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Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

ABSTRACT: BACKGROUND:Dementia patients often show neuropsychiatric symptoms, known as behavioral and psychological symptoms of dementia (BPSD). These are a common motive for medical consultations, hospitalizations, and nursing home stays. Various studies have suggested that the high prevalence of psychotropic drug use to treat BPSD in institutionalized dementia patients may lead to impaired cognitive capacity, rigidity, somnolence, and other complications during the course of the illness. The aim of this study was to design a consensus-based intervention between care levels to optimize and potentially reduce prescription of psychotropic drugs in institutionalized patients with dementia and assess the changes occurring following its implementation. METHODS:Design: Prospective, quasi-experimental, pre/post intervention, multicenter study. SCOPE:7 nursing homes associated with a single primary care team. INCLUSION CRITERIA:Institutionalized patients diagnosed with dementia and under treatment with 1 or more psychotropic drugs for at least 3?months. SAMPLE:240 individuals; mean age, 87?years (SD: 6.795); 75% (180) women. INTERVENTION:Creation of evidence-based therapeutic guidelines for psychotropic drug use in the treatment of BPSD by consensus between reference professionals. Joint review (primary care and geriatric care nursing home professionals) of the medication based on the guidelines and focusing on individual patient needs. Primary variable: Number of psychotropic drugs used per patient. ASSESSMENT:Preintervention, immediate postintervention, and at 1 and 6?months. RESULTS:Overall, the number of psychotropic drugs prescribed was reduced by 28% (from 636 before to 458 after the intervention). The mean number of psychotropic drugs prescribed per patient decreased from 2.71 at baseline to 1.95 at 1?month postintervention and 2.01 at 6?months (p

SUBMITTER: Massot Mesquida M

PROVIDER: S-EPMC6323667 | biostudies-other | 2019 Jan

REPOSITORIES: biostudies-other

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Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

Massot Mesquida Mireia M Tristany Casas Montserrat M Franzi Sisó Alicia A García Muñoz Isabel I Hernández Vian Óscar Ó Torán Monserrat Pere P

BMC geriatrics 20190108 1

<h4>Background</h4>Dementia patients often show neuropsychiatric symptoms, known as behavioral and psychological symptoms of dementia (BPSD). These are a common motive for medical consultations, hospitalizations, and nursing home stays. Various studies have suggested that the high prevalence of psychotropic drug use to treat BPSD in institutionalized dementia patients may lead to impaired cognitive capacity, rigidity, somnolence, and other complications during the course of the illness. The aim ...[more]

PMID: 30621606

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Project description:BackgroundResearch suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach.MethodsWe used Leontjevas' model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators.ResultsThe intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations' readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations.ConclusionsBarriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.

Project description:BackgroundPsychotropic medications are commonly prescribed to people with dementia (PwD) for non-cognitive symptoms of dementia (NCSD), but have significant risks. A national audit was performed in acute hospitals in the Republic of Ireland (ROI) to establish baseline practice prior to the launch and implementation of a National Clinical Guideline on the appropriate prescribing of psychotropic medications for NCSD. The objective of this study was to analyse psychotropic prescribing patterns and compare these with international data and with existing (limited) data from a previous audit round.MethodsThe pooled anonymous dataset from the second round of the Irish National Audit of Dementia Care (INAD-2) was analysed. The audit had collected retrospective data from 30 random healthcare records from each of 30 acute hospitals in 2019. Inclusion criteria were a clinical diagnosis of dementia of any type, hospital stay of 72 hours or more, and discharge or death within the audit period. Most hospitals (87%) self-audited their healthcare records, but a random sample of six healthcare records (20%) from each hospital were re-audited by a highly trained healthcare auditor. The audit tool was based on a tool used in the England and Wales National Audit of Dementia audit rounds (Royal College of Psychiatrists), adapted to the Irish healthcare setting and national priorities.ResultsIn total, 893 cases were included, as one hospital could not retrieve 30 cases even within a more prolonged audit period. The sample comprised 55% females and 45% males; the median age was 84 years (interquartile range 79-88 years) and the majority (89.6%) were >75 years of age. Only 52% of healthcare records specified the type of dementia; within these, the most common diagnosis was Alzheimer's disease (45%). Most PwD (83%) were receiving psychotropic medication on admission; 40% were prescribed new or increased psychotropic medication during admission, mainly for medical indications, including end-of-life care and delirium. Anticonvulsants or cognitive enhancers were rarely prescribed for NCSD in hospital. However, new/increased antipsychotic medication was prescribed for NCSD in 11.8-17.6% of the total cohort, while 4.5-7.7% were prescribed a benzodiazepine for anxiety or NCSD. Overall, there was poor documentation of risk/benefit, or of discussion with the patient/family, and apparently inadequate review for efficacy and tolerability. Concurrently, acetylcholinesterase inhibitors appeared to be underused for cognitive impairment in the community.ConclusionThis audit provides baseline data on psychotropic medication prescription for NCSD in Irish hospitals prior to a specific Irish guideline on this topic. Reflecting this, most PwD were receiving psychotropic medications on admission, and many were prescribed new/increased psychotropic medication in hospital, often without evidence of appropriate decision making and prescribing processes.

