Pursuing appropriate psychotropic treatment for older people with dementia in long-term care facilities

Editorial
*Liang-Kung Chen1
1Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
DOI:http://dx.doi.org/10.24816/jcgg.2018.v9i1.01

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kim, et al., reported substantial psychotropic drug utilization among Koreans with dementia living in long-term care facilities (LTCFs) – 40% of prescriptions were inappropriate to the indication;1 these results raise suspicion of ‘chemical restraint’ among institutionalized older people with dementia in Korea.  Although the prevalence  of antipsychotic prescription among LTCF residents in Korea may be high, the results were commensurate with previous reports.2 Despite US FDA alerts against using antipsychotics among older people with dementia, antipsychotics remain a common tool for managing behavioral and psychotic symptoms of dementia (BPSD).3 This evidence implies widespread use of psychotropics as chemical restraints in long-term care settings globally. On the other hand, it may also reflect an overwhelming burden of  dementia  care in LTCFs due to insufficient staff or resources to offer non-pharmacological support. Whatever the cause, psychotropic drug use is strongly associated with adverse outcomes of dementia care. A typical scenario for inappropriate use of psychotropics is adding or up-titrating medication when an older person with dementia is hospitalized for acute care of illness aggravated by existing BPSD and psychotropics.4 After discharge, LTCF staff might maintain the psychotropic prescription unless it is modified by onsite physicians. This may partly explain the high rate of inappropriate antipsychotics prescription in Korean LTCFs.1

Notwithstanding modest benefit of a 12-week course of antipsychotics in treating aggression and psychosis among people with dementia, adverse events have been widely reported; these include extrapyramidal symptoms, sedation, falls, accelerated cognitive decline, stroke,  pneumonia, and  death.5 Despite well-known adverse effects of psychotropics on people with dementia, prescription rates remain high worldwide. This may  reflect the burden of dementia care in long-term care settings, and may  also be attributable to lack of knowledge or resources to conduct evidence-based non- pharmacological intervention.6 Use of  physical or chemical restraints has been reported  to be more likely among the most physically and cognitively frail LTCF residents.7 As such residents impose the heaviest burden of care, the prescription of antipsychotics may also depend on the adequacy of care resources.

Reducing antipsychotic prescriptions among LTCF residents with dementia may require public sector intervention; directives issued by the Swedish government authorities successfully decreased the use of antipsychotics in LTCFs 8. Clear practice guidelines for LCTFs or government directives may be the most forceful ways to reduce the utilization of antipsychotic drugs among people with dementia. However, since the prescription of antipsychotics to LCTF residents with dementia is influenced by multiple complex factors, involving different stakeholders, more holistic approach to reducing the use of antipsychotics in LTCFs is needed.6 Besides government’s directives, physicians

practicing in LTCFs should be aware of the potential risks associated with long-term antipsychotic use for residents with dementia. Promoting quality of dementia care requires concerted efforts involving all stakeholders to reach a consensus on quality standards for dementia care.

Keywords:

psychotropic treatment older people,dementia,long-term care facilities

References

  1. Kim S, Choi H, Yoo J, Kim S, Kim BS, Choi H, et al. Factors correlated with initiating antipsychotics among dementia patients in Korean long-term care facilities: National Health Insurance Service- Senior Cohort (2002-2013). J Clin Gerontol Geriatr .2017;8:114-22.
  2. Feng Z, Hirdes JP, Smoth TF, Finne-Soveri H, Chi I, Du Pasquier JN, et al. Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study. Int J Geriatr Psychiatry. 2009;24:1110-8.
  3. Daidoji K, Sakata Y, Sumiotomo K, Ishii M, Toyada T, Kawaguchi M. Concomitant use of psychotropics and donepezil in Japanese patients with dementia: pooled postmarketing surveillance data analysis. J Clin Gerontol Geriatr. 2016;7:131-5.
  4. Chen LK. Care for older people with dementia in acute care: a call to action. J Clin Gerontol Geriatr. 2017;8;77-8.
  5. Gereri P, De Fazio P, Manfredi V, De Sarro G. Use and safety of antipsychotics in behavioral disorders in elderly people with dementia. J CLin Psychopharmacol .2014;34:109-23.
  6. Chen RC, Liu CL, Lin MH, Peng LN, Chen LY, Liu LK, et al. Non- pharmacological treatment reducing not only behavioral symptoms, but also psychotic symptoms of older adults with dementia: a prospective cohort study in Taiwan. Geriatr Gerontol Int. 2014;14:440-6.
  7. Lam K, Kwan JSK, Wai Kwan C, Chong AML, Lai CKY, Lou VWQ , et al. Factors associated with the trend of physical and chemical restraint use among long-term care facility residents in Hong Kong: Data from an 11-year observational study. J Am Med Dir Assoc. 2017;18:1043-8.
  8. Karlsson S, Rahm Hallberg I,  Midloy  P,  Fagerstrom  C.  Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia – a review of the Swedish context. BMC Psychiatry. 2017;17:251.
  9. Walsh KA, Dennehy R, Sinnott C, Browne J, Byrne S, McSharry J, et al. Influences on decision-making regarding antipsychotic prescribing in nursing home residents with dementia: a systematic review and synthesis of qualitative evidence. J Am Med Dir Assoc. 2017;18:897.e1- 897.e12.

References

  1. Kim S, Choi H, Yoo J, Kim S, Kim BS, Choi H, et al. Factors correlated with initiating antipsychotics among dementia patients in Korean long-term care facilities: National Health Insurance Service- Senior Cohort (2002-2013). J Clin Gerontol Geriatr .2017;8:114-22.

  2. Feng Z, Hirdes JP, Smoth TF, Finne-Soveri H, Chi I, Du Pasquier JN, et al. Use of physical restraints and antipsychotic medications in nursing homes: a cross-national study. Int J Geriatr Psychiatry. 2009;24:1110-8.


  3. Daidoji K, Sakata Y, Sumiotomo K, Ishii M, Toyada T, Kawaguchi M. Concomitant use of psychotropics and donepezil in Japanese patients with dementia: pooled postmarketing surveillance data analysis. J Clin Gerontol Geriatr. 2016;7:131-5.


  4. Chen LK. Care for older people with dementia in acute care: a call to action. J Clin Gerontol Geriatr. 2017;8;77-8.


  5. Gereri P, De Fazio P, Manfredi V, De Sarro G. Use and safety of antipsychotics in behavioral disorders in elderly people with dementia. J CLin Psychopharmacol .2014;34:109-23.


  6. Chen RC, Liu CL, Lin MH, Peng LN, Chen LY, Liu LK, et al. Non- pharmacological treatment reducing not only behavioral symptoms, but also psychotic symptoms of older adults with dementia: a prospective cohort study in Taiwan. Geriatr Gerontol Int. 2014;14:440-6.


  7. Lam K, Kwan JSK, Wai Kwan C, Chong AML, Lai CKY, Lou VWQ , et al. Factors associated with the trend of physical and chemical restraint use among long-term care facility residents in Hong Kong: Data from an 11-year observational study. J Am Med Dir Assoc. 2017;18:1043-8.


  8. Karlsson S, Rahm Hallberg I,  Midloy  P,  Fagerstrom  C.  Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia – a review of the Swedish context. BMC Psychiatry. 2017;17:251.


  9. Walsh KA, Dennehy R, Sinnott C, Browne J, Byrne S, McSharry J, et al. Influences on decision-making regarding antipsychotic prescribing in nursing home residents with dementia: a systematic review and synthesis of qualitative evidence. J Am Med Dir Assoc. 2017;18:897.e1- 897.e12.