Top

Drugs & Aging

Published in:

Open Access 01-01-2017 | Original Research Article

Prevalence of, and Resident and Facility Characteristics Associated With Antipsychotic Use in Assisted Living vs. Long-Term Care Facilities: A Cross-Sectional Analysis from Alberta, Canada

Authors: Kathryn J. Stock, Joseph E. Amuah, Kate L. Lapane, David B. Hogan, Colleen J. Maxwell

Published in: Drugs & Aging | Issue 1/2017

Abstract

Background

Potentially inappropriate antipsychotic use in long-term care (LTC) facilities has been the focus of significant policy and clinical attention over the past 20 years. However, most initiatives aimed at reducing the use of these medications have overlooked assisted living (AL) settings.

Objective

We sought to compare the prevalence of antipsychotic use (including potentially inappropriate use) among older AL and LTC residents and to explore the resident and facility-level factors associated with use in these two populations.

Methods

We performed cross-sectional analyses of 1089 residents (mean age 85 years; 77% female) from 59 AL facilities and 1000 residents (mean age 85 years; 66% female) from 54 LTC facilities, in Alberta, Canada. Research nurses completed comprehensive resident assessments at baseline (2006–2007). Facility-level factors were assessed using standardized administrator interviews. Generalized linear models were used to estimate odds ratios for associations, accounting for clustering by facility.

Results

Over a quarter of residents in AL (26.4%) and LTC (31.8%) were using antipsychotics (p = 0.006). Prevalence of potentially inappropriate use was similar in AL and LTC (23.4 vs. 26.8%, p = 0.09). However, among users, the proportion of antipsychotic use deemed potentially inappropriate was significantly higher in AL than LTC (AL: 231/287 = 80.5%; LTC: 224/318 = 70.4%; p = 0.004). In both settings, comparable findings regarding associations between resident characteristics (including dementia, psychiatric disorders, frailty, behavioral symptoms, and antidepressant use) and antipsychotic use were observed. Few facility characteristics were associated with overall antipsychotic use, but having a pharmacist on staff (AL), or an affiliated physician (LTC) was associated with a lower likelihood of potentially inappropriate antipsychotic use.

Conclusion

Our findings illustrate the importance of including AL settings in clinical and policy initiatives aimed at reducing inappropriate antipsychotic use among older vulnerable residents.

Available only for authorised users

Choosing Wisely Canada. Psychiatry: thirteen things physicians and patients should question. 2015. Available from: http://www.choosingwiselycanada.org/recommendations/psychiatry/. Accessed April 2016.

Levinson DR, editor. Medicare atypical antipsychotic drug claims for elderly nursing home residents. Publication No. OEI-07-08-00150. Washington, DC: Department of Health and Human Services, Office of Inspector General. May 2011. Available from: http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf. Accessed March 2016.

Health Quality Ontario. Looking for balance: antipsychotic medication use in Ontario long-term care homes. Toronto: Queen’s Printer for Ontario; 2015.

Foebel AD, Liperoti R, Onder G, et al. Use of antipsychotic drugs among residents with dementia in European long-term care facilities: results from the SHELTER study. J Am Med Dir Assoc. 2014;15(12):911–7.CrossRefPubMed

Maher AR, Maglione M, Bagley S, et al. Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis. JAMA. 2011;306(12):1359–69.CrossRefPubMed

Ray WA, Chung CP, Murray KT, et al. Atypical antipsychotic drugs and the risk of sudden cardiac death. N Engl J Med. 2009;360(3):225–35.CrossRefPubMedPubMedCentral

Gill SS, Rochon PA, Herrmann N, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005;330:445.CrossRefPubMedPubMedCentral

Shin JY, Choi NK, Jung SY, et al. Risk of ischemic stroke with the use of risperidone, quetiapine and olanzapine in elderly patients: a population-based, case-crossover study. J Psychopharmacol. 2013;27(7):638–44.CrossRefPubMed

Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med. 2008;168(10):1090–6.CrossRefPubMed

10.

