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Patterns of Antipsychotic Dispensation to Long-Term Care Residents

Open AccessPublished:October 26, 2022DOI:https://doi.org/10.1016/j.jamda.2022.09.009

      Abstract

      Objectives

      To describe dispensing patterns of antipsychotic medications to long-term care (LTC) residents and assess factors associated with continuation of an antipsychotic after a fall-related hospitalization.

      Design

      A retrospective cohort study.

      Setting and Participants

      Nova Scotia Seniors Pharmacare Program (NSSPP) beneficiaries age 66 years and older who resided in LTC and received at least 1 dispensation of an antipsychotic within the study period of April 1, 2009, to March 31, 2017.

      Methods

      Linkage of administrative claims data from the NSSPP and the Canadian Institute of Health Information Discharge Abstract Database identified LTC residents with an antipsychotic dispensation and from the subgroup of those dispensed antipsychotic medications who experienced a fall-related hospitalization. Antipsychotic dispensing patterns were reported with counts and means. Predictors of continuation of an antipsychotic after a fall-related hospitalization (sex, length of stay, days supplied, age, year of admission, rural/urban) were reported and analyzed with multiple logistic regression.

      Results

      There were 19,164 unique NSSPP beneficiaries who were dispensed at least 1 prescription for an antipsychotic medication. Of those who received at least 1 antipsychotic dispensation 90% (n = 17,201) resided in LTC. A mean of 40% (n = 2637) of LTC residents received at least 1 antipsychotic dispensation in each year. Risperidone and quetiapine were dispensed most frequently.
      Of the 544 beneficiaries residing in LTC who survived a fall-related hospitalization, 439 (80.7%) continued an antipsychotic after hospital discharge. Female sex [OR 1.7, 95% CI (1.013‒2.943)], age 66‒69 [OR 4.587, 95% CI (1.4‒20.8)], 75-79 [OR 2.8, 95% CI (1.3‒6.3)], and 80‒84 years [OR 3.1, 95% CI (1.6‒6.4)] (compared with age 90+ years) were associated with increased risk of antipsychotic continuation.

      Conclusions and Implications

      With 90% of antipsychotic dispensations in Nova Scotia being to LTC residents and 40% of LTC residents being dispensed antipsychotics in any year there is a need to address this level of antipsychotic dispensation to older adults.

      Keywords

      With the global prevalence of dementia projected to triple by 2050, an understanding of the patterns of antipsychotic use for symptom management in older adults with dementia is increasingly important.
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      suggest that a trial of antipsychotics be considered if the behaviors identified put the safety of the patient or their carers at risk of harm. A trial of antipsychotic medications should last 4‒6 weeks and then, if appropriate, be tapered. Antipsychotics have only small and likely nonsignificant effects on improvement of dementia-related psychosis
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      and increase risks of mortality, cerebrovascular events, and may cause somnolence, falls, fractures, or injuries. Antipsychotic prevalence in long term care (LTC) is related to the prevalence of dementia in the residence.
      2021 Alzheimer’s disease facts and figures.
      Estimates from Ontario, Canada in 2015 identified 54.1% of patients admitted to LTC had a dementia diagnosis at admission.
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      By the 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
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      STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
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      In Canada, risperidone is the only antipsychotic with a Health Canada approved indication
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      Risperidone - Restriction of the Dementia Indication.
      for short-term use in the treatment of behavioral or psychological symptoms of dementia.
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      Injurious falls are serious events for older adults. The level of function prior to the fall may not be regained.
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      Avoiding falls is therefore a priority. Some risk factors for falls can be modified. Medications can increase risk of falls and are often modifiable.
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      The present study has 2 objectives: (1) to identify dispensing patterns of antipsychotic medications for older persons who reside in LTC from April 1, 2009, to March 31, 2017, in Nova Scotia, Canada; and (2) to identify the proportion who continued an antipsychotic after a fall-related hospitalization and describe factors associated with antipsychotic continuation.

      Methods

      Study Setting

      The cohort included beneficiaries of the Nova Scotia Seniors Pharmacare Program (NSSPP) residing in LTC. The NSSPP is a voluntary provincial drug insurance plan for those age 65 years or older in the province of Nova Scotia, Canada (https://novascotia.ca/dhw/pharmacare/seniors-pharmacare.asp?wbdisable=true). Study inclusion required being an eligible NSSPP beneficiary, 66 years of age and older (to allow for 1 year look back) and having resided in any of the 92 LTC homes in Nova Scotia
      • Scotia C.N.
      Government adding more than 260 new long-term care beds, replacing hundreds more. News Releases.
      for more than 30 days. Beneficiaries with short stays for respite or end of life palliation were excluded from the study. LTC in Nova Scotia provides 24-hour nursing care to people who are medically stable but require assistance with activities of daily living
      Long Term Care. novascotia.ca.
      and sites are designated as public (not for profit) (14%), private (for profit) (48%), or voluntary (not for profit) (38%).
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      • et al.
      Pathways for best practice diffusion: the structure of informal relationships in Canada’s long-term care sector.

      Sources of Data

      Health Data Nova Scotia (HDNS) (https://medicine.dal.ca/departments/department-sites/community-health/research/hdns.html) provided data and performed linkage based on encrypted health card number to the following administrative databases: (1) Seniors Pharmacare (PHARM); (2) Master patient registry (MASTER); and (3) the Canadian Institute of Health Information Discharge Abstract Database (DAD). Data were provided in fiscal years over the period April 1, 2009, to March 31, 2017. The PHARM database provided prescription claims data for antipsychotic medications as defined by the 2015 WHO-ATC codes (https://www.whocc.no/atc_ddd_index/). Antipsychotics were classified as first or second generation agents (Appendix A).
      WHOCC - ATC/DDD Index.
      Demographic details (age, sex) of the beneficiary were captured from the dispensation records in the PHARM database. The MASTER database provided information on residential setting (community or LTC), and the geographic location of residence via postal code (urban/rural). The DAD (https://www.cihi.ca/en/discharge-abstract-database-metadata-dad) provided administrative, clinical, and demographic information on hospital discharges.

