Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR]=0.54, 95% confidence interval [CI]=0.44-0.67), certified nursing assistants (OR=0.87, 95% CI=0.77-0.99) and total nurse staff (OR=0.87, 95% CI=0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR=0.10, 95% CI=0.04-0.26). Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

Deficiency of Care Reports on Inappropriate Psychotropic Medication Use Related to Care for Behavioral Symptoms of Dementia

To determine the prevalence and patient-specific predictors of the use of 10 presumptively inappropriate medications used to treat medical conditions among nursing home residents, and to use this information to examine alternative screening strategies using computerized assessment data to identify residents who are at high risk of receiving inappropriate medications. Retrospective, cross-sectional study. All persons residing in all 252 nursing homes in two states during the last 6 months of 1991 (N = 21,884). Data were from Minimum Data Set Plus (MDS+) assessments, gathered as part of the Health Care Financing Administration (HCFA) Multistate Nursing Home Casemix and Quality Demonstration Project. The MDS+ is an expanded version of the federally mandated Minimum Data Set (MDS) that includes additional information on medications and their doses and schedules (frequency, standing vs prn). The reliability of the MDS has been demonstrated previously. Medications were defined as inappropriate using explicit criteria from published literature. Outcome measures were the standing use of each or any of 10 presumptively inappropriate medications used to treat medical (rather than psychiatric or behavioral) conditions. Potential predictors of inappropriate medication use included patient demographic characteristics, payer, a proxy measure for length of stay and admission source, functional status, number of standing medications, and state. A total of 12% of residents were prescribed one or more of 10 presumptively inappropriate medications on a standing basis, a figure that differed substantially between states (14.0% vs 7.4% (P < .001)). The most prevalent inappropriate medications were dipyridamole (5.4% of residents), amitriptyline (3.3%), and methyldopa (1.8%). Among patients receiving 0 to 3, 4 to 6, and 7+ medications, 5%, 12%, and 19%, respectively, were receiving at least one inappropriate medication. In multivariate logistic regression analyses, the strongest predictors of inappropriate medication use were state and the total number of standing medications prescribed. Including other statistically significant predictors of inappropriate medication use (age > 65 years, never having been married, severe functional limitations, being a long-stay patient, and medical diagnosis) did not substantially improve the overall predictive ability of the model. A substantial proportion of nursing home residents receives presumptively inappropriate medications to treat medical conditions. Selecting persons prescribed large numbers of medications for further review may be the most efficient method for nursing home or pharmacy personnel to identify residents at high risk of receiving inappropriate medications. Extensive additional information on residents' characteristics, although widely available through the Minimum Data Set, does not significantly improve the ability to identify residents receiving inappropriate medications for medical conditions. State-specific policies or provider practices also influence the likelihood of presumptively inappropriate medication use among nursing home residents and deserve further investigation.

Inappropriate medication use is a major problem for the elderly. Although increasing attention has been paid to inappropriate prescription medication use, most previous research has been limited to the investigation of prevalence and trends. Few studies provide the empirical evidence for the adverse effect of inappropriate medication use on health outcomes at the national level. This study is the first attempt to assess the relationship between inappropriate prescription use and health status for the elderly in the United States. Based on the 1996 Medical Expenditure Panel Survey, inappropriate medication use in a national representative elderly population was first identified using Beers criteria. A survey type of ordered probit model was then estimated to quantify the effect of inappropriate drug use on patient self-perceived health status measured using a five-point scale (poor, fair, good, very good, and excellent). After controlling for a set of possible confounding factors, it was found that individuals using inappropriate medications in Round 1 were more likely than those not using inappropriate medications to report poorer health status in Round 2. Other risk factors for poor health status include a higher number of prescriptions, being black, having low education, and having one or more chronic diseases. This study provides strong evidence of a significant adverse effect of inappropriate medication use on patient health status. These findings lend partial support to the use of Beers criteria in assessing the quality of prescribing and the appropriateness of medication use in the elderly population.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia.

