Perceptions vs. evidence: therapeutic substitutes for antipsychotics in patients with dementia in long-term care.

OBJECTIVE: To compare differences between clinician perceptions of therapeutic substitutes for antipsychotics prescribed to patients with dementia in long term care (LTC) and published evidence. METHODS: A mixed-methods approach that included a drug information search, online survey of 55 LTC clinicians and a comprehensive literature review was used. For 41 pharmacologic antipsychotic substitute candidates identified, LTC clinicians rated the likelihood they would substitute each for patients with dementia and identified non-pharmacologic antipsychotic substitutes. The quality of evidence supporting the most likely antipsychotic substitutes was assessed using a modified GRADE approach. RESULTS: Among 36 (65%) of LTC clinicians responding, the pharmacologic candidates deemed likely or somewhat likely to be substituted for an antipsychotic were: valproic acid, serotonin modulator antidepressants, short-acting benzodiazepines, serotonin reuptake inhibitor antidepressants, alpha-adrenoceptor antagonist, buspirone, acetaminophen, serotonin-norepinephrine reuptake inhibitor antidepressants, memantine, and a cholinesterase inhibitor. High quality evidence supporting these substitutions existed for only memantine and cholinesterase inhibitors, while high quality evidence cautioning against this substitution existed for valproic acid. Activities and music therapy were the most commonly cited non-pharmacologic substitutes but the supporting evidence for each is sparse. CONCLUSION: Perceptions of LTC clinicians regarding substitutes for antipsychotics in LTC patients with dementia vary widely and are often discordant with published evidence.

Associations between State-Level High School HIV Education Policies and Adolescent HIV Risk Behaviors.

BACKGROUND: School-based human immunodeficiency virus (HIV) education can reach most adolescents, but inconsistencies exist in state-level content policies. The purpose of this study was to evaluate the associations between state-level high school HIV education policies and adolescent HIV risk behaviors. METHODS: This was a cross-sectional analysis of the 2019 Youth Risk Behavior Survey linked to the Guttmacher Institute Sex and HIV Education report. Logistic regression models examined the associations of state-level HIV education mandates and content policies with 3 HIV risk behaviors: (1) 4 or more lifetime sexual partners; (2) substance use before last sex; (3) condomless last sex. RESULTS: Across 33 states, 128,986 high school students were included. Multivariable adjusted models demonstrated no associations between mandated HIV education and risk behaviors. Covering abstinence along with other safe sex options was associated with lower odds, whereas stressing abstinence was associated with higher odds of at least 4 lifetime sexual partners and condomless last sex. Discriminatory sexual orientation content was associated with increased condomless last sex; associations for all HIV risk behaviors were stronger among sexual minority youth. CONCLUSIONS: Increased HIV risk behaviors associated with state policies stressing abstinence or requiring discriminatory sexual orientation content support the need for comprehensive and inclusive HIV education.

Psychoactive medication therapy and delirium screening in skilled nursing facilities.

BACKGROUND: A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use. METHODS: This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay. RESULTS: Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition. CONCLUSION: In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs.

Beyond the Health Deficit Count: Examining Deficit Patterns in a Deficit-Accumulation Frailty Index.

BACKGROUND/OBJECTIVES: Exploring deficit patterns among frail people may reveal subgroups of different prognostic importance. DESIGN: Analysis of National Health and Aging Trends Study. SETTING: Community. PARTICIPANTS: Community dwelling older adults with mild to moderate frailty (deficit-accumulation frailty index (FI) of 0.25-0.40) (n = 1821). MEASUREMENTS: Latent class analysis identified distinct clinical subgroups based on comorbidity (range: 0-10), National Health and Aging Trends Study dementia classification, and short physical performance battery (SPPB) (range: 0-12). Survival analyses compared 5-year mortality by subgroups. RESULTS: Three latent classes existed: Class 1 (n = 831, mean FI = 0.30) had 2.7% probable dementia, high comorbidities (mean = 3.6), and low physical impairment (SPPB mean = 9.9); Class 2 (n = 734, mean FI = 0.32) had 6.9% probable dementia, low comorbidities (mean = 2.8), and moderate physical impairment (SPPB mean = 6.2); Class 3 (n = 256, mean FI = 0.34) had 20.7% probable dementia, low comorbidities (mean = 2.4), and high physical impairment (SPPB mean = 2.0). Compared to Class 1, Classes 2 and 3 experienced higher 5-year mortality (C2: 1.28 (95% confidence intervals (CI) = 1.00-1.62); C3: 1.87 (95% CI = 1.29-2.73)). CONCLUSION: Deficit patterns among the mild-to-moderately frail provide additional prognostic information and highlight opportunities for preventive interventions.