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(15):1934–43.CrossRefPubMed

11.

Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med. 2007;146(11):775–86.CrossRefPubMed

12.

Standing Senate Committee on Social Affairs, Science and Technology. Prescription pharmaceuticals in Canada: off-label use. 2014. Available from: http://www.parl.gc.ca/Content/SEN/Committee/412/soci/rep/rep05jan14-e.pdf. Accessed 2 May 2016.

13.

Maglione M, Ruelaz Maher A, Hu J, et al. Off-label use of atypical antipsychotics: an update. Comparative Effectiveness Review No. 43. (Prepared by the Southern California Evidence-based Practice Center under Contract No. HHSA290-2007-10062-1.) Rockville (MD): Agency for Healthcare Research and Quality. September 2011. Available from: https://www.effectivehealthcare.ahrq.gov/ehc/products/150/778/CER43_Off-LabelAntipsychotics_20110928.pdf. Accessed 2 May 2016.

14.

Eguale T, Buckeridge DL, Winslade NE, et al. Drug, patient, and physician characteristics associated with off-label prescribing in primary care. Arch Intern Med. 2012;172(10):781–8.CrossRefPubMed

15.

Eguale T, Buckeridge DL, Verma A, et al. Association of off-label drug use and adverse drug events in an adult population. JAMA Intern Med. 2016;176(1):55–63.CrossRefPubMed

16.

Health Canada. Drug product database. In: Drugs and health products. 2015 Jun 18. Available from: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/databasdon/index-eng.php. Accessed 2 May 2 2016.

17.

U.S. Food and Drug Administration. FDA alert on antipsychotics. Silver Spring (MD): U.S. Department of Health and Human Services. 2009 Oct 16. Available from: http://www.canhr.org/newsroom/newdev_archive/2009/FDA-Alert-on-Antipsychotics.pdf. Accessed March 2016.

18.

Health Canada. Atypical antipsychotic drugs and dementia: advisories warnings and recalls for health professionals. Ottawa (ON): Government of Canada. 2013 June 3. Available from: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2005/14307a-eng.php. Accessed March 2016.

19.

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(15):1525–38.CrossRefPubMed

20.

Kleijer BC, van Marum RJ, Egberts AC, et al. The course of behavioral problems in elderly nursing home patients with dementia when treated with antipsychotics. Int Psychogeriatr. 2009;21(5):931–40.CrossRefPubMed

21.

Seitz DP, Gill SS, Herrmann N, et al. Pharmacological treatments for neuropsychiatric symptoms of dementia in long-term care: a systematic review. Int Psychoger. 2013;25(2):185–203.CrossRef

22.

Conn D, Gibson M, McCabe D. 2014 CCSMH guideline update: the assessment and treatment of mental health issues in long term care homes: (focus on mood and behaviour symptoms). Toronto (ON): Canadian Coalition for Seniors’ Mental Health (CCSMH); 2014. Available from: www.ccsmh.ca. Accessed 22 Oct 2016.

23.

Valiyeva E, Herrmann N, Rochon PA, et al. Effects of regulatory warnings on antipsychotic prescription rates among elderly patients with dementia: a population-based time series analysis. CMAJ. 2008;179(5):438–46.CrossRefPubMedPubMedCentral

24.

Selbæk G, Kirkevold O, Engedal K. The course of psychiatric and behavioral symptoms and the use of psychotropic medication in patients with dementia in Norwegian nursing homes: a 12-month follow-up study. Am J Geriatr Psychiatry. 2008;16(7):528–36.CrossRefPubMed

25.

Barnes TR, Banerjee S, Collins N, et al. Antipsychotics in dementia: prevalence and quality of antipsychotic drug prescribing in UK mental health services. Br J Psychiatry. 2012;201(3):221–6.CrossRefPubMed

26.

Choosing Wisely Canada. Treating disruptive behaviour in people with dementia. 2014. Available from: http://www.choosingwiselycanada.org/wp-content/uploads/2014/04/Antipsychotic-EN-web.pdf. Accessed April 2016.

27.

