Antipsychotics were used by one-third of cognitively impaired persons. The majority of cognitively impaired persons (n=1909) lived in residential care. Antipsychotics were used by 15.9% of persons living at home and by 37.7% of those in residential care. Antipsychotic users (n=563) were younger, had poorer cognition, lower ADL score and they lived more frequently in residential care setting than non-users of antipsychotics (n=1188) (Table 11). The three most frequently administered antipsychotics were risperidone, quetiapine and olanzapine. Altogether 105 persons used other antipsychotics, mainly conventional ones. At least two concomitant antipsychotics were used by some 5% of persons. The frequencies of all NPS subgroups were higher among the users of antipsychotics than among the non-users. Likewise, BZRD were more common among the users of antipsychotics than the non-users, but there was no significant difference in the use of antidepressants.
Table 11. Characteristics, NPSs and use of psychotropic drugs and anti-dementia drugs in cognitively impaired users and non-users of antipsychotics.
Variable Users of AChEI = Acetylcholinesterase inhibitor, ADL (Activities of Daily Living) score = Barthel Index, scale 0-100, BZD = benzodiazepines, BZRD = Benzodiazepines and Related Drugs, MMSE = Mini Mental State Examination, scale 0-30
*missing data on MMSE n=770
45
In both unvariate and multivariate analyses, use of antipsychotics was associated with living in residential care and use of BZRD (Table 12). In univariate analysis, all hyperactivity symptoms and psychotic symptoms as well as anxiety and apathy in the mood and apathy subgroup were positively associated with antipsychotic use. Such NPSs as agitation/aggression, disinhibition and hallucinations were associated in the multivariate analysis, but a negative association was found between MMSE, age and antipsychotic drug use.
Table 12. Associations of antipsychotic drug use with characteristics of persons, use of other psychotropic drugs and anti-dementia drugs and NPSs.
Variable
Anti-dementia drugs 0.96 (0.79-1.17) Other psychotropic drugs
ADL score = Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, C I= Confidence Interval, MMSE = Mini-Mental State Examination, NPS = Neuropsychiatric Symptom
*Forward selection. Variables included in the model are shown
5.4 ANTIPSYCHOTIC USE AND ASSOCIATIONS WITH NPSS AMONG PERSONS WITH COGNITIVE IMPAIRMENT (STUDY II, N=1909)
Antipsychotics were used by one-third of cognitively impaired persons. The majority of cognitively impaired persons (n=1909) lived in residential care. Antipsychotics were used by 15.9% of persons living at home and by 37.7% of those in residential care. Antipsychotic users (n=563) were younger, had poorer cognition, lower ADL score and they lived more frequently in residential care setting than non-users of antipsychotics (n=1188) (Table 11). The three most frequently administered antipsychotics were risperidone, quetiapine and olanzapine. Altogether 105 persons used other antipsychotics, mainly conventional ones. At least two concomitant antipsychotics were used by some 5% of persons. The frequencies of all NPS subgroups were higher among the users of antipsychotics than among the non-users. Likewise, BZRD were more common among the users of antipsychotics than the non-users, but there was no significant difference in the use of antidepressants.
Table 11. Characteristics, NPSs and use of psychotropic drugs and anti-dementia drugs in cognitively impaired users and non-users of antipsychotics.
Variable Users of AChEI = Acetylcholinesterase inhibitor, ADL (Activities of Daily Living) score = Barthel Index, scale 0-100, BZD = benzodiazepines, BZRD = Benzodiazepines and Related Drugs, MMSE = Mini Mental State Examination, scale 0-30
*missing data on MMSE n=770
45
In both unvariate and multivariate analyses, use of antipsychotics was associated with living in residential care and use of BZRD (Table 12). In univariate analysis, all hyperactivity symptoms and psychotic symptoms as well as anxiety and apathy in the mood and apathy subgroup were positively associated with antipsychotic use. Such NPSs as agitation/aggression, disinhibition and hallucinations were associated in the multivariate analysis, but a negative association was found between MMSE, age and antipsychotic drug use.
