Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners

Welberry, Heidi; Jorm, Louisa; Schaffer, Andrea L; Barbieri, Sebastiano; Hsu, Benjumin; Harris, Mark; Hall, John; Brodaty, Henry

doi:10.5694/mja2.51153

Cited by 16 publications

(10 citation statements)

References 17 publications

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“…Even though we report BPSD levels close to what is reported at admission to nursing homes [ 12 ], earlier work shows that prescription rates of antidepressants, antipsychotics, anxiolytics, sedatives, and hypnotics persistently increase during the first 6 months stay [ 12 , 46 , 51 ]. In our study, the use of these medications was not associated with dropout due to nursing home admission, while on the contrary, impaired functioning, dependency in activities of daily living, and BPSD were associated with nursing home admission.…”

Section: Discussionsupporting

confidence: 75%

“…A recent retrospective cohort study with a 1-year follow-up on 9324 patients with dementia in England concluded that higher continuity of GP care was associated with safer prescribing and lower rates of major adverse events [ 45 ]. Another retrospective study including 2250 new residents with dementia found that psychotropic drugs were dispensed at higher rates for those who changed GP when entering Australian residential care compared to those who continued seeing their regular GP [ 46 ]. This illustrates the importance of maintaining a continuous patient-GP relationship in preventing potentially inappropriate initiation of psychotropic medicines [ 45 , 46 ].…”

Section: Discussionmentioning

confidence: 99%

“…Another retrospective study including 2250 new residents with dementia found that psychotropic drugs were dispensed at higher rates for those who changed GP when entering Australian residential care compared to those who continued seeing their regular GP [ 46 ]. This illustrates the importance of maintaining a continuous patient-GP relationship in preventing potentially inappropriate initiation of psychotropic medicines [ 45 , 46 ]. The prescribing practices in our study likely reflect the considerable focus placed on limiting excessive psychotropic drugs among PwD in recent years, underscoring that the continuous deprescribing process is more than simply drug withdrawal [ 47 ].…”

Section: Discussionmentioning

confidence: 99%

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The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

Gedde

Husebø

Mannseth

et al. 2022

BMC Med

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Background There is limited knowledge regarding the process of deprescribing psychotropic drugs to people with dementia (PwD) conducted by general practitioners (GP). We investigated the impact of a multicomponent intervention, emphasizing medication reviews, on psychotropic drugs and behavioral and psychological symptoms (BPSD) in home-dwelling PwD and quantified change in patient-GP communication evaluated by their informal caregivers. Methods LIVE@Home.Path is a stepped-wedge closed-cohort cluster randomized controlled trial for people with mild to moderate dementia aged ≥65 and their informal caregivers (dyads) in Norway. Complementary to health care as usual (control condition), municipal coordinators implemented the multicomponent LIVE intervention: Learning, Innovation, Volunteer support, and Empowerment (including medication review by the PwD’s regular GPs). Block-randomization was used to allocate dyads in three groups receiving the intervention sequentially in periods of 6 months duration. Prepandemic data from the first period is reported, resulting in a 1:2 intervention-to-control ratio. Primary outcome was change in psychotropic drug use. Secondary outcomes were changes in BPSD by Neuropsychiatric Inventory and Cornell Scale of Depression in Dementia and patient-GP communication by an adaption of the Clinical Global Impression of Change. Results Four hundred thirty-eight dyads were screened, 280 included, and 237 participated at 6 months (intervention group n=67; control condition n=170). At baseline, 63% used psychotropic medication regularly: antidementia drugs (47%), antidepressants (13%), hypnotics/sedatives (13%), antipsychotics (5%), and anxiolytics (2%). At 6 months, medication reviews were more frequently conducted in the intervention group compared to control (66% vs 42%, P=0.001). We found no differences regarding a change in drug use and BPSD. Patient-GP communication enhanced in the intervention group (mean score 0.95 [standard deviation 1.68] vs 0.41 [1.34], P=0.022). In the intervention group, control group, and overall sample, the informal caregivers of those who had their medications reviewed reported improved patient-GP communication compared to those who did not. Conclusions Change in psychotropic drug use and BPSD did not differ, even though patient-GP communication improved with medication reviews. Restricted psychotropic drug use among PwD likely reflects more judicious prescribing practices in recent years. Nevertheless, medication reviews could be cultivated to optimize pharmacologic treatment for this complex population. Trial registration ClinicalTrials.gov: NCT04043364; registered 15/03/2019.