      Objective 1: Antipsychotic Dispensation Trends

      Reporting included the NSSPP beneficiary age and sex at time of the first dispensed antipsychotic medication and dose in each fiscal year and for the overall study period.

      Objective 2: Antipsychotic Use Prior to and Following Fall-Related Hospitalization

      The NSSPP and DAD data were linked to identify LTC dwelling NSSPP beneficiaries age 66 years and older with a fall-related hospitalization up to 100 days following dispensation of an antipsychotic. Only the first fall-related hospitalization was evaluated per fiscal year. If a patient had a fall-related hospitalization in more than 1 year each was counted as a unique event.
      Age category, sex, the hospital length of stay, year of hospital admission, rurality, disposition (discharge or death), and details of any antipsychotic dispensation including days supplied of antipsychotic medication in the 100 days following discharge from hospital were determined for the cohort with a fall-related hospitalization. The maximum allowed drug supply for beneficiaries of the the NSSPP insurance is 100 days, so any antipsychotic medications continued after the fall-related hospitalization would need to be refilled within 100 days of hospital discharge.
      Benefits and Reimbursement | novascotia.ca.

      Analysis

      Descriptive statistics summarized population characteristics using counts, frequencies, and means as appropriate. Annual trends in antipsychotic dispensation were analyzed using the Cochrane-Armitage trend test for trends in binomial proportions (sex and age) across fiscal years both overall and by specific drug. Multiple logistic regressions were used to model the outcome of continued antipsychotic dispensation after fall-related hospitalization with predictors sex, length of stay (0‒7, 8‒14, or more than 14 days), days supplied (less than 30, 30‒59, 60‒89, 90 or more days), age (66‒69, 70‒74, 75‒79, 80‒84, 85‒89, 90 or more years), year of admission, and rural or urban location (as designated by the second digit of the postal code). A sex-stratified analysis was completed to investigate sex differences in risk for antipsychotic continuation. Significance was accepted as a P value of <.05.
      All statistical analyses were completed with SAS v 9.3 (SAS Institute Inc).

      Ethics

      The Health Sciences Research Ethics Board, Dalhousie University, Halifax, Nova Scotia (#2014-3302) approved this project.

      Results

      The NSSPP had on average 103,620 beneficiaries (59.1% female) 65 years of age and older in each of the eight fiscal years between April 1, 2009, and March 31, 2017. A mean 6816 (6.5%) NSSPP beneficiaries (75.2% female) 66 years of age and older resided in LTC in each year (Appendix B).

      Objective 1: Antipsychotic Dispensation Trends

      From fiscal year 2009 through 2016, 19,164 NSSPP beneficiaries (12.4%) received at least 1 antipsychotic dispensation, and 17,201 (90%) of those beneficiaries were LTC residents. Figure 1, Table 1, and Appendix B show further details of the distribution of antipsychotic dispensations across the years of study by sex, age, and as a proportion of beneficiaries residing in LTC. Approximately 40% of Nova Scotian older adults residing in LTC were dispensed an antipsychotic at least once in each year (range of 38% to 41%) with no evidence of change in this rate over time (Cochrane-Armitage P value = .4184). As Figure 1 shows, within the general population of NSSPP beneficiaries both men and women were more likely to be dispensed an antipsychotic at older ages. This pattern is reversed when looking only at beneficiaries who are residents of LTC; in LTC both men and women become less likely to receive an antipsychotic as they age. Over 50% of men and women in the 66- to 69-year-old age group received an antipsychotic dispensation, decreasing to around 30% in the 90 years of age and older age group. (Cochran-Armitage P < .0001, 2016 data shown in Table 2 and all years are presented in Appendix B).
      Figure thumbnail gr1
      Fig. 1Proportion of eligible men and women who are NSSPP beneficiaries and NSSPP beneficiaries residing in LTC, by age category, receiving at least 1 antipsychotic drug dispensation per year, 2009‒2016.
      Table 1Characteristics of NSSPP Beneficiaries Residing in LTC and Receiving at Least 1 Antipsychotic Dispensation in Fiscal Years 2009 and 2016
      Fiscal Year20092016
      n (%)n (%)
      Total
      NSSPP beneficiaries 66 years of age and older residing in LTC receiving at least 1 antipsychotic dispensation represented 40.7% and 39.2% of all NSSPP beneficiaries residing in LTC for the years 2009 and 2016, respectively.
      26972525
      Female1954 (72.5)1720 (68.1)
      Age, y
       66‒69194 (7.2)245 (9.7)
       70‒74292 (10.8)310 (12.3)
       75‒79473 (17.5)396 (15.7)
       80‒84574 (21.3)488 (19.3)
       85‒89572 (21.2)570 (22.6)
       90+592 (22.0)516 (20.4)
      Urban1713 (63.5)1609 (63.7)
      NSSPP beneficiaries 66 years of age and older residing in LTC receiving at least 1 antipsychotic dispensation represented 40.7% and 39.2% of all NSSPP beneficiaries residing in LTC for the years 2009 and 2016, respectively.
      Table 2Sex and Age Distribution of LTC Residents Including Antipsychotic Dispensations in 2016
      Age Group (y)66‒6970‒7475‒7980‒8485‒8990+
      Female22635052883311361685
      Female person with ≥1 antipsychotic dispensation, n (%)
      Cochrane Armitage test for trend P < .0001.
      128 (56.6)189 (54.0)214 (40.5)319 (38.3)426 (37.5)453 (26.9)
      Male205248328380333200
      Male person with ≥1 antipsychotic dispensation, n (%)
      Cochrane Armitage test for trend P < .0001.
      117 (57)130 (52.4)182 (55.5)169 (44.5)144 (43.2)63 (31.5)
      Cochrane Armitage test for trend P < .0001.
      Antipsychotic dispensations were predominantly for second generation agents (average 82.9%) with risperidone and quetiapine in greatest proportions (Table 3). There were small changes in the prescribing rates of individual drugs, with the rate of risperidone dispensation dropping from 43% to 33% and quetiapine and haloperidol increasing over that same period (Cochran-Armitage P value <.0001 for risperidone, quetiapine, and haloperidol, P value = .3285 for olanzapine). Mean daily risperidone dose was 0.8 mg/day in each year of study. Mean daily quetiapine dose was highest in 2009 at 70.7 mg/day and fell to 57.8 mg/day in fiscal year 2016. Details of dosing of specific agents are available in Appendix C.
      Table 3Specific Antipsychotic Dispensations to NSSPP Beneficiaries Residing in LTC for First Antipsychotic Dispensation for Fiscal Years 2009 through 2016
      Year20092010201120122013201420152016p-value
      n (%)n (%)n (%)n (%)n (%)n (%)n (%)n (%)
      NSSPP beneficiaries with ≥1 antipsychotic dispensation26972756272526732637264226202525
      All second-generation antipsychotics (%)2275 (84.4)2289 (83.1)2296 (84.3)2206 (82.5)2175 (82.5)2183 (82.6)2134 (81.5)2072 (82.1)
       risperidone (%)1166 (43.0)1064 (38.0)980 (36.0)911 (34.0)878 (33.3)905 (34.3)850 (32.4)845 (33.5)<.0001
       quetiapine (%)911 (33.8)1029 (37.3)1103 (40.5)1082 (40.5)1086 (41.2)1057 (40.0)1079 (41.2)1011 (40.0)<.0001
       olanzapine (%)198 (7.3)196 (7.1)207 (7.6)207 (7.7)199 (7.6)208 (7.9)193 (7.4)202 (8.0).3285
       other second-generation antipsychotics
      clozapine, aripiprazole, or paliperidone.
      (%)
      006 (0.2)6 (0.2)12 (0.5)13 (0.5)12 (0.5)14 (0.6)<.0001
      All first-generation antipsychotics (%)417 (15.5)427 (15.5)426 (15.6)465 (17.4)457 (17.3)451 (17.1)483 (18.4)450 (17.8)
       haloperidol (%)144 (5.3)190 (6.9)176 (6.5)221 (8.3)241 (9.1)250 (9.5)253 (9.7)230 (9.1)<.0001
       other first-generation antipsychotics
      levopromazine, loxapine, perphenazine, chlorpromazine, triluoperazine, prochlorperazine, flupentixoil, fluphenazine, periciazine, zuclopenthixol, pimozide.
      (%)
      273 (10.1)237 (8.6)250 (9.2)244 (9.1)216 (8.2)201 (7.6)230 (8.8)220 (8.7).0386
      P values are calculated using the Cochrane Armitage test, using all other prescriptions as the control group.
      clozapine, aripiprazole, or paliperidone.
      levopromazine, loxapine, perphenazine, chlorpromazine, triluoperazine, prochlorperazine, flupentixoil, fluphenazine, periciazine, zuclopenthixol, pimozide.

