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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

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          Abstract

          Background

          Potentially 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.

          Objective

          We 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.

          Methods

          We 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.

          Results

          Over 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.

          Conclusion

          Our 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 material

          The 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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          Atypical antipsychotic drugs and the risk of sudden cardiac death.

          Wayne Ray, Cecilia P Chung, Katherine T Murray … (2009)
          Users of typical antipsychotic drugs have an increased risk of serious ventricular arrhythmias and sudden cardiac death. However, less is known regarding the cardiac safety of the atypical antipsychotic drugs, which have largely replaced the older agents in clinical practice. We calculated the adjusted incidence of sudden cardiac death among current users of antipsychotic drugs in a retrospective cohort study of Medicaid enrollees in Tennessee. The primary analysis included 44,218 and 46,089 baseline users of single typical and atypical drugs, respectively, and 186,600 matched nonusers of antipsychotic drugs. To assess residual confounding related to factors associated with the use of antipsychotic drugs, we performed a secondary analysis of users of antipsychotic drugs who had no baseline diagnosis of schizophrenia or related psychoses and with whom nonusers were matched according to propensity score (i.e., the predicted probability that they would be users of antipsychotic drugs). Current users of typical and of atypical antipsychotic drugs had higher rates of sudden cardiac death than did nonusers of antipsychotic drugs, with adjusted incidence-rate ratios of 1.99 (95% confidence interval [CI], 1.68 to 2.34) and 2.26 (95% CI, 1.88 to 2.72), respectively. The incidence-rate ratio for users of atypical antipsychotic drugs as compared with users of typical antipsychotic drugs was 1.14 (95% CI, 0.93 to 1.39). Former users of antipsychotic drugs had no significantly increased risk (incidence-rate ratio, 1.13; 95% CI, 0.98 to 1.30). For both classes of drugs, the risk for current users increased significantly with an increasing dose. Among users of typical antipsychotic drugs, the incidence-rate ratios increased from 1.31 (95% CI, 0.97 to 1.77) for those taking low doses to 2.42 (95% CI, 1.91 to 3.06) for those taking high doses (P<0.001). Among users of atypical agents, the incidence-rate ratios increased from 1.59 (95% CI, 1 .03 to 2.46) for those taking low doses to 2.86 (95% CI, 2.25 to 3.65) for those taking high doses (P=0.01). The findings were similar in the cohort that was matched for propensity score. Current users of typical and of atypical antipsychotic drugs had a similar, dose-related increased risk of sudden cardiac death. 2009 Massachusetts Medical Society
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            Reliability of the interRAI suite of assessment instruments: a 12-country study of an integrated health information system

            John P Hirdes, Gunnar Ljunggren, John Morris … (2008)
            Background A multi-domain suite of instruments has been developed by the interRAI research collaborative to support assessment and care planning in mental health, aged care and disability services. Each assessment instrument comprises items common to other instruments and specialized items exclusive to that instrument. This study examined the reliability of the items from five instruments supporting home care, long term care, mental health, palliative care and post-acute care. Methods Paired assessments on 783 individuals across 12 nations were completed within 72 hours of each other by trained assessors who were blinded to the others' assessment. Reliability was tested using weighted kappa coefficients. Results The overall kappa mean value for 161 items which are common to 2 or more instruments was 0.75. The kappa mean value for specialized items varied among instruments from 0.63 to 0.73. Over 60% of items scored greater than 0.70. Conclusion The vast majority of items exceeded standard cut-offs for acceptable reliability, with only modest variation among instruments. The overall performance of these instruments showed that the interRAI suite has substantial reliability according to conventional cut-offs for interpreting the kappa statistic. The results indicate that interRAI items retain reliability when used across care settings, paving the way for cross domain application of the instruments as part of an integrated health information system.
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              Antipsychotic drug use and mortality in older adults with dementia.

              Daniel Anderson, Susan E Bronskill, Steven S. Gill … (2007)
              Antipsychotic drugs are widely used to manage behavioral and psychological symptoms in dementia despite concerns about their safety. To examine the association between treatment with antipsychotics (both conventional and atypical) and all-cause mortality. Population-based, retrospective cohort study. Ontario, Canada. Older adults with dementia who were followed between 1 April 1997 and 31 March 2003. The risk for death was determined at 30, 60, 120, and 180 days after the initial dispensing of antipsychotic medication. Two pairwise comparisons were made: atypical versus no antipsychotic use and conventional versus atypical antipsychotic use. Groups were stratified by place of residence (community or long-term care). Propensity score matching was used to adjust for differences in baseline health status. A total of 27,259 matched pairs were identified. New use of atypical antipsychotics was associated with a statistically significant increase in the risk for death at 30 days compared with nonuse in both the community-dwelling cohort (adjusted hazard ratio, 1.31 [95% CI, 1.02 to 1.70]; absolute risk difference, 0.2 percentage point) and the long-term care cohort (adjusted hazard ratio, 1.55 [CI, 1.15 to 2.07]; absolute risk difference, 1.2 percentage points). Excess risk seemed to persist to 180 days, but unequal rates of censoring over time may have affected these results. Relative to atypical antipsychotic use, conventional antipsychotic use was associated with a higher risk for death at all time points. Sensitivity analysis revealed that unmeasured confounders that increase the risk for death could diminish or eliminate the observed associations. Information on causes of death was not available. Many patients did not continue their initial treatments after 1 month of therapy. Unmeasured confounders could affect associations. Atypical antipsychotic use is associated with an increased risk for death compared with nonuse among older adults with dementia. The risk for death may be greater with conventional antipsychotics than with atypical antipsychotics.
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                Author and article information

                Contributors
                Colleen J. Maxwell: 519-888-4567 , colleen.maxwell@uwaterloo.ca
                Journal
                Journal ID (nlm-ta): Drugs Aging
                Journal ID (iso-abbrev): Drugs Aging
                Title: Drugs & Aging
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1170-229X
                ISSN (Electronic): 1179-1969
                Publication date (Electronic): 9 November 2016
                Publication date PMC-release: 9 November 2016
                Publication date (Print): 2017
                Volume: 34
                Issue: 1
                Pages: 39-53
                Affiliations
                [1 ]Schools of Pharmacy and Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1 Canada
                [2 ]School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON Canada
                [3 ]Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
                [4 ]Community Health Sciences and Medicine, University of Calgary, Calgary, AB Canada
                [5 ]Institute for Clinical Evaluative Sciences, Toronto, ON Canada
                Article
                Publisher ID: 411
                DOI: 10.1007/s40266-016-0411-0
                PMC ID: 5222893
                PubMed ID: 27830567
                SO-VID: a2743123-0ae0-4740-925e-309aaab21ad3
                Copyright © © The Author(s) 2016
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100003179, Alberta Heritage Foundation for Medical Research;
                Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Categories
                Subject: Original Research Article
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                issue-copyright-statement © Springer International Publishing Switzerland 2017

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