Inappropriate medication use is a major patient safety concern, especially for the elderly population. Using explicit criteria, prior studies have found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992, respectively. To determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996, to assess trends over 10 years, categorize inappropriate medication use according to explicit criteria, and to examine risk factors for inappropriate medication use. Respondents aged 65 years or older (n = 2455) to the 1996 Medical Expenditure Panel Survey, a nationally representative survey of the US noninstitutionalized population were included. A 7-member expert panel was convened to categorize inappropriate medications. Prevalence of use of 33 potentially inappropriate medications. In 1996, 21.3% (95% confidence interval [CI], 19.5%-23.1%) of community-dwelling elderly patients in the United States received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients (95% CI, 2.0%-3.2%) used at least 1 of the 11 medications that should always be avoided by elderly patients; 9.1% (95% CI, 7.9%-10.3%) used at least 1 of the 8 that would rarely be appropriate; and 13.3% (95% CI, 11.7%-14.9%) used at least 1 of the 14 medications that have some indications but are often misused. Use of some inappropriate medications declined between 1987 and 1996. Persons with poor health and more prescriptions had a significantly higher risk of inappropriate medication use. Overall inappropriate medication use in elderly patients remains a serious problem. Despite challenges in using explicit criteria for assessing inappropriate medications for elderly patients, such criteria can be applied to population-based surveys to identify opportunities to improve quality of care and patient safety. Enhancements of existing data sources to include dosage, duration, and indication may augment national improvement and monitoring efforts.

Instruments to Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: An ACTTION Systematic Review

ObjectivesInappropriate use of psychotropic medications in the elderly, particularly those with dementia, is a critical safety and quality concern. This pilot quality improvement study used a novel Department of Veterans...

Introduction: At present, 7.2% of the population in Singapore is in the geriatric age group, which will increase to 18.4% in the year 2030. The frailest segment of the geriatric population live in nursing homes. They suffer from multiple co-morbidities requiring multiple medication use. Polypharmacy and inappropriate medication use have been considered as quality indicators for nursing home care. As no data of these indicators are available in Singapore, this study was planned to assess the prevalence of polypharmacy and inappropriate medication use in Singapore nursing homes. Materials and Methods: A total of 454 residents in the geriatric age group residing in 3 randomly selected nursing homes were involved in the study. Case notes were reviewed for demographic information, clinical history and medication use. The data were analysed for polypharmacy (5 or more medication orders) and inappropriate medication use (based on established criteria). Results: Residents were on an average of 5.32 medications. Polypharmacy and inappropriate medication use were seen in 266 (58.6%) and 318 (70.0%) residents, respectively. There was significant association between polypharmacy and inappropriate medication use [P &lt;0.001, χ2 = 82.56 at 95% confidence interval (CI)]. The most common medication-related problems were the use of medication without proper indication (n = 302), significant potential for adverse drug reactions (n = 281) and drug interactions (n = 141). Conclusion: The prevalence of polypharmacy and inappropriate medication use is high in Singapore nursing homes. Current practice of medication use in the nursing homes may lead to significant adverse drug reactions and drug interactions. A multidisciplinary approach involving geriatricians, nursing home physicians, nurses and pharmacists may potentially reduce polypharmacy and inappropriate medication use in Singapore nursing homes.

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults

To determine the association between inappropriate medication use and self-reported adverse drug effects (ADEs). Prospective cohort study with three annual mailed surveys. Population-based sample of Iowa Medicare beneficiaries. Cohort members (n5626) with established mobility disability and complete pharmacy dispensing records, continuous Medicare eligibility, and survey data. The number of unique drug ingredients dispensed and inappropriate use were assessed for the year before the ADE survey. Inappropriate medication use was defined according to published criteria: contraindicated drugs for elderly people, drug-disease interactions (constructed from linked Medicare claims), drug-drug interactions, and therapeutic duplications. An ADE was defined from the following question: "In the past 12 months, have you experienced an unwanted effect or side effect of a medication?" Of respondents to the ADE survey, 22.0% reported having experienced an ADE in the past year, and 322 (51.4%) received at least one potential inappropriate medication. Factors associated univariately with ADE self-report were number of medications, number of mobility limitations, any inappropriate medication use, and each of the individual domain appropriateness indicators, as well as number of different domains of inappropriate use. The adjusted odds ratio for developing an ADE was 2.14 (95% confidence interval=1.26-3.65) for those with inappropriate use versus no inappropriate use. Efforts to reduce ADEs by reducing medication inappropriateness should be encouraged as a complement to efforts focused on reducing the number of medications prescribed.