Table 12. Associations of antipsychotic drug use with characteristics of persons, use of other psychotropic drugs and anti-dementia drugs and NPSs.
Variable
Anti-dementia drugs 0.96 (0.79-1.17) Other psychotropic drugs
ADL score = Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, C I= Confidence Interval, MMSE = Mini-Mental State Examination, NPS = Neuropsychiatric Symptom
*Forward selection. Variables included in the model are shown
5.5 PHYSICAL RESTRAINTS AND ASSOCIATIONS WITH PSYCHOTROPIC DRUG USE AND NPSS WITH SUBGROUPS IN RESIDENTIAL CARE (STUDY III, N=1439)
Half of the patients were restrained with bedrails (n= 671, 49%) (Table 13). In addition, 93 persons were restrained with a tray table in a wheelchair, 44 persons with a belt around the trunk and 3 persons with binding of one or more extremities with straps. Locking the door was used in 73, removing a walking or standing aid in 11 and physical force in four persons in the preceding 24 hours. Bedrails were used for 96% of bedridden and for 40% of non-bedridden persons, but other restraints were much rarer. The use of multiple restraints was more common among persons with hyperactivity. Hyperactivity subgroup symptoms were more frequently present among those restrained than among non-restrained persons (37% vs. 29%, p<0.001).
Table 13. Physical restraints used in the preceding 24 hours in residential care.
Physical restraints used n (%)
Some form of physical restraint was used for 721 persons (52%) during the preceding 24 hours in residential care facilities (Table 14). Restrained persons were slightly older, had much lower ADL and were more often cognitively impaired than non-restrained individuals. Restrained persons used less often antipsychotics, antidepressants and anti-dementia drugs than the others.
Bedrails (on one or both sides) were used for a total of 671 persons (49%).
Table 14. Characteristics of persons, NPSs and use of psychotropics and anti-dementia drugs among non-restrained and restrained persons in residential care.
ADL score = Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, NPS = Neuropsychiatric Symptom
In the multivariate analysis, restraint use was associated with the NPS psychosis subgroup and use of BZRD (Table 15). BZRD were associated with the risk of being restrained. ADL score and use of antipsychotics or antidepressants were negatively associated with restraint use. No association was found between restraints and anti-dementia drug use. Concomitant use of two
Bedrails 671 (48.4)
or more restraints was associated with higher prevalence of hyperactivity and psychosis symptoms. No such relationship was seen with the symptoms of the mood and apathy subgroup.
Better ADL functioning was associated with a lower risk of restraining, and those who were bedridden were most often exposed to physical restraints.
Table 15. Associations of restraint use with NPS subgroups and use of psychotropic and anti-dementia drugs among persons in residential care in multivariate logistic regression analysis.
Characteristic Odds ratio (95% CI) Female sex 0.82 (0.58-1.17)
Age 1.00 (0.99-1.02)
ADL score 0.93 (0.92-0.93) Cognitive impairment 1.16 (0.70-1.93) NPS subgroups Anti-dementia drugs 0.81 (0.58-1.14) BZRD = Benzodiazepines and Related Drugs,
CI = Confidence Interval, NPS = Neuropsychiatric symptom
5.6 NON-PHARMACOLOGICAL APPROACHES FOR NPSS IN RESIDENTIAL CARE
Non-pharmacological treatments were frequently used in residential care to alleviate NPSs; 54%
(n=774) of the patients in residential care had received some form of this treatment in preceding 24 hours. Persons with at least one detected NPS were treated with various approaches (Table 16). Altogether 483 persons (65%) were verbally assured to alleviate NPSs, both sexes in a similar manner. It was more common to give time and comfort to female patients (55% vs. 39%) (p<0.001).
