6.3. Strengths and limitations of the study
6.3.2 Limitations of the study
Due to high the number of institutions and home care units, it was not possible to evaluate the interrater reliability. The cross-sectional design of the study did not enable assessments of to causality between drug use and NPSs, nor could the indications of psychotropic drug use or the possible risk for chemical restraining be assessed. The dates of dementia diagnosis, the initiation of anti-dementia or psychotropic drugs and the duration of detected NPSs or restraining could not be assessed. In the present study, the doses of the used drugs were not taken into account, but merely the use or non-use of a psychotropic or an anti-dementia drug.
The assessment of NPSs was based on merely determining the presence or absence of NPI-defined NPSs. However, the same pattern is followed in NPI-Q, which has had good concordance with the NPI, and has been shown to be a reliable tool in assessing NPSs in dementia (Kaufer et al. 2000). As a limitation, assessment of the severity into three categories (mild, moderate, severe) was not done here. Furthermore, the number of nurses rating the NPSs was high. In this study, apathy was not recognized by the nurses as well as other NPSs. Apathy appears to be difficult to identify in clinical practice, as it may be difficult to distinguish from depression due to overlapping of NPSs (Starkstein et al. 2005). However, apathy is very common and persistent in depressed older persons (Yuen et al. 2015). Concerning the BI, it is well documented and validated for stroke patients, but there have been some uncertainties when used with older people with many chronic diseases (Sainsbury et al. 2005).
A physician-made diagnosis of dementia from medical records collected by a nurse is not always indicative of a clinically verified diagnosis. In fact, up to 30% of dementia diagnoses in LTC are missing, and of NH residents, as many as 90% may have dementia (Lithgow et al. 2012).
The classification of patients’ cognition into four categories (normal, slightly impaired, moderately impaired and severely impaired) by nurses is not comparable with standardized questionnaires; however, it was done by skilled nurses who knew the patient. Since a recent MMSE was available for less than half of the patients, it was used as a characteristic, not as a classification tool.
57
7 Conclusions
In conclusion, a comprehensive overview of persons in home care and residential care in a geographically defined area was achieved in terms of drug use, physical restraints, ADL functioning and prevalence of NPSs. Most of these individuals had some degree of cognitive impairment. Both anti-dementia drugs and psychotropics seemed to be used frequently. The use of antipsychotics was high in both care settings.
1. Anti-dementia drugs were commonly used in the both care settings, long-term residential care and home care. AChEI and/or memantine use was associated with the mood and apathy subgroup symptoms. Combination therapy with both AChEI and memantine associated with the hyperactivity subgroup symptoms. Non-users of anti-dementia drugs had two to three NPSs less than the users, and their ADL scores were higher than thoses who used anti-dementia drugs. Further studies are needed on the effectiveness of anti-anti-dementia drugs to ensure effective and safe pharmacotherapy for our vulnerable patients with dementia.
2. Antipsychotics were commonly used in cognitively impaired persons in home care (16%), but especially common they were in the same group in residential care (39%). Their use was associated with hallucinations, disinhibition and agitation/aggression as well as BZRD use and living in residential care. Instead of using antipsychotics to alleviate all NPSs, antipsychotics should be used only for the most severe NPSs at the lowest effective dose and their need should be reviewed regularly.
3. Half of the persons in residential care were exposed to physical restraints in preceeding 24 hours, mostly bedrails. Psychotic symptoms were associated with the restraint use as well as concomitant use of at least two restraints with hyperactivity subgroup symptoms. BZRD were associated with the increased risk, but the use of antipsychotics or antidepressants was associated with a lower risk of being restrained. Better ADL scores were related to a lower risk of restraining, and bedridden persons were most often exposed to physical restraints. The need for and use of restraints should always be tailored individually, and the need should be re-assessed regularly.
4. The most frequently used non-pharmacological approaches in residential care were verbal assurance (65%) and giving time and comfort (50%), both of which are unspecific and easily accomplished treatments. More targeted non-pharmacological strategies should be employed.
prevalences (51% and 50%, respectively) than in a recent Swedish study reporting NPSs, prevalence rates of NPSs 92% in NHs (Björk et al. 2016). In residential care, restraint use, NPSs and non-pharmacological treatments for NPSs were evaluated over the previous 24 hours, also increasing the reliability of the data. The cross-sectional design enabled the evaluation of associations between NPSs and patient characteristics of the patients as well as uses of medication and physical restraints at a specific time point.