      Objective 2: Antipsychotic Dispensation Prior to and Following a Fall-Related Hospitalization

      There were 1185 NSSPP beneficiaries dispensed an antipsychotic up to 100 days before a fall-related hospitalization. Of this group, 599 (50.5%) resided in LTC at the time of antipsychotic dispensation (Table 4), and 544 of those (90.8%) survived the fall-related hospitalization to discharge from hospital. Of the 544 that were discharged, 439 (80.7%) made a claim for an antipsychotic within 100 days after discharge. The most frequently dispensed antipsychotic after discharge was quetiapine (48.8%), followed by risperidone (34.4%), and olanzapine (7.3%). First generation antipsychotics represented only 9.6% of antipsychotic claims.
      Table 4Characteristics of NSSPP Beneficiaries Residing in LTC with an Antipsychotic Dispensation before a Fall-Related Hospitalization
      Study Population (n = 544)Antipsychotic Dispensed after HospitalizationAntipsychotic Not Dispensed after Hospitalization
      439 (80.7%)109 (20.0%)
      Female (%)344 (78.4)77 (70.6)
      Age, y
       66‒69 (%)27 (6.2)7 (6.4)
       70‒74 (%)35 (8.0)9 (8.3)
       75‒79 (%)73 (16.6)12 (11.0)
       80‒84 (%)115 (26.2)16 (14.7)
       85‒89 (%)110 (25.1)35 (32.1)
       90+ (%)79 (18.0)30 (27.5)
      Geographic location, urban (%)280 (63.8)68 (62.4)
      Length of stay in d, mean (range)19.58 (0-243)32.50 (0-899)
      Antipsychotic prior to hospitalization
       Quetiapine (%)223 (50.8)36 (33.0)
       Risperidone (%)154 (35.1)41 (37.6)
       Olanzapine (%)31 (7.1)6 (5.5)
       Haloperidol (%)9 (2.1)16 (14.7)
       Loxapine (%)5 (1.1)
       Other antipsychotics: trifluoperazine, methotrimeprazine, clozapine, perphenazine, pimozide, flupentixol, chlorpromazine, or prochlorperazine (%)17 (3.9)10 (9.2)
      Antipsychotic after hospitalization
       Quetiapine (%)214 (48.7)
       Risperidone (%)151 (34.4)
       Olanzapine (%)32 (7.3)
       Haloperidol (%)18 (4.1)
       Loxapine (%)8 (1.8)
       Other antipsychotics: trifluoperazine, methotrimeprazine, clozapine, perphenazine, pimozide, flupentixol, chlorpromazine, or prochlorperazine (%)16 (3.6)
      Multiple logistic regression analyzed the relationships between patient attributes and risk of continued antipsychotic dispensation post fall-related hospitalization and is summarized in Table 5. Female individuals were more likely to be dispensed an antipsychotic [OR 1.74, 95% CI (1.01, 2.94)] after fall-related hospitalization, as were those age 66‒69, 85‒79 and 80‒84 years compared with those age 90 years and older. Table 5 also includes the results of the multiple regression modeling stratified by sex; note these numbers should be taken with caution as sample sizes are small. There was a clear linear pattern in men demonstrating that continued dispensation was more common at younger ages, while this pattern did not hold for women.
      Table 5Characteristics Associated with Continuation of an Antipsychotic after a Fall-Related Hospitalization after Multiple Logistic Regression and Models Stratified by Sex
      VariableFull ModelFemaleMale
      OR95% CIOR95% CIOR95% CI
      Age
       66‒69 y4.59
      denotes P < .05.
      [1.4, 20.8]2.76[0.6, 13]49.03
      denotes P < .05.
      [3.3, >999]
       70‒74 y1.94[0.8, 4.9]1.63[0.5, 4.9]14.21
      denotes P < .05.
      [1.6, 185.9]
       75‒79 y2.8
      denotes P < .05.
      [1.3, 6.3]2.51
      denotes P < .05.
      [1, 6.3]16.19
      denotes P < .05.
      [1.9, 198.8]
       80‒84 y3.12
      denotes P < .05.
      [1.6, 6.4]3.2
      denotes P < .05.
      [1.4, 7.1]11.46
      denotes P < .05.
      [1.4, 131.7]
       85‒89 y1.29[0.7, 2.3]1.16[0.6, 2.2]6.52[0.9, 71]
       90+ y (referent)1.01.01.0
      Female1.74
      denotes P < .05.
      [1, 2.9]
      Urban0.95[0.6, 1.5]0.89[0.5, 1.5]1.06[0.4, 2.8]
      Days supplied
       <30 d (referent)1.01.01.0
       30‒60 d1.2[0.8, 1.9]0.91[0.5, 1.6]3.56
      denotes P < .05.
      [1.3, 10.8]
       60‒89 d0.8[0.2, 4.3]0.46[0.1, 2.9]8.94[0.4, 375.1]
       90+ d1.15[0.3, 5.3]1.2[0.2, 6]0.58[0, 18.6]
      Year of fall0.96[0.9, 1.1]0.94[0.8, 1.1]0.96[0.8, 1.2]
      Length of hospital stay
       0‒7 d (referent)1.01.01.0
       7‒14 d1.37[0.7, 2.7]0.71[0.4, 1.3]0.97[0.3, 3.2]
       14+ d0.79[0.5, 1.4]0.95[0.5, 2]5.86
      denotes P < .05.
      [1.4, 41.5]
      denotes P < .05.