In assessing somatic condition there seemed to be no substantial sex differences; every fifth person was assessed somatically. Apparently, NPSs were then often related to a somatic condition, e.g. pain or discomfort. Physical exercise was used for every tenth patient with at least one NPS. Music was utilized in the treatment of 103 persons (14%). Team assistance to alleviate NPSs was reported in only 18 cases. Discussions with relatives were employed in 14% of cases (n=107), equally often among the sexes. Hobby crafts, gardening or arts were used in 2% of cases.
5.5 PHYSICAL RESTRAINTS AND ASSOCIATIONS WITH PSYCHOTROPIC DRUG USE AND NPSS WITH SUBGROUPS IN RESIDENTIAL CARE (STUDY III, N=1439)
Half of the patients were restrained with bedrails (n= 671, 49%) (Table 13). In addition, 93 persons were restrained with a tray table in a wheelchair, 44 persons with a belt around the trunk and 3 persons with binding of one or more extremities with straps. Locking the door was used in 73, removing a walking or standing aid in 11 and physical force in four persons in the preceding 24 hours. Bedrails were used for 96% of bedridden and for 40% of non-bedridden persons, but other restraints were much rarer. The use of multiple restraints was more common among persons with hyperactivity. Hyperactivity subgroup symptoms were more frequently present among those restrained than among non-restrained persons (37% vs. 29%, p<0.001).
Table 13. Physical restraints used in the preceding 24 hours in residential care.
Physical restraints used n (%)
Some form of physical restraint was used for 721 persons (52%) during the preceding 24 hours in residential care facilities (Table 14). Restrained persons were slightly older, had much lower ADL and were more often cognitively impaired than non-restrained individuals. Restrained persons used less often antipsychotics, antidepressants and anti-dementia drugs than the others.
Bedrails (on one or both sides) were used for a total of 671 persons (49%).
Table 14. Characteristics of persons, NPSs and use of psychotropics and anti-dementia drugs among non-restrained and restrained persons in residential care.
ADL score = Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, NPS = Neuropsychiatric Symptom
In the multivariate analysis, restraint use was associated with the NPS psychosis subgroup and use of BZRD (Table 15). BZRD were associated with the risk of being restrained. ADL score and use of antipsychotics or antidepressants were negatively associated with restraint use. No association was found between restraints and anti-dementia drug use. Concomitant use of two
Bedrails 671 (48.4)
or more restraints was associated with higher prevalence of hyperactivity and psychosis symptoms. No such relationship was seen with the symptoms of the mood and apathy subgroup.
Better ADL functioning was associated with a lower risk of restraining, and those who were bedridden were most often exposed to physical restraints.
Table 15. Associations of restraint use with NPS subgroups and use of psychotropic and anti-dementia drugs among persons in residential care in multivariate logistic regression analysis.
Characteristic Odds ratio (95% CI) Female sex 0.82 (0.58-1.17)
Age 1.00 (0.99-1.02)
ADL score 0.93 (0.92-0.93) Cognitive impairment 1.16 (0.70-1.93) NPS subgroups Anti-dementia drugs 0.81 (0.58-1.14) BZRD = Benzodiazepines and Related Drugs,
CI = Confidence Interval, NPS = Neuropsychiatric symptom
5.6 NON-PHARMACOLOGICAL APPROACHES FOR NPSS IN RESIDENTIAL CARE
Non-pharmacological treatments were frequently used in residential care to alleviate NPSs; 54%
(n=774) of the patients in residential care had received some form of this treatment in preceding 24 hours. Persons with at least one detected NPS were treated with various approaches (Table 16). Altogether 483 persons (65%) were verbally assured to alleviate NPSs, both sexes in a similar manner. It was more common to give time and comfort to female patients (55% vs. 39%) (p<0.001).
In assessing somatic condition there seemed to be no substantial sex differences; every fifth person was assessed somatically. Apparently, NPSs were then often related to a somatic condition, e.g. pain or discomfort. Physical exercise was used for every tenth patient with at least one NPS. Music was utilized in the treatment of 103 persons (14%). Team assistance to alleviate NPSs was reported in only 18 cases. Discussions with relatives were employed in 14% of cases (n=107), equally often among the sexes. Hobby crafts, gardening or arts were used in 2% of cases.