6.3.2 Limitations of the study
Due to high the number of institutions and home care units, it was not possible to evaluate the interrater reliability. The cross-sectional design of the study did not enable assessments of to causality between drug use and NPSs, nor could the indications of psychotropic drug use or the possible risk for chemical restraining be assessed. The dates of dementia diagnosis, the initiation of anti-dementia or psychotropic drugs and the duration of detected NPSs or restraining could not be assessed. In the present study, the doses of the used drugs were not taken into account, but merely the use or non-use of a psychotropic or an anti-dementia drug.
The assessment of NPSs was based on merely determining the presence or absence of NPI-defined NPSs. However, the same pattern is followed in NPI-Q, which has had good concordance with the NPI, and has been shown to be a reliable tool in assessing NPSs in dementia (Kaufer et al. 2000). As a limitation, assessment of the severity into three categories (mild, moderate, severe) was not done here. Furthermore, the number of nurses rating the NPSs was high. In this study, apathy was not recognized by the nurses as well as other NPSs. Apathy appears to be difficult to identify in clinical practice, as it may be difficult to distinguish from depression due to overlapping of NPSs (Starkstein et al. 2005). However, apathy is very common and persistent in depressed older persons (Yuen et al. 2015). Concerning the BI, it is well documented and validated for stroke patients, but there have been some uncertainties when used with older people with many chronic diseases (Sainsbury et al. 2005).
A physician-made diagnosis of dementia from medical records collected by a nurse is not always indicative of a clinically verified diagnosis. In fact, up to 30% of dementia diagnoses in LTC are missing, and of NH residents, as many as 90% may have dementia (Lithgow et al. 2012).
The classification of patients’ cognition into four categories (normal, slightly impaired, moderately impaired and severely impaired) by nurses is not comparable with standardized questionnaires; however, it was done by skilled nurses who knew the patient. Since a recent MMSE was available for less than half of the patients, it was used as a characteristic, not as a classification tool.
57
7 Conclusions
In conclusion, a comprehensive overview of persons in home care and residential care in a geographically defined area was achieved in terms of drug use, physical restraints, ADL functioning and prevalence of NPSs. Most of these individuals had some degree of cognitive impairment. Both anti-dementia drugs and psychotropics seemed to be used frequently. The use of antipsychotics was high in both care settings.
1. Anti-dementia drugs were commonly used in the both care settings, long-term residential care and home care. AChEI and/or memantine use was associated with the mood and apathy subgroup symptoms. Combination therapy with both AChEI and memantine associated with the hyperactivity subgroup symptoms. Non-users of anti-dementia drugs had two to three NPSs less than the users, and their ADL scores were higher than thoses who used anti-dementia drugs. Further studies are needed on the effectiveness of anti-anti-dementia drugs to ensure effective and safe pharmacotherapy for our vulnerable patients with dementia.
2. Antipsychotics were commonly used in cognitively impaired persons in home care (16%), but especially common they were in the same group in residential care (39%). Their use was associated with hallucinations, disinhibition and agitation/aggression as well as BZRD use and living in residential care. Instead of using antipsychotics to alleviate all NPSs, antipsychotics should be used only for the most severe NPSs at the lowest effective dose and their need should be reviewed regularly.
3. Half of the persons in residential care were exposed to physical restraints in preceeding 24 hours, mostly bedrails. Psychotic symptoms were associated with the restraint use as well as concomitant use of at least two restraints with hyperactivity subgroup symptoms. BZRD were associated with the increased risk, but the use of antipsychotics or antidepressants was associated with a lower risk of being restrained. Better ADL scores were related to a lower risk of restraining, and bedridden persons were most often exposed to physical restraints. The need for and use of restraints should always be tailored individually, and the need should be re-assessed regularly.
4. The most frequently used non-pharmacological approaches in residential care were verbal assurance (65%) and giving time and comfort (50%), both of which are unspecific and easily accomplished treatments. More targeted non-pharmacological strategies should be employed.
8 Implications for future
1. Combinations of AchEI and memantine were common in our area. However, the studies of their efficacy on NPSs are relatively scarce. More RTCs are needed to evaluate their usefulness.
2. The widespread and common use of antipsychotics among older persons with cognitive impairment warrants studies to analyze the risks associated with chemical restraining.
Educational interventions on medical staff may have a substantial decreasing impact on prescribing of antipsychotics.
3. Because of the common use of physical restraints in residential care, we need further studies to implement restraint-free practices at all levels of health care, in the future even in home care. The improvement of the care towards restraint-free services requires improvement in co-operation between general practitioners, nurses and specialists.