Canadian Foundation for Healthcare Improvement. Reducing antipsychotic medication use collaborative. 2016. Available from: http://www.cfhi-fcass.ca/WhatWeDo/reducing-antipsychotic-medication-use-collaborative. Accessed March 2016.

28.

Centers for Medicare and Medicaid Services. Partnership to improve dementia care in nursing homes: antipsychotic drug use in nursing homes trend update. 2014. Available from: https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-10-27-Trends.pdf. Accessed March 2016.

29.

Bueckert V. Can decreasing antipsychotic use lead to growth in mental and emotional health? Alberta RN Summer. 2014;70(2):12–4.

30.

Zimmerman S, Scales K, Wiggins B, et al. Addressing antipsychotic use in assisted living residents with dementia. J Am Geriatr Soc. 2015;63(9):1970–1.CrossRefPubMed

31.

Maxwell CJ, Amuah JE, Hogan DB, et al. Elevated hospitalization risk of assisted living residents with dementia in Alberta, Canada. J Am Med Dir Assoc. 2015;16(7):568–77.CrossRefPubMed

32.

Zimmerman S, Sloane PD, Reed D. Dementia prevalence and care in assisted living. Health Aff (Millwood). 2014;33(4):658–66.CrossRefPubMed

33.

Alberta Health and Wellness. Continuing care strategy: aging in the right place. Edmonton (AB): Government of Alberta; Dec 2008. Available from: http://www.health.alberta.ca/documents/Continuing-Care-Strategy-2008.pdf. Accessed March 2016.

34.

Canadian Centre for Elder Law. Discussion paper on assisted living: Past, present and future legal trends in Canada. Vancouver (BC): British Columbia Law Institute; 2007. Available from: http://www.bcli.org/publication/discussion-paper-assisted-living-past-present-and-future-legal-trends-canada-0. Accessed March 2016.

35.

Hogan DB, Amuah JE, Strain LA, et al. High rates of hospital admission among older residents in assisted living facilities: opportunities for intervention and impact on acute care. Open Med. 2014;8(1):e33–45.PubMedPubMedCentral

36.

Beeber AS, Zimmerman S, Reed D, et al. Licensed nurse staffing and health service availability in residential care and assisted living. J Am Geriatr Soc. 2014;62(5):805–11.CrossRefPubMedPubMedCentral

37.

Stearns SC, Park J, Zimmerman S, et al. Determinants and effects of nurse staffing intensity and skill mix in residential care/assisted living settings. Gerontologist. 2007;47(5):662–71.CrossRefPubMed

38.

Strain LA, Maxwell CJ, Wanless D, et al. Designated assisted living (DAL) and long-term care (LTC) in Alberta: selected highlights from the Alberta Continuing Care Epidemiological Studies (ACCES). Edmonton (AB): ACCES Research Group, University of Alberta; 2011. Available from: http://hdl.handle.net/10402/era.23779. Accessed 16 Sept 2016.

39.

Wanless D, Strain LA, Maxwell CJ. Designated assisted living (DAL) and long-term care (LTC) in Alberta: Alberta Continuing Care Epidemiological Studies (ACCES) methodology. Edmonton (AB): ACCES Research Group, University of Alberta; 2011. Available from: http://hdl.handle.net/10402/era.23788. Accessed 16 Sept 2016.

40.

Maxwell CJ, Soo A, Hogan DB, et al. Predictors of nursing home placement from assisted living settings in Canada. Can J Aging. 2013;4:1–16.

41.

Hirdes JP, Ljunggren G, Morris JN, et al. Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system. BMC Health Serv Res. 2008;8:277.CrossRefPubMedPubMedCentral

42.

Kim H, Jung Y, Sung M, et al. Reliability of the interRAI long term care facilities (LTCF) and interRAI home care (HC). Geriatr Gerontol Int. 2015;15:220–8.CrossRefPubMed

43.

Poss JW, Jutan NM, Hirdes JP, et al. A review of evidence on the reliability and validity of minimum data set data. Healthc Manage Forum. 2008;21:33e39.CrossRef

44.

