Antipsychotic Use in Nursing Home Residents With Dementia
The final sample included 204 residents: 155 randomly selected residents with dementia and receiving an antipsychotic medication, 27 residents considered to have been successfully tapered off an antipsychotic medication, and 22 residents for whom there had been an unsuccessful taper. Medical record abstraction was completed for all 204 residents. (See Table 2 for responses from all sources.)
Interviews were conducted with 466 individuals. Twenty-six DONs were interviewed regarding 48 residents, 91 RNs and LPNs for 198 residents, 244 CNAs regarding 204 residents, 27 prescribers regarding 61 residents, 23 pharmacists regarding 175 residents and, 14 psychiatrists regarding 57 residents. Family members of 41 residents were also interviewed. (See Table 3 for interview responses.)
When data from selected residents were compared with U.S. NH population data, residents in the selected sample were older (≥85, 47.6% vs 42%), had longer NH stays (≥2 years, 51% vs 25.2%), and were more likely to be nonwhite (78.8% vs 65.7%).
In the sample of 204 residents, two were on an as-needed medication only, 173 were prescribed routine medication according to CMS guidelines for maximum total daily dosing, 28 were prescribed doses that exceeded CMS guidelines for maximum total daily dosing, and two were prescribed two different antipsychotic agents at the same time.
The reasons that providers, staff and family members most often cited or from medical records were related to resident behaviors. The behaviors most frequently noted were aggressive behaviors, including any physical aggression (85 residents); verbal aggression (91 residents); and problems with daily care (51 residents). Residents may exhibit more than one behavior so that frequencies do not add up to total number of residents for whom behaviors were provided as explanations for antipsychotic use (n = 171).
For 159 residents, respondents or medical records identified at least one psychiatric diagnosis, symptom, or characterization as a reason for use of an antipsychotic medication. Of the 159 residents, at least one respondent or the medical record identified 95 (60%) as having a diagnosis related to psychosis. Other psychiatric diagnoses or characterizations noted frequently were loss of contact with reality (n = 65, 42%), depression (n = 54, 34%), and anxiety (n = 35, 22%). Moreover, the prescribers and consultant psychiatrists who were interviewed about residents who were currently receiving an antipsychotic offered psychiatric explanations for only approximately one-third of those residents; for the majority of residents, they provided only behavioral explanations.
Emotional reasons for antipsychotic use were identified at least once for 105 residents. For 95 residents, specific emotional issues were reported, including anger or agitation. For 20 residents, interviewees or medical records stated that the antipsychotic medication was given because the resident was "sad" or "crying."
Interviewees or medical records listed "cognitive diagnoses or symptoms" as the reason for antipsychotic use at least once for 114 residents. These included delirium, dementia, and confusion.
For 11 residents, a rationale other than those listed in Table 2 was given for antipsychotic use. In 29 residents, respondents gave a general rationale (e.g., "behaviors," "psychiatric diagnosis") without specifics. "Quality-of-life issues" were reported as the reason at least once for each of 26 residents.
Response rates varied according to interviewee category from 30% to 96%, with RN and LPNs (96%) and CNAs (95%) having the highest response rates and prescribers (physicians, nurse practitioners, physician assistants, psychiatrists) having the lowest (30%). Not all interviewees offered a rationale for the use of antipsychotics for the specific resident under consideration. (See Table 3 for interviewees who gave specific rationales in their response.)
There were few differences between NHs with high and low antipsychotic use. Staff and leaders of facilities with lower antipsychotic medication use consistently identified social services as having an influence on decision-making regarding antipsychotic medication use. Staff and leaders of facilities with high antipsychotic medication use tended to identify consultant psychiatry more often than staff from lower-use facilities as having an influence. NHs with high antipsychotic use had higher percentages of nonwhite, male, and younger residents than NHs with lower use. NHs with high antipsychotic use were more frequently located in census tracts with less-educated, lower-income, and nonwhite populations than NHs with lower antipsychotic use. Families of residents in NHs with lower use of antipsychotic medications were more likely to indicate that they knew when the medication was started.