Table 16. Use of non-pharmacological approaches for NPSs in residential care for females and
*Data concerning gender was missing in two cases
All NPS subgroups were much more abundant among users of non-pharmacological approaches (Table 17). More than half of the users had hyperactivity as well as mood and apathy symptoms and one-fifth had psychotic symptoms. Antipsychotics were even more commonly used among the users of non-pharmacological approaches (46%) than among their peers (26%).
Such a clear difference was not found in the use of antidepressants or BZRD. Both groups were restrained approximately equally often. The mean ADL score was slightly better among those treated with non-pharmacological methods.
Table 17. NPS subgroups, use of psychotropic and anti-dementia drugs and use of physical restraints in patients treated or not treated with non-pharmacological approaches in residential care.
Variable ADL score: Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, NPS = Neuropsychiatric Symptom
49
6 Discussion
6.1 MAIN FINDINGS
More than 50% of persons in both care settings suffered from at least one NPS. In residential care facilities, one-fifth and in home care 15% of patients had two to three NPSs concomitantly. One-fifth of the home care population suffered from depressive symptoms. Hyperactivity symptoms, such as agitation/aggression and irritability, were detected in every third person, and psychotic symptoms in every tenth person. Non-pharmacological treatments for NPSs were used for more than half (54%) of the patients in residential care. The prevalence of NPSs during the preceeding 24 hours in residential care and during the preceding week in home care was 51% and 50%, respectively.
The use of anti-dementia drugs and psychotropic was scrutinized in the aged population receiving residential or regular home care in the South Savo Hospital District. Anti-dementia drugs were frequently used, presumably according to the national treatment guidelines, and their use was associated with the hyperactivity and psychosis NPS subgroups. Diagnosed dementia was found in 56% of persons in residential care, and anti-dementia drugs were used by 36%. Two-thirds of the total population was evaluated to be cognitively impaired which is in line with previous studies (Björk et al. 2016). In home care, dementia had been diagnosed in 31%, and the proportion of anti-dementia drug users was 28%. The use of any anti-dementia drug or combinations of AChEIs and memantine were associated with the mood and apathy subgroup.
A combination therapy was associated with hyperactivity symptoms. Antipsychotics were used by one-third of cognitively impaired persons, 38% in residential care and 16% in home care settings.
Antipsychotic drug use was associated in the multivariate analysis with residential care, BZRD use and symptoms of agitation/aggression, disinhibition and psychosis. Half of the patients in residential care were exposed to physical restraints, with bedrails being the most common.
Psychotic symptoms were associated with a higher risk of physical restraints, and hyperactivity was common when multiple restraints were used. The use of antipsychotics or antidepressants was associated with a lower risk of being restrained, but use of BZRD was associated with a higher risk. Better ADL was associated with a lower risk of restraining, and bedridden persons were most often exposed to physical restraints. Such non-pharmacological treatments as verbal assurance and giving time and comfort to patients were commonly used to alleviate NPSs.
6.2 DISCUSSION OF RESULTS
6.2.1 Users and non-users of anti-dementia drugs and associations with NPSs in dementia (Study I)
Two-thirds of persons with diagnosed dementia used anti-dementia medications. In home care, anti-dementia drugs were used by 28% of patients, and in residential care this figure was 36%. In the population with diagnosed dementia, use of anti-dementia drugs was associated with the mood and apathy subgroup. Hyperactivity symptoms associated with the concomitant use of AChEI and memantine. Psychotic symptoms were not associated with the use of AChEIs, memantine or their combinations. Mood symptoms and apathy symptoms was the most prevalent NPS subgroup among the users of anti-dementia drugs. As the study was
cross-Table 16. Use of non-pharmacological approaches for NPSs in residential care for females and
*Data concerning gender was missing in two cases
All NPS subgroups were much more abundant among users of non-pharmacological approaches (Table 17). More than half of the users had hyperactivity as well as mood and apathy symptoms and one-fifth had psychotic symptoms. Antipsychotics were even more commonly used among the users of non-pharmacological approaches (46%) than among their peers (26%).