Rockwood K, Mitnitski AB, MacKnight C. Some mathematical models of frailty and their clinical implications. Rev Clin Gerontol. 2002;12(2):109–17.CrossRef

45.

Searle SD, Mitnitski A, Gahbauer EA, et al. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8:24.CrossRefPubMedPubMedCentral

46.

Perlman CM, Hirdes JP. The aggressive behavior scale: a new scale to measure aggression based on the minimum data set. J Am Geriatr Soc. 2008;56(12):2298–303.CrossRefPubMed

47.

Canadian Institute for Health Information. Indicator library: potentially inappropriate use of antipsychotics in long-term care. 2016. Available from: http://indicatorlibrary.cihi.ca/display/HSPIL/Potentially+Inappropriate+Use+of+Antipsychotics+in+Long-Term+Care. Accessed April 2016.

48.

Larrayadieu A, Abellan van Kan G, Piau A, et al. Associated factors with antipsychotic use in assisted living facilities: a cross-sectional study of 4367 residents. Age Ageing. 2011;40(3):368–75.CrossRefPubMed

49.

Hughes CM, Lapane KL, Mor V. Influence of facility characteristics on use of antipsychotic medications in nursing homes. Med Care. 2000;38(12):1164–73.CrossRefPubMed

50.

Alanen HM, Finne-Soveri H, Noro A, Leinonen E. Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland. Age Ageing. 2006;35(5):508–13.CrossRefPubMed

51.

Gruber-Baldini AL, Boustani M, Sloane PD, et al. Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management. J Am Geriatr Soc. 2004;52(10):1610–7.CrossRefPubMed

52.

Canadian Institute for Health Information. Drug use among seniors on public drug programs in Canada, 2012: revised October 2014. Ottawa: CIHI; 2014.

53.

Canadian Institute for Health Information. Your health system: potentially inappropriate use of antipsychotics in long-term care. 2016. Available from: http://yourhealthsystem.cihi.ca/enbref/?lang=en#!/indicators/008/potentially-inappropriate-use-of-antipsychotics-in-long-term-care/;mapC1;mapLevel2/. Accessed April 2016.

54.

Alberta Health Services. Strategic clinical networks: appropriate use of antipsychotic medication in long term care. Available from: http://www.albertahealthservices.ca/assets/about/scn/ahs-scn-sb-seniors-aua.pdf. Accessed 16 Sep 2016.

55.

Kamble P, Chen H, Sherer J, Aparasu RR. Antipsychotic drug use among elderly nursing home residents in the United States. Am J Geriatr Pharmacother. 2008;6(4):187–97.CrossRefPubMed

56.

Kronhaus A, Fuller S, Zimmerman S, et al. Prevalence and medication management of dementia by a medical practice providing onsite care in assisted living. J Am Med Dir Assoc. 2016;17(7):673.e9–15.CrossRef

57.

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(6):511–9.CrossRefPubMed

58.

Peri K, Kerse N, Moyes S, et al. Is psychotropic medication use related to organisational and treatment culture in residential care. J Health Organ Manag. 2015;29(7):1065–79.CrossRefPubMed

59.

Foebel AD, Onder G, Finne-Soveri H, et al. Physical restraint and antipsychotic medication use among nursing home residents with dementia. J Am Med Dir Assoc. 2016;17(2):184.e9,184.e14.

60.

McNabney MK, Samus QM, Lyketsos CG, et al. The spectrum of medical illness and medication use among residents of assisted living facilities in Central Maryland. J Am Med Dir Assoc. 2008;9(8):558–64.CrossRefPubMedPubMedCentral

61.

Cornege-Blokland E, Kleijer BC, Hertogh CM, van Marum RJ. Reasons to prescribe antipsychotics for the behavioral symptoms of dementia: a survey in Dutch nursing homes among physicians, nurses, and family caregivers. J Am Med Dir Assoc. 2012;13(1):80.e1, 80.e6.

62.

