Factors Associated with Psychotropic Medication Use in People Living with Dementia in the Community: A Systematic Review and Meta-Analysis.

BACKGROUND: There has been considerable focus on the use of psychotropic agents in people living with dementia in long-term care. However, psychotropic use often commences well before transitioning to long-term care. OBJECTIVES: To synthesize the available literature to identify factors associated with psychotropic medication use in people living with dementia in the community. METHODS: This PROSPERO-registered review reports findings from a comprehensive search of Embase, PsycINFO, and PubMed (including MEDLINE) databases according to predefined inclusion and exclusion criteria (2010-2022). Inclusion criteria were original prospective or retrospective design research papers enrolling people diagnosed with dementia utilizing a psychotropic medication and living at home. Quality and risk of bias was assessed Newcastle-Ottawa Quality Assessment Scale. The last search was conducted in November 2022. Thematic analysis was used to synthesize the emergent factors identified, and a meta-analysis was undertaken on suitable data. RESULTS: The search identified 619 articles. After review and exclusions, 39 articles were included for synthesis, including 1,338,737 people. The majority of papers (67%) were rated as low risk of bias and corresponding good quality. Thematic analysis suggested associations between psychotropic prescribing and patient and environmental factors, with little data concerning carer and prescriber factors. Such factors included age (< 75 years, > 90 years), sex, more advanced functional decline, and living alone. Meta-analysis identified significant associations between psychotropic use and respite (temporary full-time care or hospitalization) and comorbid psychiatric illness. CONCLUSIONS: While it is clear from this review that there remains a significant lack of clarity as to the reasons why these medications are being utilized in this population, this review provides greater insight and understanding into the context of psychotropic use. The study has highlighted an opportunity for further targeted research to be conducted and provides a much-needed context for this to occur. PROSPERO REGISTRATION NUMBER: CRD42021286322.

Medication-Related Complaints in Residential Aged Care.

Complaints reflect a person's or family's experience within the aged care system and provide important insight into community expectations and consumer priorities. Crucially, when aggregated, complaints data can serve to indicate problematic trends in care provision. Our objective was to characterize the areas of medication management most frequently complained about in Australian residential aged care services from 1 July 2019 to 30 June 2020. A total of 1134 complaint issues specifically referenced medication use. Using content analysis, with a dedicated coding framework, we found that 45% of these complaints related to medicine administration processes. Three categories received nearly two thirds of all complaints: (1) not receiving medication at the right time; (2) inadequate medication management systems; and (3) chemical restraint. Half of the complaints described an indication for use. These were, in order of frequency: 'pain management', 'sedation', and 'infectious disease/infection control'. Only 13% of medication-related complaints referred to a specific pharmacological agent. Opioids were the most common medication class referred to in the complaint dataset, followed by psychotropics and insulin. When compared to complaint data composition overall, a higher proportion of anonymous complaints were made about medication use. Residents were significantly less likely to lodge complaints about medication management, probably due to limited engagement in this part of clinical care provision.

Antipsychotic prescribing in people admitted to hospital with dementia or delirium.

OBJECTIVE: To evaluate antipsychotic prescribing in people with dementia or delirium admitted to a large regional Queensland hospital. METHODS: A retrospective observational study analysing medical records of patients prescribed antipsychotics over 6 months. RESULTS: We audited a sample of 141 patients, 65 years or over (over 45 years for indigenous peoples) with dementia or delirium, without severe mental illness, prescribed antipsychotics. Over a third (35%) were prescribed antipsychotics prior to admission, with 73% prescribed a new antipsychotic in hospital. Only 23% received documented review of antipsychotic therapy. Under half (48%) had evidence of non-pharmacological interventions as first-line management. Sixty-eight patients (48%) were discharged with antipsychotics; however, only 4% were provided an antipsychotic management plan. CONCLUSIONS: Initiation and continuation of antipsychotics in patients with dementia or delirium in hospital is common, with infrequent review. There is significant potential to reduce prescribing antipsychotics in people admitted to hospital with dementia or delirium.

Clinical impact of antipsychotic and benzodiazepine reduction: findings from a multicomponent psychotropic reduction program within long-term aged care.

OBJECTIVES: To explore the relationships between dose changes to antipsychotic and/or benzodiazepine medications and resident outcomes, including variations in neuropsychiatric symptoms, quality of life (QoL), and social withdrawal, within a multicomponent, interdisciplinary antipsychotic and benzodiazepine dose reduction program. DESIGN: Prospective, observational, longitudinal study. INTERVENTION: The Reducing Use of Sedatives (RedUSe) project involved 150 Australian Long-Term Care Facilities (LTCFs) incorporating auditing and benchmarking of prescribing, education, and multidisciplinary sedative reviews. SETTING: A convenience sample of LTCFs (n = 28) involved in RedUSe between January 2015 and March 2016. PARTICIPANTS: Permanent residents (n = 206) of LTCFs involved in RedUSe taking an antipsychotic and/or benzodiazepine daily. Residents were excluded if they had a severe psychiatric condition where antipsychotic therapy should generally be maintained long-term (e.g., bipolar disorder, schizophrenia) or were considered end-stage palliative. MEASUREMENTS: Neuropsychiatric symptoms (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory (CMAI)), QoL (Assessment of Quality of Life-4D), and social withdrawal (Multidimensional Observation Scale for Elderly Subjects-withdrawal subscale) were measured at baseline and 4 months where nursing staff completed psychometric tests as proxy raters. RESULTS: There was no evidence that psychometric measures were worsened following dose reductions. In fact, dose reduction was associated with small, albeit non-statistically significant, improvements in behavior, particularly less physically non-aggressive behavior with both drug groups (-0.36 points per 10% reduction in antipsychotic dose, -0.17 per 10% reduction in benzodiazepine dose) and verbally agitated behavior with benzodiazepine reduction (-0.16 per 10% dose reduction), as measured with the CMAI. Furthermore, antipsychotic reduction was associated with non-statistically significant improvements in QoL and social withdrawal. CONCLUSIONS: Antipsychotic and benzodiazepine dose reduction in LTCFs was not associated with deterioration in neuropsychiatric symptoms, QoL, or social withdrawal. Trends toward improved agitation with antipsychotic and benzodiazepine dose reduction require further evaluation in larger, prospective, controlled studies.