Inappropriate use of medications has become an international cause for concern in geriatric patients, who are at high risk of drug-related morbidity. This study is the first attempt to determine the prevalence of inappropriate drug use in elderly Lebanese outpatients, using community pharmacy data, and to identify factors that predict potentially inappropriate drug intake in this population. Records of elderly patients aged > or =65 years were selected from different community pharmacies. Each patient profile was reviewed and to confirm patient record information, in-person interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, courses of therapy were assessed and classified as either appropriate or inappropriate. Courses of therapy that were judged inappropriate were further classified according to the specific area of inappropriate use (i.e. Beers' criteria, duplicate therapy, indication, dose, dose frequency including missing doses, duration and discontinuation of therapy, adverse effects, drug-drug and/or drug-disease interactions, and poor memory). Statistical analyses were performed to estimate the prevalence of inappropriate medication use and to identify potentially predictive factors of such use arising from patients' sociodemographic characteristics, health factors and drug regimen intake. A total of 350 elderly patient profiles were reviewed, from which 277 evaluable records were obtained. More than half (59.6%) of the patients taking drugs at the time of the study were taking at least one inappropriate medication. Inappropriate medication use was most frequently identified in terms of Beers' criteria (22.4%), missing doses (18.8%) or incorrect frequency of administration of drugs (13.0%). Factors predicting potentially inappropriate drug intake included female sex (65.7% vs 53.3% for males, p = 0.03) and alcohol intake (p = 0.007). There were also significant associations between the likelihood of use of an inappropriate drug and (i) increased number of medical illnesses (p < 0.00002); and (ii) consumption of an over-the-counter drug (OTC) and/or prescription drug (p = 0.048 and p = 0.0035, respectively). The likelihood of use of an inappropriate drug was higher again when patients concurrently used both OTC and prescription drugs (p < 0.0002). The present study is the first to describe and assess inappropriate medication use by elderly outpatients in the Lebanese community setting. With increasing availability of newer and more appropriate medications, use of potentially inappropriate drugs may decrease. Pharmacists have a major role to play in counselling patients about the importance of appropriate drug use.

