Abstract
Objective
Current information on opioid use in nursing home residents, particularly those with
dementia, is unknown. We examined the temporal trends in opioid use by dementia severity
and the association of dementia severity with opioid use in long-term care nursing
home residents.
Design
Repeated measures cross-sectional study.
Setting
Long-term care nursing homes.
Participants
Using 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term
care residents (n = 734,739) from each year who had 120 days of consecutive stay.
In a secondary analysis, we included residents who had an emergency department visit
for a fracture (n = 12,927).
Measurements
Dementia was classified as no, mild, moderate, and severe based on the first MDS assessment
each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged
(>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents
with a fracture, opioid use was measured within 7 days after emergency department
discharge. Association of dementia severity with opioid use was evaluated using logistic
regression.
Results
Overall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups.
Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate,
and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose
opioids decreased with increasing severity of dementia. For example, severe dementia
reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval
(CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose
(1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.
Conclusions and Implications
Use of opioids declined in nursing home residents from 2011 to 2017, and the use was
lower in residents with dementia, possibly reflecting suboptimal pain management in
this population.
Keywords
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References
- Alzheimer's disease and nursing homes.Health Aff (Millwood). 2014; 33: 650-657
- Assessment and treatment of pain in people with dementia.Nat Rev Neurol. 2012; 8: 264-274
- Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.BMJ. 2011; 343: d4065
- Pain, agitation, and behavioural problems in people with dementia admitted to general hospital wards: A longitudinal cohort study.Pain. 2015; 156: 675-683
- The impact of dementia on the pain experience.Pain. 1996; 67: 7-15
- Analgesic drug prescription and use in cognitively impaired nursing home residents.Nurs Res. 1998; 47: 235-242
- Pain management in long-term care.Am J Nurs. 1999; 99: 48-52
- Pain in cognitively impaired nursing home patients.J Pain Symptom Manage. 1995; 10: 591-598
- Correlates and management of nonmalignant pain in the nursing home. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology.J Am Geriatr Soc. 1999; 47: 936-942
- Frequency and predictors of analgesic prescribing in U.S. nursing home residents with persistent pain.J Am Geriatr Soc. 2017; 65: 286-293
- Pain and pharmacologic pain management in long-stay nursing home residents.Pain. 2017; 158: 1091-1099
- Prevalence of long-term opioid use in long-stay nursing home residents.J Am Geriatr Soc. 2018; 66: 48-55
- Opioid use and the risk of falls, fall injuries and fractures among older adults: A systematic review and meta-analysis.J Gerontol A Biol Sci Med Sci. 2020; 75: 1989-1995
- American Geriatrics Society 2019 Updated AGS Beers Criteria(R) for potentially inappropriate medication use in older adults.J Am Geriatr Soc. 2019; 67: 674-694
- Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline.Ann Intern Med. 2018; 169: 367-375
- Trends and patterns of geographic variation in opioid prescribing practices by state, United States, 2006-2017.JAMA Netw Open. 2019; 2: e190665
- Opioid prescriptions in older Medicare beneficiaries after the 2014 federal rescheduling of hydrocodone products.J Am Geriatr Soc. 2018; 66: 945-953
- Decline in opioid prescribing after federal rescheduling of hydrocodone products.Pharmacoepidemiol Drug Saf. 2018; 27: 513-519
- Time trends in opioid prescribing among Ontario long-term care residents: A repeated cross-sectional study.CMAJ Open. 2019; 7: E582-E589
- The residential history file: Studying nursing home residents' long-term care histories(∗).Health Serv Res. 2011; 46: 120-137
- Comparison of methods to identify long term care nursing home residence with administrative data.BMC Health Serv Res. 2017; 17: 376
- Long-term opioid therapy in older cancer survivors: A retrospective cohort study.J Am Geriatr Soc. 2019; 67: 945-952
- Hospital prescribing of opioids to Medicare beneficiaries.JAMA Intern Med. 2016; 176: 990-997
- Cognitive status of older adults on admission to a skilled nursing facility according to a hospital discharge diagnosis of dementia.J Am Med Dir Assoc. 2017; 18: 726-728
- Nursing home data compendium 2015 edition.(Available at:)
- Comorbidity measures for use with administrative data.Med Care. 1998; 36: 8-27
- A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data.Med Care. 2009; 47: 626-633
- A chronic disease score from automated pharmacy data.J Clin Epidemiol. 1992; 45: 197-203
- Trends in opioids prescribed at discharge from emergency departments among adults: United States, 2006–2017. National Health Statistics Reports; no 135.National Center for Health Statistics, Hyattsville, MD2020
- A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture.J Pain Symptom Manage. 2000; 19: 240-248
- Are nursing home patients with dementia diagnosis at increased risk for inadequate pain treatment?.Int J Geriatr Psychiatry. 2005; 20: 730-737
- Prevalence and management of pain, by race and dementia among nursing home residents: United States, 2004.NCHS Data Brief. 2010; : 1-8
- Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions.Alzheimers Dement (N Y). 2018; 4: 661-668
- Frequent use of opioids in patients with dementia and nursing home residents: A study of the entire elderly population of Denmark.Alzheimers Dement. 2015; 11: 691-699
- Pain management in dementia: So far, not so good.J Gerontol Geriatr. 2016; 50: 75
- Prescription opioids and risk of dementia or cognitive decline: A prospective cohort study.J Am Geriatr Soc. 2015; 63: 1519-1526
- Association of chronic opioid use with presidential voting patterns in US counties in 2016.JAMA Netw Open. 2018; 1: e180450
- Limits on opioid prescribing leave patients with chronic pain vulnerable.JAMA. 2019; 321: 2059-2062
- CDC advises against misapplication of the guideline for prescribing opioids for chronic pain.(Available at:)https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.htmlDate accessed: April 12, 2020
- No shortcuts to safer opioid prescribing.N Engl J Med. 2019; 380: 2285-2287
- Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: A cluster randomized trial.Eur J Pain. 2014; 18: 1490-1500
Article info
Publication history
Published online: June 27, 2020
Footnotes
Funding: This work was supported by the National Institute of Health (5R01DA039192 and 3R01DA039192-03S1), the National Cancer Institute (K05-CA134923), and the Claude D. Pepper Older Americans Independence Center Award (P30-AG024832-12).
The authors declare no conflicts of interest
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© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