Project description:IntroductionThe aim of this study was to describe the number and type of drugs used to treat depressive disorders in inpatient psychiatry and to analyse the determinants of potential drug-drug interactions (pDDI) and potentially inappropriate medication (PIM).MethodsOur study was part of a larger pharmacovigilance project funded by the German Innovation Funds. It included all inpatients with a main diagnosis in the group of depressive episodes (F32, ICD-10) or recurrent depressive disorders (F33) discharged from eight psychiatric hospitals in Germany between 1 October 2017 and 30 September 2018 or between 1 January and 31 December 2019.ResultsThe study included 14,418 inpatient cases. The mean number of drugs per day was 3.7 (psychotropic drugs = 1.7; others = 2.0). Thirty-one percent of cases received at least five drugs simultaneously (polypharmacy). Almost one half of all cases received a combination of multiple antidepressant drugs (24.8%, 95% CI 24.1%-25.5%) or a treatment with antidepressant drugs augmented by antipsychotic drugs (21.9%, 95% CI 21.3%-22.6%). The most frequently used antidepressants were selective serotonin reuptake inhibitors, followed by serotonin and norepinephrine reuptake inhibitors and tetracyclic antidepressants. In multivariate analyses, cases with recurrent depressive disorders and cases with severe depression were more likely to receive a combination of multiple antidepressant drugs (Odds ratio recurrent depressive disorder: 1.56, 95% CI 1.41-1.70, severe depression 1.33, 95% CI 1.18-1.48). The risk of any pDDI and PIM in elderly patients increased substantially with each additional drug (Odds Ratio: pDDI 1.32, 95% CI: 1.27-1.38, PIM 1.18, 95% CI: 1.14-1.22) and severity of disease (Odds Ratio per point on CGI-Scale: pDDI 1.29, 95% CI: 1.11-1.46, PIM 1.27, 95% CI: 1.11-1.44), respectively.ConclusionThis study identified potential sources and determinants of safety risks in pharmacotherapy of depressive disorders and provided additional data which were previously unavailable. Most inpatients with depressive disorders receive multiple psychotropic and non-psychotropic drugs and pDDI and PIM are relatively frequent. Patients with a high number of different drugs must be intensively monitored in the management of their individual drug-related risk-benefit profiles.

Project description:Background: In recent years, patterns of the use of psychotropic drugs vary with increasing rates of psychiatric presentation and diagnosis in children and adolescents. Purpose: In this study, we aimed to investigate distributions of current psychiatric symptoms and diagnosis, patterns of the use of psychotropic drugs, and differences according to age and gender in patients presented to a child and adolescent outpatient clinic. Methods: All patients aged between 0 and 18 years presenting to a child and adolescent psychiatry outpatient clinic between November 1, 2017 and November 1, 2018 were included in the study. Files of all patients were examined in detail, and patients' demographic characteristics, symptoms, psychiatric diagnoses established according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), psychotropic drugs initiated, and side effect profiles were recorded. Psychiatric symptoms and diagnostic features of the patients were determined, and the differences were investigated according to gender. Clinical characteristics were compared between diagnosed and undiagnosed patients, and between patients with and without drug initiation. Results: Of the 2066 patients, 1298 (62.8%) were male and the mean age was 10.14 ± 4.42 years. The most common symptoms were hyperactivity (23.8%) and inattention (21.6%) in males, inattention (15.1%) and irritability (14.2%) in females, and 79% of the patients received one or more psychiatric diagnoses. The most common psychiatric diagnoses in both genders were attention-deficit hyperactivity disorder (ADHD), specific learning disorder (SLD), and conduct disorder, respectively. Of the patients who received a psychiatric diagnosis, 61.8% were using psychotropic drugs, with the majority of them (71.3%) receiving monotherapy. The most frequently initiated drugs included psychostimulants, antipsychotics, and antidepressants, with 28.7% of the drug user patients receiving multiple drug therapy. Conclusion: Our study indicates that rate of presentation to child and adolescent psychiatry outpatient clinics is increasing, and rates of diagnosis and initiation of psychiatry drugs are high among the presented children. The prevalence of ADHD shows an increase in males and females in our country, and psychiatric polypharmacy has reached significant rates.

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Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

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Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients.

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