      Discussion

      Findings: Objective 1

      We found 90% of antipsychotic dispensations to NSSPP beneficiaries over 66 years of age were to residents of LTC. Furthermore, nearly 40% of all LTC residents were dispensed at least 1 antipsychotic over the 8-year study period. In LTC the oldest age group was found to have the least proportion of antipsychotic dispensations. The proportion of men receiving antipsychotics was higher than women; however, the greater number of the women residing in LTC made the number of antipsychotics dispensations to women larger overall. In the first 2 years, risperidone was dispensed most frequently but quetiapine led antipsychotic dispensations over the final 6 years studied.

      Antipsychotic Prescribing in Other Jurisdictions

      Our study showed that antipsychotic dispensation to LTC residents in Nova Scotia, Canada exceeded many other Canadian and international jurisdictions. Previously we found that 6% of a predominantly community-dwelling cohort of older adults in Nova Scotia were dispensed at least 1 prescription for an antipsychotic over a 5-year period.
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      • Sketris I.S.
      Antipsychotic drug dispensations in older adults, including continuation after a fall-related hospitalization: identifying adherence to screening tool of older persons’ potentially inappropriate prescriptions criteria using the Nova Scotia Seniors’ Pharmacare Program and Canadian Institute for health’s discharge databases.
      We identified that the majority of these antipsychotic dispensations were to NSSPP beneficiaries who were LTC residents (90%). This exceeds other Canadian, Australian, and European estimates. In a 2009 study in Manitoba, Canada, a 20-fold difference in incident utilization of antipsychotics was found when comparing LTC-dwelling and community-dwelling older adults (21.09 vs 1.63 per 1000).
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      • Lundby C.
      • et al.
      Use of medication among nursing home residents: a Danish drug utilisation study.
      Reported differences in prevalence of antipsychotic dispensations in LTC may not solely reflect prescribing practices but may relate to measurement differences across studies or differences in the population in LTC across countries.

      Factors Related to Antipsychotic Dispensation in LTC

      Antipsychotic use in LTC has previously been shown to have an association with geographic variation, urbanicity, smaller county population, size of the facility, proximity to other LTC homes, certain resident characteristics, and staffing considerations, including access to recreation.
      • Chen Y.
      • et al.
      Unexplained variation across US nursing homes in antipsychotic prescribing rates.
      • Kleijer B.C.
      • et al.
      Variability between nursing homes in prevalence of antipsychotic use in patients with dementia.
      • Phillips L.J.
      • Birtley N.M.
      • Petroski G.F.
      • Siem C.
      • Rantz M.
      An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses.
      In the Netherlands, LTC residences with the highest use of antipsychotics were often large (>140 beds) and in urban communities.
      • Kleijer B.C.
      • et al.
      Variability between nursing homes in prevalence of antipsychotic use in patients with dementia.
      Rate ratios for antipsychotic use in Ontario, Canada LTC also demonstrated increased antipsychotic use in urban settings [rate ratio 1.03 95% CI (1.01‒1.04)] compared with rural sites [rate ratio 0.87 95% CI (0.79‒0.95)].
      • Rochon P.A.
      • et al.
      Variation in nursing home antipsychotic prescribing rates.
      Residents characteristics such as younger age, male sex, being married (χ2 = 12.62, P < .001), having dementia (Beta 1.22, P = .0004), having psychosis, being identified to have agitation, to be withdrawn from human interactions (t = 5.31, P < .001), and those with longer stays in LTC (F [2410] = 3.55, P < .05) contributed to increased antipsychotic use.
      • Alessi-Severini S.
      • Dahl M.
      • Schultz J.
      • Metge C.
      • Raymond C.
      Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases.
      ,
      • Willemse B.M.
      • et al.
      Is an unhealthy work environment in nursing home care for people with dementia associated with the prescription of psychotropic drugs and physical restraints?.
      Quetiapine dispensation was most common to LTC residents for most of the study period in our investigation, even though quetiapine is considered off-label treatment for adults with dementia in Canada.
      • Kelly M.
      • Dornan T.
      • Pringsheim T.
      The lesser of two evils: a qualitative study of quetiapine prescribing by family physicians.
      Similar to Nova Scotia, prescribing patterns of antipsychotics to residents of LTC in Manitoba, Canada also demonstrated risperidone as the most prevalent antipsychotic, followed by quetiapine.
      • Alessi-Severini S.
      • Dahl M.
      • Schultz J.
      • Metge C.
      • Raymond C.
      Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases.
      This is consistent with use reported in Scandinavian countries which identified quetiapine as the most prevalent antipsychotic.
      • Højlund M.
      • et al.
      Trends in utilization and dosing of antipsychotic drugs in Scandinavia: Comparison of 2006 and 2016.

