9.2) (21.9) (11.6)
<.01 <.01 <.01 <.01 <.01 <.01 <.01
447 294 281 374 766 191 128 540 877
(44.5) (29.3) (28.0) (37.2) (76.2) (19.0) (12.7) (53.7) (87.3)
428 (35.3) 375 (30.9) 143 (11.8) 398 (32.8) 779 (64.3) 166 (13.7) 428 (35.3) None 781 (64.4)
<.05 NS <.05 <.05 <.05 <.05 <.05 d <.05
d, not available; ADL, activity of daily living; NS, not significant. *MMSE (Mini Mental Status Exam) was collected if available in residents with a diagnosis of dementia. y Antidementia drugs include acetylcholinesterase inhibitors and memantine.
directly from home, even though there was no major difference in the proportion of residents with dementia between newly admitted, readmitted, and discharged residents. This may reflect in part a reluctance to prescribe such drugs in NHs, but probably also to discontinuation of acetylcholinesterase inhibitors as the dementia becomes more severe, when such drugs are no longer indicated. All classes of psychotropic drugs were prescribed more frequently to residents with dementia than those without, but this difference was particularly striking for antipsychotic drugs, prescribed to 28% of residents with dementia compared with 12% of residents who did not have dementia. Antipsychotic drugs are widely used to manage behavioral and psychological symptoms of dementia, which are believed to affect about 80% of NH residents with dementia.29 In our study, these drugs were particularly used in patients with productive behavioral symptoms, such as agitation, irritability, or sleep disturbances. The proportion of patients who do not have dementia, who do not necessarily present these behavioral disturbances, and who receive antipsychotics (12%) is also high, and unlikely to be justified by mental disorders for which these drugs are indicated (schizophrenia and bipolar disorders). Nonetheless, the risks associated with the use of antipsychotic drugs may well outweigh their benefits.30,31 The use of these drugs should be rare for treatment of elderly patients with dementia32 and they are contraindicated in this patient population in the United States.15 In our study, we observed a higher rate of falls in residents prescribed antipsychotic drugs (18% had experienced a fall in the previous week), although it is not possible to conclude that this is independent from the increased risk of falls associated with dementia. The proportion of residents receiving antipsychotic drugs in our survey is similar to that reported in recent surveys in Canada (20.4% in 2004),7 but are lower than the latest prescription rates reported from the United States (29.1% in 2006),3 Germany (28.4% in 2006),9 and particularly Austria (45.9%).33 The high use of psychotropic
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drugs in general, and of antipsychotic medication in particular, is likely to be a consequence of inadequate time, knowledge, and resources for implementing other nonpharmacological interventions for behavioral and psychological symptoms of dementia. Although the latter are effective, and do not carry the risks of side effects associated with drug therapy, they are time-consuming for staff to implement in routine practice in NHs. Time constraints are clearly relevant to the choice of therapeutic strategy. In addition, a large NH survey performed in the United States reported that more physician presence in the NH was associated with fewer psychotropic drug prescriptions.34 Decisions on NH staffing thus have an impact on psychotropic drug use and may thereby indirectly influence risk exposure of residents. Educational programs directed at medical and nursing staff in NHs focusing on the risk-benefit assessment of antipsychotic drug treatments may be effective in reducing the level of inappropriate antipsychotic prescribing. Policies aimed at achieving this, however, such as the French AMI-Alzheimer initiative,19 need to take into account the fact that much of this prescription is initiated before the resident is admitted to the NH, and the primary care physician remains responsible for drug prescription for NH residents after admission. For this reason, educational programs should first and foremost target primary care physicians. With respect to resource allocation in NHs, access to training in nonpharmacological interventions for NH staff and, above all, time allocated to such interventions, could be particularly useful in reducing unnecessary recourse to psychotropic drugs. Finally, better coordination between the primary care physician and the NH geriatrician may facilitate more rational use of psychotropic drugs. This study has several strengths. These include the large number of NH residents evaluated from a national sample of NHs in France. In addition, the study addressed the flow of patients in and out of the NH and compared characteristics and treatment of residents with respect to where they were admitted from and where they were discharged to. This represents a novel feature of the study, which has not been addressed extensively in previous studies, and reveals unanticipated relationships between dementia status, psychotropic drug treatment, and admission status. The study also presents a number of limitations, for example the cross-sectional nature of the survey, which precludes evaluation of how psychotropic drug use evolves following admission to the NH and in case of subsequent dementia diagnosis. The relatively low participation rate (11% of all NHs in France) also raises the issue of representativity. It is possible that this study attracted participants more interested in research or more alert to public health issues, whose standards of care may be higher than those of the average NH in France. In addition, no information was collected on reasons for prescription of psychotropic drugs or on other psychiatric diagnoses. It is likely that a minority of residents will also have been diagnosed with mental illnesses for which prescription of antipsychotic drugs is justified. It should also be noted that some of our findings may reflect specificities of the French health system, such as prescription of medication to residents being the responsibility of the community physician, and may not be transposable elsewhere. This study evaluated only individuals moving into and out of the NH in a 3-month period, and it is possible, especially given that approximately half of these cases concerned transfers to and from hospital, that frailer, more medicated residents are overrepresented, compared with those residents who were not transferred during the study period and who are not evaluated. The proportion of individuals in our study with dementia is similar to that reported in a previous study of NH residents in France10 (43.5%), however, and the reported use of antipsychotic medication is actually lower than in the previous study (27.4%).10 This may reflect the affect of public health campaigns aimed at limiting antipsychotic prescription to the elderly.
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Conclusion This large study conducted in France demonstrates, first, that movement of residents into and out of NHs and between NH and hospital is extensive. Second, prescription rates for psychotropic drugs in general and antipsychotic drugs in particular remain high, especially in residents with dementia. Even when admitted to an NH for the first time, residents are highly medicated. This indicates that several groups of health care providers, including general practitioners in the community, hospital physicians, physicians in emergency departments, and physicians in the NH, have responsibility for potentially inappropriate prescription of psychotropic drugs and should be targeted by educational measures to improve the quality of prescription of these drugs.
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