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Section: Discussionsupporting

confidence: 75%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

Gedde

Husebø

Mannseth

et al. 2022

BMC Med

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“…Additionally, these tools have not examined the risk profile of individuals at key periods in their aged care journey, including first entry into PRAC. This may be a particularly vulnerable period in terms of falls risk, with residents unfamiliar with their new surroundings, together with considerable changes to medication regimen and care [ 16 ].…”

Section: Introductionmentioning

confidence: 99%

The risk of fall-related hospitalisations at entry into permanent residential aged care

et al. 2021

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Background Entering permanent residential aged care (PRAC) is a vulnerable time for individuals. While falls risk assessment tools exist, these have not leveraged routinely collected and integrated information from the Australian aged and health care sectors. Our study examined individual, system, medication, and health care related factors at PRAC entry that are predictors of fall-related hospitalisations and developed a risk assessment tool using integrated aged and health care data. Methods A retrospective cohort study was conducted on N = 32,316 individuals ≥65 years old who entered a PRAC facility (01/01/2009-31/12/2016). Fall-related hospitalisations within 90 or 365 days were the outcomes of interest. Individual, system, medication, and health care-related factors were examined as predictors. Risk prediction models were developed using elastic nets penalised regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination. Results 64.2% (N = 20,757) of the cohort were women and the median age was 85 years old (interquartile range 80-89). After PRAC entry, 3.7% (N = 1209) had a fall-related hospitalisation within 90 days and 9.8% (N = 3156) within 365 days. Twenty variables contributed to fall-related hospitalisation prediction within 90 days and the strongest predictors included fracture history (sub-distribution hazard ratio (sHR) = 1.87, 95% confidence interval (CI) 1.63-2.15), falls history (sHR = 1.41, 95%CI 1.21-2.15), and dementia (sHR = 1.39, 95%CI 1.22-1.57). Twenty-seven predictors of fall-related hospitalisation within 365 days were identified, the strongest predictors included dementia (sHR = 1.36, 95%CI 1.24-1.50), history of falls (sHR = 1.30, 95%CI 1.20-1.42) and fractures (sHR = 1.28, 95%CI 1.15-1.41). The risk prediction models had an AUC of 0.71 (95%CI 0.68-0.74) for fall-related hospitalisations within 90 days and 0.64 (95%CI 0.62-0.67) for within 365 days. Conclusion Routinely collected aged and health care data, when integrated at a clear point of action such as entry into PRAC, can identify residents at risk of fall-related hospitalisations, providing an opportunity for better targeting risk mitigation strategies.

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“…The events leading to entry into an RACF (eg, major changes in health status) combined with the transition itself, which includes unfamiliarity with a new environment, new carers, changes in healthcare providers, medications and routines, can pose challenges to individuals, leading to poor health events after entering care. [6][7][8][9][10][11][12] Older individuals, especially those living in RACFs have frequent hospitalisations. 13 14 In Australia, 37% of RACF residents had at least one hospitalisation and 37% at least one emergency department (ED) presentation in 2018/2019.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study

et al. 2021

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ObjectivesTo: (1) examine the 90-day incidence of unplanned hospitalisation and emergency department (ED) presentations after residential aged care facility (RACF) entry, (2) examine individual-related, facility-related, medication-related, system-related and healthcare-related predictors of these outcomes and (3) create individual risk profiles.DesignRetrospective cohort study using the Registry of Senior Australians. Fine-Gray models estimated subdistribution HRs and 95% CIs. Harrell’s C-index assessed risk models’ predictive ability.Setting and participantsIndividuals aged ≥65 years old entering a RACF as permanent residents in three Australian states between 1 January 2013 and 31 December 2016 (N=116 192 individuals in 1967 RACFs).Predictors examinedIndividual-related, facility-related, medication-related, system and healthcare-related predictors ascertained at assessments or within 90 days, 6 months or 1 year prior to RACF entry.Outcome measures90-day unplanned hospitalisation and ED presentation post-RACF entry.ResultsThe cohort median age was 85 years old (IQR 80–89), 62% (N=71 861) were women, and 50.5% (N=58 714) had dementia. The 90-day incidence of unplanned hospitalisations was 18.0% (N=20 919) and 22.6% (N=26 242) had ED presentations. There were 34 predictors of unplanned hospitalisations and 34 predictors of ED presentations identified, 27 common to both outcomes and 7 were unique to each. The hospitalisation and ED presentation models out-of-sample Harrell’s C-index was 0.664 (95% CI 0.657 to 0.672) and 0.655 (95% CI 0.648 to 0.662), respectively. Some common predictors of high risk of unplanned hospitalisation and ED presentations included: being a man, age, delirium history, higher activity of daily living, behavioural and complex care needs, as well as history, number and recency of healthcare use (including hospital, general practitioners attendances), experience of a high sedative load and several medications.ConclusionsWithin 90 days of RACF entry, 18.0% of individuals had unplanned hospitalisations and 22.6% had ED presentations. Several predictors, including modifiable factors, were identified at the time of care entry. This is an actionable period for targeting individuals at risk of hospitalisations.

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Psychotropic medicine prescribing and polypharmacy for people with dementia entering residential aged care: the influence of changing general practitioners

Cited by 16 publications

References 17 publications

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

The risk of fall-related hospitalisations at entry into permanent residential aged care

Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study

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