      Findings: Objective 2

      Of the 544 LTC residents receiving continued antipsychotics within 100 days of a fall-related hospitalization, 80% had an antipsychotic dispensation in the 100 days after hospital discharge. In our sex stratified analysis, we showed that women age 75‒79 and 80‒84 years were most likely to continue an antipsychotic medication. Results for men showed that a younger age category (66‒84 years inclusive), a supply of 30‒60 days before the hospitalization, and a prolonged hospitalization were associated with antipsychotic continuation, suggesting that younger men (age category 66‒84 years) with complex care needs are more likely to remain on antipsychotics.

      Medication’s Place in Therapy Persists

      The perception remains among healthcare providers working in LTC settings that medications are among the optimal methods for managing behavioral and psychological symptoms of dementia.
      • Moth A.E.
      • Hølmkjær P.
      • Holm A.
      • Rozing M.P.
      • Overbeck G.
      What makes deprescription of psychotropic drugs in nursing home residents with dementia so challenging? a qualitative systematic review of barriers and facilitators.
      Contrary to this belief best evidence supports nonpharmacologic management strategies (eg, reminiscence and validation therapies, simulated presence therapy, aromatherapy, acupuncture, light therapy and cognitive training and rehabilitation) as the preferred treatment for managing responsive behaviors in older adults with dementia.
      • Kales H.C.
      • Gitlin L.N.
      • Lyketsos C.G.
      Assessment and management of behavioral and psychological symptoms of dementia.
      ,
      • Watt J.
      • Goodarzi Z.
      • Tricco A.C.
      • Veroniki A.A.
      • Straus S.E.
      Comparative safety and efficacy of pharmacological and non-pharmacological interventions for the behavioral and psychological symptoms of dementia: protocol for a systematic review and network meta-analysis.
      Health care professionals recognize deprescribing reduces the workload of medication administration but remain reluctant to deprescribe due to concerns of re-emergence of symptoms upon discontinuation.
      • Moth A.E.
      • Hølmkjær P.
      • Holm A.
      • Rozing M.P.
      • Overbeck G.
      What makes deprescription of psychotropic drugs in nursing home residents with dementia so challenging? a qualitative systematic review of barriers and facilitators.
      For some LTC residents cholinesterase inhibitors, which have modest effect in the management of behavioral symptoms in dementia but a more favorable adverse event profile than antipsychotics, may be an option. However, insurance coverage of these medications is influenced by regional reimbursement policies. In Nova Scotia, cholinesterase inhibitors required annual special authorization for access through the provincial drug insurance program. Similar restrictions exist in other Canadian provinces and territories, and internationally (eg, Australia, Taiwan, Finland).
      • Ilomäki J.
      • Lai E.C.-C.
      • Bell J.S.
      Using clinical registries, administrative data and electronic medical records to improve medication safety and effectiveness in dementia.
      More recently (after the data collection for this study) in Nova Scotia cholinesterase inhibitors have been made more accessible by removing special authorization requiremenets for access.
      When comparing the general population of NSSPP beneficiaries and those who reside in LTC the pattern in antipsychotic dispensation changes. Within the general population of NSSPP beneficiaries both men and women were more likely to be dispensed an antipsychotic at older ages. This pattern is reversed when looking only at beneficiaries who are residents of LTC. In LTC, both men and women become less likely to receive an antipsychotic as they age. Further research to better understand this relationship would be helpful.
      Bringing antipsychotic prescribing in line with prescribing guidelines will require intervention at the macro- and micro-levels
      • Spinewine A.
      • Evrard P.
      • Hughes C.
      Interventions to optimize medication use in nursing homes: a narrative review.
      using a systems approach.
      • Légaré F.
      • et al.
      Partnerships for knowledge translation and exchange in the context of continuing professional development.
      ,
      • Sketris I.S.
      • et al.
      Building a framework for the evaluation of knowledge translation for the Canadian Network for Observational Drug Effect Studies.
      At the micro-level organizational capacity, staffing levels, individual professional capacity, attitudes, communication and collaboration or teamwork, education, managerial expectations, and regulation or guidelines influence antipsychotic prescribing.
      • Langford A.V.
      • Chen T.F.
      • Roberts C.
      • Schneider C.R.
      Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: a scoping review.
      Legislation has greater evidence of impact on drug utilization than guidelines or recommendations at the macro-level.
      • Langford A.V.
      • Chen T.F.
      • Roberts C.
      • Schneider C.R.
      Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: a scoping review.
      A multicomponent intervention is likely the most appropriate approach. A Canadian Foundation for Healthcare Improvement (CFHI) multicenter intervention included workshops, webinars, and online learning resources. The CFHI intervention emphasized stakeholder engagement, person-centered approaches to care, and included mentoring of staff and team engagement. The intervention reduced antipsychotic use without indication in LTC residents and found no worsening of behaviors. They reported a 30% reduction in the odds of staying on antipsychotics in intervention sites compared with control sites.
      • Hirdes J.P.
      • et al.
      A Canadian cohort study to evaluate the outcomes associated with a multicenter initiative to reduce antipsychotic use in long-term care Homes.
      A pharmacist and physician team is another option to target potentially inappropriate antipsychotic use.
      • Stock K.J.
      • Amuah J.E.
      • Lapane K.L.
      • Hogan D.B.
      • Maxwell C.J.
      Prevalence of, and resident and facility characteristics associated with antipsychotic use in assisted living vs. long-term care facilities: a cross-sectional analysis from Alberta, Canada.
      An Ontario, Canada study employing a pharmacist-managed medication reconciliation program with a focus on potential medication discontinuation at transition to LTC improved medication costs, with savings estimated at $1414.52 per patient per year.
      • O’Donnell D.
      • et al.
      Cost impact of a pharmacist-driven medication reconciliation program during transitions to long-term care and retirement homes.
      Study authors reported the annual risk rate of hospitalization per patient (attributable risk/absolute risk reduction) for fall with fracture related to antipsychotic use varied from 2.3% to 8.18% dependent upon the antipsychotic used with a cost of $12,498.64 per event. If we conservatively apply this to our cohort we would anticipate 63 fall-related fractures costing the system approximately $789,000. This represents an avoidable cost that could be proactively managed with detailed medication review.

