Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents

Abstract

BACKGROUND/OBJECTIVE In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use. DESIGN Retrospective, propensity score–matched, controlled, patient‐level observational analysis. SETTING A total of 45 nursing homes in Spain. PARTICIPANTS A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score–matched controls. INTERVENTION Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid. MEASUREMENTS At 2 and 4 weeks following intervention: change from baseline drug class–specific milligram‐equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use. RESULTS Within each intervention/drug‐class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class–specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%‐32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%‐28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%‐33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%‐38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%‐33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%‐43.5%) reduction in anxiolytic MEDDs. Intervention‐associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints. CONCLUSION We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.

Reducing Psychotropic Use in Older Non-demented Spanish Care Home Residents: a Before-After Comparison of Three Methods

“…Among older non-demented Spanish care home residents, the interventions we studied were followed by lower antipsychotic and anxiolytic dosing, but unchanged antidepressant dosing. In contrast to findings for care home residents with dementia, 3 for those without dementia, application of STOPP/START criteria was generally less effective than the other interventions.…”

“…Subject and intervention selection and study implementation are detailed elsewhere. 3 In brief, we examined the short-term effects of implementation of 3 aforementioned interventions on mean equivalent daily doses (MEDDs) of 3 psychotropic medication classes: antidepressants, anxiolytics, and antipsychotics. We limited our analysis to residents aged 70-99 who lacked an Electronic Health Record (EHR)-documented dementia diagnosis (no ICD-9 or ICD-10 dementia diagnosis; Short Portable Mental Status Questionnaire or Functioning Assessment Staging Scores lower than 5).…”

“…2 In a quality improvement effort designed to do that, we found that administration of any of 3 interventions-application of STOPP/START criteria, medication-focused team rounds (TR), or a decision aid (DA)-effectively reduced psychotropic use among older Spanish nursing home residents with dementia, though STOPP/START criteria application was most effective. 3 While care home residents with dementia are at risk for psychotropic overuse and their sequelae, so might be those without dementia. 4 Therefore, we sought to analyze patients without dementia who obtained any of the 3 interventions we studied in Sanitas Mayores (Spain), a Bupa-affiliated aged care network.…”

Interventions to optimize medication use in nursing homes: a narrative review

“…The same intervention components were highlighted in a SR of factors influencing antipsychotic use among dementia NHRs [37] and in a review of interventions targeting BZRA deprescribing [39]. In Europe, a few interventions were recently evaluated, with encouraging results (Table 3 [26][27][28][29]). Similar to approaches targeting the whole medication regimen, training of HCPs and MR were important components of evaluated strategies.…”

Benzodiazepine Use and Deprescribing in Belgian Nursing Homes: Results from theCOME‐ONStudy

“…19 Only a few studies have analyzed the evolution of BZRA use through an intervention, and most of these were conducted in a limited number of countries, had limited sample size, or lacked long-term follow-up. 17,[22][23][24] Identifying those factors associated with both BZRA use and BZRA deprescribing is a key step in the process of medication optimization. Female sex, older age, depression, sleeping issues, and anxiety are factors reported to be associated with BZRA use.…”