4. The assessment of NPSs should be an important part of comprehensive dementia care. It is essential to continue to standardize the evaluation of NPSs for different populations of individuals because definitions of these symptoms, subgroups and syndromes remain inconsistent.
5. Future interventions for NPSs should focus on long-term implementation of staff training on non-pharmacological approaches. It is essential to understand how unmet needs, communication problems, understimulation and emotional discomfort relate to NPSs. Further studies are required to compare pharmacological and non-pharmacological treatments for NPSs and to define the treatments most suited to be carried out by both families and professional caregivers.
59
9 References
Aalten P, de Vugt ME, Lousberg R, Korten E, Jaspers N, Senden B, Jolles J, Verhey FR. Behavioral problems in dementia: a factor analysis of the Neuropsychiatric Inventory. Dement Geriatr Cogn Disord 15: 99-105, 2003.
Aalten P, de Vugt ME, Jaspers N, Jolles J, Verhey FRJ. The course of neuropsychiatric symptoms in dementia. Part II: relationships among behavioural subsyndromes and the influence of clinical variables. Int J Geriatr Psychiatry 20: 531-536, 2005.
Aalten P, Verhey FR, Boziki M, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni G, Girtler N, Holmes C, Hurt C, Marriott A, Mecocci P, Nobili F, Ousset PJ, Reynish E, Salmon E, Tsolaki M, Vellas B, Robert PH. Neuropsychiatric syndromes in dementia.
Results from the European Alzheimer Disease Consortium: part I. Dement Geriatr Cogn Disord 24: 457-463, 2007.
Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson's disease. Mov Disord 20: 1255-1163, 2005.
Adkins VK. Treatment of deprsessive disorders of spousal caregivers of persons with Alzheimer’s disease: a review. Am J Alzheimers Dis Other Demen 14: 289-293, 1999.
Alanen HM, Finne-Soveri H, Noro A. Use of antipsychotic medications among elderly residents in long-term institutional care: a three year follow-up. Int J Geriatr Psychiatry 21: 288-295, 2006.
Alanen HM, Finne-Soveri H, Fialova D, Topinkova E, Jonsson PV, Sœrbye LW, Berabei R, Leinonen E. Use on antipsychotic medications in older home-care patients. Report from nine European countries. Aging Clin Exp Res 20: 260-265, 2008.
Alanen HM, Finne-Soveri H, Noro A, Leinonen E. Use of antipsychotics in older home care patients in Finland. Drugs Ageing 25: 335-342, 2008.
Alanen HM, Pitkänen A, Suontaka-Jamalainen K, Kampman O, Leinonen E. Acute psychogeriatric inpatient treatment improves neuropsychiatric symptoms but impairs the level of functioning in patients with dementia. Dement Geriatr Cogn Disord 40: 290-296, 2015.
Albert MA, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, Gamst A, Holtzman DM, agust WJ, Petersen RC, Snyder PJ, Carrillo MC, Thies B, Phelps CH. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging and Alzheimer’s. Alzheimers Dement 7: 270–279, 2011.
Alexopoulos GS, Katz IR, Reynolds CF 3rd, Carpenter D, Docherty JP, Ross RW.
Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines.
J Psychiatr Pract 361-376, 2001.
Alexopoulos GS, Streim J, Carpenter D, Docherty JP; Expert consensus panel for using antipsychotic drugs in older patients. Using antipsychotic agents in older patients. J Clin Psychiatry 65: 5-99. discussion 100-2; quiz103-4, 2004.
8 Implications for future
1. Combinations of AchEI and memantine were common in our area. However, the studies of their efficacy on NPSs are relatively scarce. More RTCs are needed to evaluate their usefulness.
2. The widespread and common use of antipsychotics among older persons with cognitive impairment warrants studies to analyze the risks associated with chemical restraining.
Educational interventions on medical staff may have a substantial decreasing impact on prescribing of antipsychotics.
3. Because of the common use of physical restraints in residential care, we need further studies to implement restraint-free practices at all levels of health care, in the future even in home care. The improvement of the care towards restraint-free services requires improvement in co-operation between general practitioners, nurses and specialists.
4. The assessment of NPSs should be an important part of comprehensive dementia care. It is essential to continue to standardize the evaluation of NPSs for different populations of individuals because definitions of these symptoms, subgroups and syndromes remain inconsistent.