      Strengths

      A strength of our analysis is that most people in LTC in Nova Scotia are NSSPP beneficiaries. The study analyzes 8 years of administrative health data, which is sufficient to assess changing trends over time. The study accessed and linked multiple population registries and databases to allow study of falls from a health-system approach. The present study extends previous findings,
      • Vachon B.
      • et al.
      A concept analysis and meta-narrative review established a comprehensive theoretical definition of replication research to improve its use.
      which evaluated dispensation of antipsychotics to older adults in Nova Scotia without consideration of the location of residence. Identifying the location of residence, in particular the residence in LTC, allows an assessment of the distribution of antipsychotic prescribing within community-dwelling older adults and those who reside in LTC.
      • Trenaman S.C.
      • Hill-Taylor B.J.
      • Matheson K.J.
      • Gardner D.M.
      • Sketris I.S.
      Antipsychotic drug dispensations in older adults, including continuation after a fall-related hospitalization: identifying adherence to screening tool of older persons’ potentially inappropriate prescriptions criteria using the Nova Scotia Seniors’ Pharmacare Program and Canadian Institute for health’s discharge databases.

      Limitations

      Multiple funding models for LTC in NS exist in rural and urban settings.
      Long Term Care. novascotia.ca.
      Differences in the types of facilities are vast, including ownership model, bed number, recreation supports available, facility work environment, caregiver hours, staffing levels, skill mix, expertise or experience of staff, access to geriatricians or other physicians with expertise in the care of older adults (eg, geriatric psychiatry or care of older persons trained family physicians), presence of dementia units, or funding structure (private, public, or not for profit). These differences may impact patterns of antipsychotic use in Nova Scotia LTC homes. Additional limitations of the analysis include an inability to identify indication or other patient specific factors such as behavioral symptoms, marital status, use of physical restraint, total number of medications, or use of specific medications (benzodiazepines, antidepressants, or cholinesterase inhibitors), withdrawal from daily activities, length of stay in LTC or prescriber. As with any study of drug dispensation using administrative data we cannot determine if the medication was taken as dispensed, although this may be more likely in the supported environment of LTC. As we only report first prescription in any year we cannot identify if the dose was being tapered or was discontinued after initiation.
      These findings support continued discussion with the provincial health regulators to highlight the prevalence of antipsychotic dispensation to long-term care residents and to develop strategies to ensure appropriateness of antipsychotic dispensation in this setting. Although a goal level of antipsychotic use is challenging to predict, continued decrease in antipsychotic dispensations year after year suggests that further decreases are possible.

      Conclusions

      Antipsychotic dispensation to LTC residents, in particular dispensation of second-generation agents quetiapine and risperidone, is potentially inappropriate across many jurisdictions including NS. Even with the prompt of a fall-related hospitalization, antipsychotic medications were continued 80% of the time in our region. This reflects a lost opportunity for harm-reduction. Further study is needed to support the development of strategies to encourage regular evaluation of antipsychotic medications among residents of LTC. Strategies to support deprescribing of potentially inappropriate antipsychotics and enable nonpharmacologic management of responsive behaviors are integral to improving care of this vulnerable patient population.

      Acknowledgments

      The data used in this report were made available by Health Data Nova Scotia of Dalhousie University. Although this research is based on data obtained from the Nova Scotia Department of Health and Wellness, the observations and opinions expressed are those of the authors and do not represent those of either Health Data Nova Scotia or the Department of Health and Wellness. The Drug Evaluation Alliance of Nova Scotia (DEANS) provided funding for this project but had no role in the study design, data collection, data analysis, data interpretation, writing and approving the report, or the decision to submit for publication. We acknowledge the Canadian Network for Observational Drug Effect Studies (CNODES) for their provision of our drug codes using the WHO ATC system.

      Appendix A. Generic Drug names and Anatomic Therapeutic Classification Codes for Antipsychotic Medications