Back to table of contents Previous article Next article International NewsFull AccessRapid Rise in Psychotropic Use Becomes Global PhenomenonJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:17 Dec 2004https://doi.org/10.1176/pn.39.24.00390001bPsychotropic drug prescribing for American youth has soared over the past several decades (Psychiatric News, February 7, 2003), and now it looks as though the same trend may be occurring in other countries, a new study indicates.The study was headed by Ian Wong, Ph.D., director of the Center for Pediatric Pharmacy Research at the University of London. Results appeared in the December Archives of Disease in Childhood.Wong and his coworkers obtained data about psychotropic prescribing for youth under 18 years of age in nine countries between 2000 and 2002. The countries included France, Germany, Spain, and the United Kingdom—the four European countries with the largest markets for these medications; Argentina, Brazil, and Mexico—the three Latin-American countries with the largest markets for these medications; and Canada and the United States.Results indicated that the number of psychotropics prescribed for youth in all nine countries rose between the years 2000 and 2002, and seven of the nine countries showed a significant increase. The United Kingdom had the largest percentage increase at 68 percent, while Germany had the smallest, 13 percent.Wong told Psychiatric News that the results did not surprise him.“ American data showed a similar trend a few years ago.”He also indicated that he was not surprised to find that the United Kingdom is outpacing the United States in psychotropic prescribing for youth.“The U.S. already had a high baseline, so it can't really grow as fast as the United Kingdom. There is no doubt, however, that we are catching up.”Psychiatric News likewise asked Wong whether there was more of an increase in one category of psychotropic prescribing for youth in the countries of interest than in another category—say, more SSRI antidepressant prescribing than antipsychotic prescribing. Wong said that he and his coworkers have already learned that both SSRI and stimulant prescribing for youth increased significantly in the United Kingdom from 2000 to 2002, and that his team will now analyze more data from the United Kingdom and the other countries to further answer this question.Why psychotropic prescribing is surging not just in the United States, but also in numerous other countries is not known. Wong and his colleagues, however, offer several possible explanations in their study report: “The increase probably represents the improved recognition of pediatric psychopathology; there is also a concern that drugs are being used to replace nondrug treatments.”In any event, they pointed out, “The observed increase in so many countries should raise concern, as little research has been conducted in children to study the effects of most psychotropic medications” and because of the brouhaha about antidepressants' possibly increasing suicide risk in children (Psychiatric News, November 5).“The use of psychotropic medications in children is a global public health issue,” Wong and his colleagues concluded, “which should be studied in partnership with pharmaceutical companies, governments, and researchers to grow and expand the evidence base for their use in children.”“The problem with this type of psychotropic medication market research is that it contains no information about quality of the clinical treatment that is associated with the use of these medications,” Darrel Regier, M.D., executive director of the American Psychiatric Institute for Research and Education and director of APA's Division of Research, told Psychiatric News. “In the absence of associated data on the prevalence of treated and untreated mental disorders, and the degree to which use of these medications follow established treatment guidelines, the author is free to speculate about the implications of the increase in medication use in children.“If one starts from a public health perspective that there is well-documented evidence of undertreatment of child and adolescent mental disorders in all countries and that there is an attendant high level of disability and waste of human potential because of the absence of treatment, then the evidence of increased use of psychotropic medications could be seen in very positive terms.“If, on the other hand, one starts from a perspective that mental disorders don't exist and that medications are a means whereby poor parenting is being supported by inappropriate use of psychotropic medications, then there is a very negative spin for this information.“My concern is that the author adds a negative spin with an incomplete reporting on the effectiveness data for psychotropic medications in children and adolescents.”The study was funded by the Department of Health in England.An abstract of the study, “Increased Prescribing Trends of Pediatric Psychotropic Medications,” is posted online at<http://adc.bmjjournals.com/cgi/content/abstract/89/12/1131?>.▪ Arch Dis Child 2004 89 1131 ISSUES NewArchived

Despite multiple national initiatives to improve quality of life in nursing home (NH) residents with dementia, inefficiencies still exist regarding inappropriate psychotropic medication use to manage communication of distress. The goals of the current article are to: (a) create a person-centered care plan/process for NH community staff to manage challenging dementia behaviors; (b) provide guidelines for geriatric practitioners (GPs) to decrease psychotropic medication use in residents with dementia; (c) discuss organizational culture and its relationship to the management of non-cognitive neuropsychiatric symptoms (NPS) of dementia; and (d) emphasize nonpharmacological approaches as first-line treatment of NPS in NH residents with dementia. [Journal of Gerontological Nursing, 46(2), 9-17.].

Few studies have identified predictors of inappropriate use of medications and medical tests in bronchiolitis. This study aimed to look for potential factors associated with the inappropriate use of medications and tests in bronchiolitis. A retrospective study that included all infants under two years of age in tertiary center admitted due to Bronchiolitis from January 2015 to December 2018. We defined a composite score as the main outcome variable. 1930 patients were included. The most prescribed medications were nebulized hypertonic saline in 1789 patients (92.6%), albuterol (56%), and β-lactam antibiotics (26.4%). The medical tests more commonly ordered were hemogram (95.9%), chest X-rays (92.2%) and C-reactive protein (79.8%). After controlling for potential confounders, it was found that the length of hospital stay increases the risk of the inappropriate use of medications and tests (OR 1.29; CI 95% 1.01-1.65), whereas fever (OR 0.22; CI 95% 0.06-0.71) and leukocytosis (> 15,000/μL) (OR 0.09; CI 95% 0.03-0.32) at admission decrease the risk of the inappropriate use of medications and tests. Inappropriate use of diagnostic tests and drugs for bronchiolitis was a highly prevalent outcome in our population. Patients with longer hospitalizations, absence of fever and a normal white blood cell count at admission, were at increased risk of inappropriate use of medications and medical tests.