Correlates of Behavioral Disturbances and Pattern of Psychotropic Medication Use in Five Skilled Nursing Facilities

Abstract

There are several treatment options for behavioral disturbances (BDs) in dementia. However, the choice of a specific psychotropic agent is directed by personal preferences and local community practice patterns. We examined the relationship between common clusters of BDs and the use of different classes of psychotropic agents in our community. A cross-sectional study of 430 long-term care residents from 5 nursing homes was undertaken. The Behavior Measurement Scale (BMS) was used to measure the frequency of BDs grouped in 4 categories. Residents with > 4 BD episodes in at least one category during a 2-week observation period were the behavior group and were considered to have clinically significant BDs. A sample of patients who had < 4 BDs in all BMS categories during the same observation period defined the nonbehavior group. A BD cluster was defined as > 4 BDs occurring in one or more BMS categories during the 2-week observation. Data on functional status, comorbidity, use of benzodiazepines, antidepressants, and neuroleptic agents were collected with chart review. The chi-square test was used to examine the correlation between variables. Clinically significant BDs were identified in 27.2% (117/430) of the residents in the sample. Five of 15 behavior clusters accounted for 73% of all clinically significant BDs. The 5 clusters were verbally nonaggressive behaviors (cluster 1, 20.5%), behaviors from all 4 categories (cluster 2, 17.9%), verbally and physically nonaggressive behaviors (cluster 3, 14.5%), physically nonaggressive behaviors (cluster 4, 12.8%), and verbally aggressive and nonaggressive behaviors (cluster 5, 7.7%). Cluster 5 had a negative correlation with functional impairment (P = .009). There was a significant correlation between cluster 2 and benzodiazepine use (P = .014). No other significant correlation was found between any of the 5 clusters and demographic variables, comorbidity status, and use of antidepressant or neuroleptic medications. Residents in the behavior group had higher impairment in self-feeding (P = .036) and bathing (P < .001) and were more likely to be treated with benzodiazepines (P = .004) and neuroleptic agents (P = .009) than residents in the nonbehavior group (n = 116). The higher use of neuroleptics and benzodiazepines in the behavior group compared with the nonbehavior group indicates that BDs are being identified for treatment, but the medications used may not be efficacious. The lack of association between specific classes of psychotropic medications and distinct behavior clusters indicates that clinicians are not using a standardized approach to target the neurochemical abnormalities that may underlie certain behavior clusters. Some behavior clusters correlate with impairment in specific activities of daily living categories such as bathing and feeding, making room for nonpharmacologic interventions.

Prevalence and correlates of psychotropic drug use in Dutch nursing-home patients with dementia

“…In another American study patients with clinically relevant symptoms used antipsychotic drugs or benzodiazepines more frequently (Ramadan et al ., 2003). A Norwegian study found a significant association between the type of drug and the psychiatric symptoms for which it had been dispensed; psychotic symptoms were strongly associated with the use of antipsychotic medication, whereas depression and anxiety were strongly associated with antidepressant, anxiolytic and sedative drug use (Selbaek et al ., 2006).…”

“…In general, antipsychotic medication was more frequently prescribed in patients with at least one neuropsychiatric symptom (Lindesay et al ., 2003; Selbaek et al ., 2006). One study showed no association between different types of agitation and specific type of medication (Ramadan et al ., 2003), but in a Norwegian study there was an association between the type of psychotropic drug and the psychiatric symptoms for which it had been prescribed (Selbaek et al ., 2006).…”

Staff Turnover and Quality of Care in Nursing Homes

“…32 The general concern with 3 classes of these drugs (antianxiety, sedative/hypnotic, and antipsychotic) 38 is that the rates of use may be excessive and/or clinically unjustified, to the degree that they are used to chemically restrain residents. 39 Thus, these 3 classes of psychoactive drugs were used as a QI.…”

Self-Injurious Behaviour in nursing home residents with dementia

“…SIB was associated with prescribed benzodiazepines, but not with anti-psychotics or anti-depressants. Psychotropic medications are often prescribed to manage behavioural disturbances in dementia (Ballard self-injurious behaviour et al, 2001;Hartikainen et al, 2003;Holmquist et al, 2003;Margallo-Lana et al, 2001;Ramadan et al, 2003). They are also commonly used in institutional settings to manage SIB (Pies and Popli, 1995).…”

“…Different causal factors have been postulated and the aetiology of SIB is likely to be multifactorial, representing a final common pathway (Draper et al, 2002a;Hall and O'Connor, 2004). Dementia type, dementia severity, psychotropic drugs and measures to restrain the patient are of practical importance to the management of SIB in nursing home patients Draper et al, 2001;Margallo-Lana et al, 2001;Draper et al, 2002a;Draper et al, 2002b;Holmquist et al, 2003;Ramadan et al, 2003;Low et al, 2004).…”