      Tabled 1
      NameATC Code
      chlorpromazineN05AA01
      levomepromazineN05AA02
      promazineN05AA03
      acepromazineN05AA04
      triflupromazineN05AA05
      cyamemazineN05AA06
      chlorproethazineN05AA07
      dixyrazineN05AB01
      fluphenazineN05AB02
      perphenazineN05AB03
      prochlorperazineN05AB04
      thiopropazateN05AB05
      trifluoperazineN05AB06
      acetophenazineN05AB07
      thioproperazineN05AB08
      butaperazineN05AB09
      perazineN05AB10
      periciazineN05AC01
      thioridazineN05AC02
      mesoridazineN05AC03
      pipotiazineN05AC04
      haloperidolN05AD01
      trifluperidolN05AD02
      melperoneN05AD03
      moperoneN05AD04
      pipamperoneN05AD05
      bromperidolN05AD06
      benperidolN05AD07
      droperidolN05AD08
      fluanisoneN05AD09
      oxypertineN05AE01
      molindoneN05AE02
      sertindoleN05AE03
      ziprasidoneN05AE04
      lurasidoneN05AE05
      flupentixolN05AF01
      clopenthixolN05AF02
      chlorprothixeneN05AF03
      tiotixeneN05AF04
      zuclopenthixolN05AF05
      fluspirileneN05AG01
      pimozideN05AG02
      penfluridolN05AG03
      loxapineN05AH01
      clozapineN05AH02
      olanzapineN05AH03
      quetiapineN05AH04
      asenapineN05AH05
      clotiapineN05AH06
      sulpirideN05AL01
      sultoprideN05AL02
      tiaprideN05AL03
      remoxiprideN05AL04
      amisulprideN05AL05
      veraliprideN05AL06
      levosulpirideN05AL07
      prothipendylN05AX07
      risperidoneN05AX08
      mosapramineN05AX10
      zotepineN05AX11
      aripiprazoleN05AX12
      paliperidoneN05AX13
      iloperidoneN05AX14
      cariprazineN05AX15
      brexpiprazoleN05AX16
      pimavanserinN05AX17

      Appendix B. Characteristics of NSSPP Beneficiaries 66 Years of Age and Older Residing in LTC in Fiscal Years 2009 through 2016

      Tabled 1
      Fiscal Year20092010201120122013201420152016
      NSSPP beneficiaries, n95,26197,16298,754101,573104,906107,668110,286113,350
      NSSPP beneficiaries 66 y of age and older residing in LTC, n (% all NSSPP beneficiaries)6629 (7.0)7040 (7.2)7086 (7.2)6990 (6.9)6976 (6.6)6784 (6.3)6574 (5.9)6452 (5.7)
      Female NSSPP beneficiaries residing in LTC, n (% of LTC residents)5061 (76.4)5361 (76.2)5397 (76.2)5245 (75.0)5222 (74.6)5058 (74.6)4884 (74.3)4758 (73.7)
      NSSPP beneficiaries residing in LTC by age, in y, n (% of all LTCF residents)
       66‒69 (% of all LTC residents)354 (5.3)383 (5.4)407 (5.7)424 (6.1)441 (6.3)417 (6.2)422 (6.4)431 (6.7)
       70‒74 (% of all LTC residents)585 (8.8)599 (8.5)575 (8.1)549 (7.9)560 (8.0)572 (8.4)613 (9.3)598 (9.3)
       75‒79 (% of all LTC residents)976 (14.7)987 (14.0)952 (13.4)929 (13.3)899 (12.9)820 (12.1)838 (12.8)856 (13.3)
       80‒84 (% of all LTC residents)1384 (20.9)1517 (22.7)1538 (21.7)1482 (21.2)1401 (20.1)1362 (20.1)1321 (20.1)1213 (18.8)
       85‒89 (% of all LTC residents)1530 (23.1)1599 (22.7)1616 (22.8)1565 (22.4)1630 (23.4)1581 (23.3)1476 (22.5)1469 (22.8)
       90+ (% of all LTC residents)1800 (27.2)1955 (27.8)1998 (28.2)2041 (29.2)2045 (29.3)2032 (30.0)1904 (29.0)1885 (29.2)
      NSSPP beneficiaries residing in LTC and receiving at least 1 dispensation for an antipsychotic, n (% of all LTC residents)2697 (40.7)2756 (39.1)2725 (38.5)2673 (38.2)2637 (37.8)2642 (38.9)2620 (39.9)2525 (39.1)
       Women, n (% NSSPP beneficiaries residing in LTC receiving an antipsychotic)1954 (72.4)1996 (72.4)1950 (71.6)1878 (70.3)1842 (69.9)1844 (69.8)1822 (69.5)1720 (68.1)
       Men, n (% NSSPP residing in LTC receiving an antipsychotic)743 (27.6)760 (27.6)775 (28.4)795 (29.7)795 (30.1)798 (30.2)798 (30.5)805 (31.9)
      NSSPP beneficiaries residing in LTC receiving at least 1 dispensation for an antipsychotic by age, in y, n (% NSSPP beneficiaries residing in LTC by age)
       66‒69 (% of LTC residents of age group)194 (54.8)201 (52.5)213 (52.3)233 (55.0)241 (54.6)227 (54.4)242 (57.3)245 (56.8)
       70‒74 (% of LTC residents of age group)292 (49.9)297 (49.6)288 (50.1)297 (54.1)291 (51.9)322 (56.3)322 (52.5)310 (51.8)
       75‒79 (% of LTC residents of age group)473 (48.5)465 (47.1)454 (47.7)430 (46.3)420 (46.7)394 (48.0)400 (47.7)396 (46.3)
       80‒84 (% of LTC residents of age group)574 (41.5)593 (39.1)608 (39.5)602 (40.6)553 (39.5)546 (40.1)561 (42.5)488 (40.2)
       85‒89 (% of LTC residents of age group)572 (37.4)592 (37.0)570 (35.3)514 (32.8)525 (32.2)554 (35.0)543 (36.8)570 (38.8)
       90+ (% of LTC residents of age group)592 (32.9)608 (31.1)592 (29.3)597 (29.3)607 (29.7)599 (29.5)552 (29.0)516 (27.4)
      Antipsychotic dispensation in urban location, by postal code, n (% of all urban beds)1713 (85.1)1744 (81.3)1730 (79.5)1703 (76.9)1688 (73.6)1687 (72.9)1699 (71.7)1609 (61.8)
      Antipsychotic dispensation in rural location, by postal code, n (% of all rural beds)984 (88.2)1012 (80.4)995 (79.5)970 (76.7)949 (76.9)955 (71.2)921 (71.0)916 (57.9)
      NSSPP beneficiaries 66 years of age and older residing in a LTC represented 7% and 5.7% of all NSSPP beneficiaries for the years 2009 and 2016, respectively.