Results
The final sample included 204 residents: 155 randomly selected residents with dementia and receiving an antipsychotic medication, 27 residents considered to have been successfully tapered off an antipsychotic medication, and 22 residents for whom there had been an unsuccessful taper. Medical record abstraction was completed for all 204 residents. (See Table 2 for responses from all sources.)
Interviews were conducted with 466 individuals. Twenty-six DONs were interviewed regarding 48 residents, 91 RNs and LPNs for 198 residents, 244 CNAs regarding 204 residents, 27 prescribers regarding 61 residents, 23 pharmacists regarding 175 residents and, 14 psychiatrists regarding 57 residents. Family members of 41 residents were also interviewed. (See Table 3 for interview responses.)
When data from selected residents were compared with U.S. NH population data, residents in the selected sample were older (≥85, 47.6% vs 42%), had longer NH stays (≥2 years, 51% vs 25.2%), and were more likely to be nonwhite (78.8% vs 65.7%).
In the sample of 204 residents, two were on an as-needed medication only, 173 were prescribed routine medication according to CMS guidelines for maximum total daily dosing, 28 were prescribed doses that exceeded CMS guidelines for maximum total daily dosing, and two were prescribed two different antipsychotic agents at the same time.
Resident Behaviors
The reasons that providers, staff and family members most often cited or from medical records were related to resident behaviors. The behaviors most frequently noted were aggressive behaviors, including any physical aggression (85 residents); verbal aggression (91 residents); and problems with daily care (51 residents). Residents may exhibit more than one behavior so that frequencies do not add up to total number of residents for whom behaviors were provided as explanations for antipsychotic use (n = 171).
Presence of Psychiatric Diagnosis
For 159 residents, respondents or medical records identified at least one psychiatric diagnosis, symptom, or characterization as a reason for use of an antipsychotic medication. Of the 159 residents, at least one respondent or the medical record identified 95 (60%) as having a diagnosis related to psychosis. Other psychiatric diagnoses or characterizations noted frequently were loss of contact with reality (n = 65, 42%), depression (n = 54, 34%), and anxiety (n = 35, 22%). Moreover, the prescribers and consultant psychiatrists who were interviewed about residents who were currently receiving an antipsychotic offered psychiatric explanations for only approximately one-third of those residents; for the majority of residents, they provided only behavioral explanations.
Emotional
Emotional reasons for antipsychotic use were identified at least once for 105 residents. For 95 residents, specific emotional issues were reported, including anger or agitation. For 20 residents, interviewees or medical records stated that the antipsychotic medication was given because the resident was "sad" or "crying."
Cognitive
Interviewees or medical records listed "cognitive diagnoses or symptoms" as the reason for antipsychotic use at least once for 114 residents. These included delirium, dementia, and confusion.
Other Reasons
For 11 residents, a rationale other than those listed in Table 2 was given for antipsychotic use. In 29 residents, respondents gave a general rationale (e.g., "behaviors," "psychiatric diagnosis") without specifics. "Quality-of-life issues" were reported as the reason at least once for each of 26 residents.
Response rates varied according to interviewee category from 30% to 96%, with RN and LPNs (96%) and CNAs (95%) having the highest response rates and prescribers (physicians, nurse practitioners, physician assistants, psychiatrists) having the lowest (30%). Not all interviewees offered a rationale for the use of antipsychotics for the specific resident under consideration. (See Table 3 for interviewees who gave specific rationales in their response.)
Differences Between High and Low Antipsychotic Use NHs
There were few differences between NHs with high and low antipsychotic use. Staff and leaders of facilities with lower antipsychotic medication use consistently identified social services as having an influence on decision-making regarding antipsychotic medication use. Staff and leaders of facilities with high antipsychotic medication use tended to identify consultant psychiatry more often than staff from lower-use facilities as having an influence. NHs with high antipsychotic use had higher percentages of nonwhite, male, and younger residents than NHs with lower use. NHs with high antipsychotic use were more frequently located in census tracts with less-educated, lower-income, and nonwhite populations than NHs with lower antipsychotic use. Families of residents in NHs with lower use of antipsychotic medications were more likely to indicate that they knew when the medication was started.
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