Such a clear difference was not found in the use of antidepressants or BZRD. Both groups were restrained approximately equally often. The mean ADL score was slightly better among those treated with non-pharmacological methods.
Table 17. NPS subgroups, use of psychotropic and anti-dementia drugs and use of physical restraints in patients treated or not treated with non-pharmacological approaches in residential care.
Variable ADL score: Barthel Index, scale 0-100, BZRD = Benzodiazepines and Related Drugs, NPS = Neuropsychiatric Symptom
49
6 Discussion
6.1 MAIN FINDINGS
More than 50% of persons in both care settings suffered from at least one NPS. In residential care facilities, one-fifth and in home care 15% of patients had two to three NPSs concomitantly. One-fifth of the home care population suffered from depressive symptoms. Hyperactivity symptoms, such as agitation/aggression and irritability, were detected in every third person, and psychotic symptoms in every tenth person. Non-pharmacological treatments for NPSs were used for more than half (54%) of the patients in residential care. The prevalence of NPSs during the preceeding 24 hours in residential care and during the preceding week in home care was 51% and 50%, respectively.
The use of anti-dementia drugs and psychotropic was scrutinized in the aged population receiving residential or regular home care in the South Savo Hospital District. Anti-dementia drugs were frequently used, presumably according to the national treatment guidelines, and their use was associated with the hyperactivity and psychosis NPS subgroups. Diagnosed dementia was found in 56% of persons in residential care, and anti-dementia drugs were used by 36%. Two-thirds of the total population was evaluated to be cognitively impaired which is in line with previous studies (Björk et al. 2016). In home care, dementia had been diagnosed in 31%, and the proportion of anti-dementia drug users was 28%. The use of any anti-dementia drug or combinations of AChEIs and memantine were associated with the mood and apathy subgroup.
A combination therapy was associated with hyperactivity symptoms. Antipsychotics were used by one-third of cognitively impaired persons, 38% in residential care and 16% in home care settings.
Antipsychotic drug use was associated in the multivariate analysis with residential care, BZRD use and symptoms of agitation/aggression, disinhibition and psychosis. Half of the patients in residential care were exposed to physical restraints, with bedrails being the most common.
Psychotic symptoms were associated with a higher risk of physical restraints, and hyperactivity was common when multiple restraints were used. The use of antipsychotics or antidepressants was associated with a lower risk of being restrained, but use of BZRD was associated with a higher risk. Better ADL was associated with a lower risk of restraining, and bedridden persons were most often exposed to physical restraints. Such non-pharmacological treatments as verbal assurance and giving time and comfort to patients were commonly used to alleviate NPSs.
6.2 DISCUSSION OF RESULTS
6.2.1 Users and non-users of anti-dementia drugs and associations with NPSs in dementia (Study I)
Two-thirds of persons with diagnosed dementia used anti-dementia medications. In home care, anti-dementia drugs were used by 28% of patients, and in residential care this figure was 36%. In the population with diagnosed dementia, use of anti-dementia drugs was associated with the mood and apathy subgroup. Hyperactivity symptoms associated with the concomitant use of AChEI and memantine. Psychotic symptoms were not associated with the use of AChEIs, memantine or their combinations. Mood symptoms and apathy symptoms was the most prevalent NPS subgroup among the users of anti-dementia drugs. As the study was
cross-sectional, conclusions could not be drawn concerning the causality between the drug use and NPSs and their subgroups.
A recent study from Swedish that NHs showed 56 % of residents were ADL-dependent and
A recent study from Swedish that NHs showed 56 % of residents were ADL-dependent and