      Appendix C. Dose and Duration of Antipsychotic Use Based on Dispensation Data

      Figure thumbnail fx1
      Figure thumbnail fx2
      Figure thumbnail fx3
      Tabled 1
      Dosing Over Time, by Drug - Mean (n; [CI])
      Drug Name20092010201120122013201420152016
      quetiapine70.7 (1047; [65.5, 75.9])66.9 (1211; [62.1, 71.7])63.2 (1312; [58.9, 67.5])65.4 (1347; [61, 69.8])64.7 (1394; [60.2, 69.2])64.5 (1352; [59.9, 69.1])60.8 (1389; [56.9, 64.7])57.8 (1608; [54.3, 61.3])
      risperidone0.8 (1378; [0.7, 0.9])0.8 (1322; [0.8, 0.8])0.8 (1260; [0.8, 0.8])0.8 (1142; [0.7, 0.9])0.8 (1142; [0.8, 0.8])0.8 (1225; [0.7, 0.9])0.8 (1132; [0.8, 0.8])0.8 (1338; [0.8, 0.8])
      haloperidol3.4 (192; [2.7, 4.1])4.9 (285; [3.9, 5.9])8 (289; [6.7, 9.3])9.8 (422; [8.5, 11.1])10.3 (454; [9.1, 11.5])11.6 (555; [10.5, 12.7])10.5 (577; [9.3, 11.7])10.4 (597; [9.5, 11.3])
      olanzapine9.3 (204; [8.3, 10.3])9.2 (205; [8.3, 10.1])9.4 (226; [8.4, 10.4])10 (217; [8.9, 11.1])9.2 (213; [8.2, 10.2])8.6 (225; [7.7, 9.5])9.6 (209; [8.6, 10.6])9.1 (248; [8.2, 10])
      levomepromazine or methoprazin19 (74; [13.9, 24.1])36.5 (111; [25.6, 47.4])49.4 (121; [37.7, 61.1])58.8 (85; [46, 71.6])69.1 (102; [54.7, 83.5])69.7 (117; [55.9, 83.5])49.3 (150; [42.2, 56.4])57.3 (208; [48.6, 66])
      prochlorperazine16 (44; [11.9, 20.1])22.2 (81; [19.3, 25.1])15.9 (41; [13.2, 18.6])18.8 (68; [16.4, 21.2])25.3 (45; [19.1, 31.5])16.3 (18; [11.4, 21.2])19.2 (49; [15.4, 23])17.1 (24; [11.8, 22.4])
      loxapine15.3 (50; [10.8, 19.8])20.1 (47; [14.1, 26.1])17.4 (44; [13.8, 21])12.2 (56; [9.4, 15])19 (35; [13, 25])22.1 (35; [14, 30.2])21 (37; [15.2, 26.8])22.5 (45; [14.6, 30.4])
      perphenazin6.7 (44; [5.3, 8.1])5.6 (52; [4.4, 6.8])6.8 (31; [5.1, 8.5])6.6 (36; [5.2, 8])7.8 (31; [6.2, 9.4])7.5 (26; [5.7, 9.3])8.1 (30; [6.4, 9.8])8.6 (5; [2.9, 14.3])
      chlorpromazin90.4 (33; [63.1, 117.7])91.4 (43; [65.1, 117.7])108.8 (37; [75.5, 142.1])111.2 (32; [80.4, 142])95.6 (31; [66.8, 124.4])133.4 (24; [88.6, 178.2])135.3 (22; [80.4, 190.2])166.7 (30; [124.4, 209])
      trifluoperazine16.6 (25; [11.8, 21.4])16.9 (24; [11.5, 22.3])11.2 (30; [6.9, 15.5])12.6 (21; [7.6, 17.6])13.4 (33; [9.5, 17.3])14 (29; [9.3, 18.7])16.6 (22; [11.1, 22.1])13.3 (28; [9.1, 17.5])
      flupentixol20.3 (10; [1, 39.6])10.9 (7; [−2.1, 23.9])10.2 (13; [3.2, 17.2])12.1 (17; [4.9, 19.3])6.2 (13; [3.9, 8.5])15.7 (12; [0.5, 30.9])18.4 (14; [0.2, 36.6])18.9 (16; [3, 34.8])
      fluphenazin47.4 (15; [23.6, 71.2])7 (5; [4.6, 9.4])7.6 (7; [5.6, 9.6])18.8 (13; [4.6, 33])6.5 (12; [5.1, 7.9])8.2 (13; [3.6, 12.8])8.4 (11; [4.2, 12.6])8.9 (10; [5.7, 12.1])
      clozapine75 (<5; [25.9, 124.1])75 (<5; [25.9, 124.1])283.3 (9; [140, 426.6])137.5 (6; [36.5, 238.5])125 (7; [36.2, 213.8])161.1 (9; [42.1, 280.1])262.5 (6; [116.2, 408.8])177.5 (10; [96, 259])
      pimozide3.2 (6; [2.2, 4.2])3.7 (6; [3.1, 4.3])3.6 (5; [2.8, 4.4])3.3 (7; [2.6, 4])3.3 (<5; [2.3, 4.3])4.8 (<5; [2.6, 7])6 (6; [3.2, 8.8])6.4 (5; [3.1, 9.7])
      aripiprazole10 (<5; [10, 10])7.5 (<5; [NA, NA])5 (6; [2.2, 7.8])7.6 (7; [3.2, 12])8.9 (6; [3.2, 14.6])7.1 (9; [3, 11.2])
      zuclopenthixol14.3 (<5; [NA, NA])139.4 (<5; [-51.6, 330.4])45.8 (<5; [4.9, 86.7])25 (<5; [NA, NA])
      periciazine43.3 (<5; [26, 60.6])50 (<5; [30.5, 69.5])15 (<5; [NA, NA])
      paliperidone100 (<5; [NA, NA])3.6 (<5; [NA, NA])3.6 (<5; [3.6, 3.6])
      Supply over time, by drug - mean (n; [CI]).

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