Economic Barriers to Antiretroviral Therapy in Nursing Homes.

OBJECTIVES: Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs. DESIGN: A cross-sectional study. SETTING: NHs. PARTICIPANTS: A total of 694 newly admitted long-stay (>100 d) NH residents with HIV. MEASUREMENTS: We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk-adjusted generalized estimating equation logistic models. RESULTS: All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24-.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20-1.88). CONCLUSION: People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777-782, 2020.

Access to HIV Medication in the Community Versus a Nursing Home for the Medicare Eligible HIV population.

Access to appropriate antiretroviral therapy (ART) is key to people living with HIV/AIDS (PLWH) living a near normal life time, which has resulted in increasing numbers of PLWH requiring nursing home care for age-related reasons. However, one study found that 21% of Medicare eligible PLWH in US nursing homes between 2011 and 2013 were not dispensed ART through the nursing home pharmacy. Cost-sharing assistance programs exist to facilitate access to medications for low-income community dwelling older adults, but these programs do not necessarily extend to people admitted to a nursing home, which may cause interruptions in access to ART for PLWH in this setting. Policies may need to be updated to reduce drug-related financial burden to PLWH and nursing homes in order to maintain continued access to ART in the nursing home setting.

The Effect of PrEP on HIV Incidence Among Men Who Have Sex With Men in the Context of Condom Use, Treatment as Prevention, and Seroadaptive Practices.

BACKGROUND: HIV preexposure prophylaxis (PrEP) is an effective tool in preventing HIV infection among high-risk men who have sex with men (MSM). It is unknown how effective PrEP is in the context of other implemented HIV prevention strategies, including condom use, seroadaption, and treatment as prevention (TasP). We evaluate the impact of increasing uptake of PrEP in conjunction with established prevention strategies on HIV incidence in a high-risk population of MSM through simulation. METHODS: Agent-based simulation models representing the sexual behavior of high-risk, urban MSM in the United States over the period of 1 year were used to evaluate the effect of PrEP on HIV infection rates. Simulations included data for 10,000 MSM and compared increasing rates of PrEP uptake under 8 prevention paradigms: no additional strategies, TasP, condom use, seroadaptive behavior, and combinations thereof. RESULTS: We observed a mean of 103.2 infections per 10,000 MSM in the absence of any prevention method. PrEP uptake at 25% without any additional prevention strategies prevented 30.7% of infections. In the absence of PrEP, TasP, condom use, and seroadaptive behavior independently prevented 27.1%, 48.8%, and 37.7% of infections, respectively, and together prevented 72.2%. The addition of PrEP to the 3 aforementioned prevention methods, at 25% uptake, prevented an additional 5.0% of infections. CONCLUSIONS: To achieve a 25% reduction in HIV infections by 2020, HIV prevention efforts should focus on significantly scaling up access to PrEP in addition to HIV testing, access to antiretroviral therapy, and promoting condom use.

Screening Tool of Older Person's Prescriptions/Screening Tools to Alert Doctors to Right Treatment Medication Criteria Modified for U.S. Nursing Home Setting.

OBJECTIVES: To develop a set of prescribing indicators measurable with available data from electronic nursing home (NH) databases by adapting the European-based 2014 Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tools to Alert Doctors to Right Treatment (START) criteria of potentially inappropriate and underused medications for the U.S. DESIGN: A two-stage expert panel process. In the first stage, the investigator team reviewed 114 criteria for compatibility and measurability. In the second stage, an online modified e-Delphi (OMD) panel was convened to rate the validity of criteria, and two webinars were held to identify criteria with highest relevance to U.S. NHs. PARTICIPANTS: Seventeen experts with recognized reputations in NH care participated in the e-Delphi panel and 12 in the webinar. MEASUREMENTS: Compatibility and measurability were assessed by comparing criteria with U.S. terminology and setting standards and data elements in NH databases. Validity was rated using a 9-point Likert-type scale (1 = not valid at all, 9 = highly valid). Mean, median, interpercentile ranges, and agreement were determined for each criterion score. Relevance was determined by ranking the mean panel ratings on criteria that reached agreement; the webinar participants reviewed and approved half of the criteria with the highest mean values. RESULTS: Fifty-three STOPP/START criteria were deemed to be compatible with the U.S. NH setting and measurable using data from electronic NH databases. E-Delphi panelists rated 48 criteria as valid for U.S. NHs. Twenty-four criteria were deemed to be most relevant, consisting of 22 measures of potentially inappropriate medications and two measures of underused medications. CONCLUSION: This study created the first explicit criteria for assessing the quality of prescribing in U.S. NHs.