Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada

Maxwell, Colleen J.; Amuah, Joseph E.; Hogan, David B.; Cepoiu‐Martin, Monica; Gruneir, Andrea; Patten, Scott B.; Soo, Andrea; Clair, Kenneth Le; Wilson, Kimberley; Hagen, Brad; Strain, Laurel A.

doi:10.1016/j.jamda.2015.01.079

Cited by 42 publications

(48 citation statements)

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“…As there have been very few studies of antipsychotic use in AL [30, 70], and none to date in Canada, our prevalence estimates for this setting also provide an important benchmark to assess future trends in use as well as the impact of relevant clinical and/or policy interventions. This is especially important given that AL is emerging as a particularly attractive residential care option for older adults with dementia [31, 32]. Among the 19 studies included in a recent systematic review on care-delivery interventions to manage agitation and aggressive in dementia among residents of AL and LTC [71], only one small study was from AL and it did not report the impact of the intervention on antipsychotic use [72].…”

Section: Discussionmentioning

confidence: 99%

“…AL residents typically have substantial health needs albeit fewer compared with LTC residents. Data from USA and Canada indicate that rates of dementia are high in AL (upwards of 60%) [31, 32]. Within some regions, AL is viewed as a substitute for LTC facility-based care [33, 34], but staffing levels are often lower with fewer skilled staff members per resident [35–37].…”

Section: Introductionmentioning

confidence: 99%

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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

et al. 2016

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BackgroundPotentially 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.ObjectiveWe 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.MethodsWe 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.ResultsOver 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.ConclusionOur findings illustrate the importance of including AL settings in clinical and policy initiatives aimed at reducing inappropriate antipsychotic use among older vulnerable residents.Electronic supplementary materialThe online version of this article (doi:10.1007/s40266-016-0411-0) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2016

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“…Healthcare utilization, including hospital admissions [7–11] and emergency department (ED) visits [10–13], has been shown to be elevated among older adults diagnosed with dementia. Hospital and ED visits are particularly relevant for persons with dementia given their heightened risks for cognitive and functional decline during and after hospitalization [14–16].…”

Section: Introductionmentioning

confidence: 99%

Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort

et al. 2017

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BackgroundFor community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.Methods and findingsA retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC.Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72–2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51–1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07–1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03–1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions.ConclusionsOlder adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes.

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“…Careful medication management in older adults with dementia is therefore of utmost relevance. Transitions of care, especially hospitalizations, common in the course of dementia play a key role in medication management. They offer an opportunity for medication review and deprescription but may also lead to an increased use of medications .…”

Section: Introductionmentioning

confidence: 99%

Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications

Reinold

Palese

Romanese

et al. 2019

Int J Geriat Psychiatry

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Objectives: To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB). Methods and design:This retrospective cohort study included all patients aged 65 years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3 months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score.Results: Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99).Conclusions: ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.

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Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada

Cited by 42 publications

References 64 publications

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

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

Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort

Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications

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