Poudel A, Peel NM, Nissen L, et al. Potentially inappropriate prescribing in older patients discharged from acute care hospitals to residential aged care facilities. Ann Pharmacother. 2014;48(11):1425–33.CrossRefPubMed

63.

Rockwood K, Howlett SE, MacKnight C, et al. Prevalence, attributes and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian Study of Health and Aging. J Gerontol Med Sci. 2004;59A:1310–7.CrossRef

64.

Hogan DB, Freiheit EA, Strain LA, et al. Comparing frailty measures in their ability to predict adverse outcome among older residents of assisted living. BMC Geriatr. 2012;12:56.CrossRefPubMedPubMedCentral

65.

Stock, K. High-risk medication use, frailty and hospitalization among older assisted living residents. Master’s thesis, University of Waterloo, Waterloo, Ontario. 2015. Available from: https://uwspace.uwaterloo.ca/handle/10012/9661. Accessed April 2016.

66.

Pollock BG, Mulsant BH, Rosen J, et al. Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients. Am J Psychiatry. 2002;159(3):460–5.CrossRefPubMed

67.

Rochon PA, Stukel TA, Bronskill SE, et al. Variation in nursing home antipsychotic prescribing rates. Arch Intern Med. 2007;167(7):676–83.CrossRefPubMed

68.

Kleijer BC, van Marum RJ, Frijters DH, et al. Variability between nursing homes in prevalence of antipsychotic use in patients with dementia. Int Psychogeriatr. 2014;26(3):363–71.CrossRefPubMed

69.

Chen Y, Briesacher BA, Field TS, et al. Unexplained variation across US nursing homes in antipsychotic prescribing rates. Arch Intern Med. 2010;170(1):89–95.CrossRefPubMedPubMedCentral

70.

Zimmerman S, Anderson WL, Brode S, et al. Systematic review: Effective characteristics of nursing homes and other residential long-term care settings for people with dementia. J Am Geriatr Soc. 2013;61(8):1399–409.CrossRefPubMed

71.

Jutkowitz E, Brasure M, Fuchs E, et al. Care-delivery interventions to manage agitation and aggression in dementia nursing home and assisted living residents: a systematic review and meta-analysis. J Am Geriatr Soc. 2016;64(3):477–88.CrossRefPubMed

72.

Teri L, Huda P, Gibbons L, et al. STAR: a dementia-specific training program for staff in assisted living residences. Gerontologist. 2005;45(5):686–93.CrossRefPubMed

Title: Prevalence of, and Resident and Facility Characteristics Associated With Antipsychotic Use in Assisted Living vs. Long-Term Care Facilities: A Cross-Sectional Analysis from Alberta, Canada
Authors: Kathryn J. Stock
Joseph E. Amuah
Kate L. Lapane
David B. Hogan
Colleen J. Maxwell
Publication date: 01-01-2017
Publisher: Springer International Publishing
Published in: Drugs & Aging / Issue 1/2017
Print ISSN: 1170-229X
Electronic ISSN: 1179-1969
DOI: https://doi.org/10.1007/s40266-016-0411-0

ACC 2024 Congress Coverage

Heart Failure Video

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Prevalence of, and Resident and Facility Characteristics Associated With Antipsychotic Use in Assisted Living vs. Long-Term Care Facilities: A Cross-Sectional Analysis from Alberta, Canada

Abstract

Background

Objective

Methods

Results

Conclusion

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Objective

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2017

Risk Factors for Initiation of Potentially Inappropriate Medications in Community-Dwelling Older Adults with and without Alzheimer’s Disease

The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

How Antibiotics Should be Prescribed to Hospitalized Elderly Patients with Community-Acquired Pneumonia

Pharmacological Management of Allergic Rhinitis in the Elderly

A Comparison of Sex Differences in Psychotropic Medication Use in Older People with Alzheimer’s Disease in the US and Finland

A Comparison of Pharmacokinetic and Pharmacodynamic Properties Between Faster-Acting Insulin Aspart and Insulin Aspart in Elderly Subjects with Type 1 Diabetes Mellitus

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page