5. Future interventions for NPSs should focus on long-term implementation of staff training on non-pharmacological approaches. It is essential to understand how unmet needs, communication problems, understimulation and emotional discomfort relate to NPSs. Further studies are required to compare pharmacological and non-pharmacological treatments for NPSs and to define the treatments most suited to be carried out by both families and professional caregivers.
59
9 References
Aalten P, de Vugt ME, Lousberg R, Korten E, Jaspers N, Senden B, Jolles J, Verhey FR. Behavioral problems in dementia: a factor analysis of the Neuropsychiatric Inventory. Dement Geriatr Cogn Disord 15: 99-105, 2003.
Aalten P, de Vugt ME, Jaspers N, Jolles J, Verhey FRJ. The course of neuropsychiatric symptoms in dementia. Part II: relationships among behavioural subsyndromes and the influence of clinical variables. Int J Geriatr Psychiatry 20: 531-536, 2005.
Aalten P, Verhey FR, Boziki M, Bullock R, Byrne EJ, Camus V, Caputo M, Collins D, De Deyn PP, Elina K, Frisoni G, Girtler N, Holmes C, Hurt C, Marriott A, Mecocci P, Nobili F, Ousset PJ, Reynish E, Salmon E, Tsolaki M, Vellas B, Robert PH. Neuropsychiatric syndromes in dementia.
Results from the European Alzheimer Disease Consortium: part I. Dement Geriatr Cogn Disord 24: 457-463, 2007.
Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson's disease. Mov Disord 20: 1255-1163, 2005.
Adkins VK. Treatment of deprsessive disorders of spousal caregivers of persons with Alzheimer’s disease: a review. Am J Alzheimers Dis Other Demen 14: 289-293, 1999.
Alanen HM, Finne-Soveri H, Noro A. Use of antipsychotic medications among elderly residents in long-term institutional care: a three year follow-up. Int J Geriatr Psychiatry 21: 288-295, 2006.
Alanen HM, Finne-Soveri H, Fialova D, Topinkova E, Jonsson PV, Sœrbye LW, Berabei R, Leinonen E. Use on antipsychotic medications in older home-care patients. Report from nine European countries. Aging Clin Exp Res 20: 260-265, 2008.
Alanen HM, Finne-Soveri H, Noro A, Leinonen E. Use of antipsychotics in older home care patients in Finland. Drugs Ageing 25: 335-342, 2008.
Alanen HM, Pitkänen A, Suontaka-Jamalainen K, Kampman O, Leinonen E. Acute psychogeriatric inpatient treatment improves neuropsychiatric symptoms but impairs the level of functioning in patients with dementia. Dement Geriatr Cogn Disord 40: 290-296, 2015.
Albert MA, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, Gamst A, Holtzman DM, agust WJ, Petersen RC, Snyder PJ, Carrillo MC, Thies B, Phelps CH. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging and Alzheimer’s. Alzheimers Dement 7: 270–279, 2011.
Alexopoulos GS, Katz IR, Reynolds CF 3rd, Carpenter D, Docherty JP, Ross RW.
Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines.
J Psychiatr Pract 361-376, 2001.
Alexopoulos GS, Streim J, Carpenter D, Docherty JP; Expert consensus panel for using antipsychotic drugs in older patients. Using antipsychotic agents in older patients. J Clin Psychiatry 65: 5-99. discussion 100-2; quiz103-4, 2004.
Alexopoulos GS. Depression in the elderly. Lancet 365: 1961-1970, 2005.
Alexopoulos GS, Jeste DV, Chung H, Carpenter D, Ross R, Docherty JP. The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary. Postgrad Med No: 6-22, 2005.
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Ashton H. The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry 18: 249-255, 2005.
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Azermai M, Elseviers M, Petrovic M, van Bortel L, Stichele RV. Assessment of antipsychotic prescribing in Belgian nursing homes. Int Psychogeriatr 8: 1240-1248, 2011.
Azermai M, Vander Stichele RR, Van Bortel LM, Elseviers MM.Barriers to antipsychotic discontinuation in nursing homes: an exploratory study. Aging Ment Health 18: 346-533, 2014.
Bains J, Birks J, Dening T. Antidepressants for treating depression in dementia. Cochrane Database Syst Rev 4: CD003944, 2002.
Baker R, Bell S, Baker E, Gibson S, Holloway J, Pearce R, Dowling Z, Thomas P, Assey J, Wareing LA. A randomized controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. Br J Clin Psychol 40: 81-96, 2001.
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Ballard C, O’Brien J, Reichelt K, Perry E. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled
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