Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease.

BACKGROUND: In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long-stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. METHODS: Using an 80% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time-series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011-June 30, 2012) and after (July 1, 2012-September 30, 2015) ARI implementation. RESULTS: We identified 874,487 long-stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI-associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI-associated increases in non-benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post-ARI membership in the psychosis and Parkinson's cohorts. CONCLUSIONS: Our study documents antipsychotic use significantly declined in non-ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI-associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make-up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Examining transitions of care among nursing home residents with and without antipsychotic medication use.

OBJECTIVES: This study examines the association between antipsychotic (AP) medication use and care transitions in the nursing home (NH) population. METHODS: This cross-sectional study used data from a 5% random sample of Medicare beneficiaries between 2011 and 2015. Propensity score adjusted negative binomial regression was performed and conditional probabilities of having a first transition from the NH to specific locations were calculated. RESULTS: Among 150,284 eligible beneficiaries, the majority were female (67%), white (84%), and >75 years old (63%). Controlling for resident characteristics, the odds of having any transition was 5% lower among those with AP use [IRR (95% confidence interval (CI))=0.95(0.94-0.96)] relative to those with no AP use. Residents with AP use had higher proportions of transitions to hospital (22.7% vs. 19.5%, p < 0.01), emergency department (19.6% vs. 10.7%, p < 0.01), and different NH (1.5% vs. 0.4%, p < 0.01), and lower proportions of transition to non-healthcare locations compared to those without AP use. CONCLUSIONS: Findings demonstrate that residents with AP use had higher probabilities of transitions to more costly care settings such as the emergency department and hospital compared to those without AP use. Future longitudinal studies will help to inform clinical interventions aimed at improving the quality of care for this population.

Substance Use Disorders in Postacute and Long-Term Care Settings.

Substance use disorders (SUDs) have not been rigorously studied in postacute and long-term care (PALTC) populations. SUDs are among the fastest growing disorders in the community dwelling older population. Untreated SUDs often lead to overdose deaths, emergency department visits, and hospitalizations due to SUD-related adverse effects, especially exacerbation of comorbid physical and mental health conditions. Primary care providers (PCPs) working in PALTC settings can and should play a key role in its prevention and treatment. This clinical review identifies several practical strategies that PCPs can incorporate in their daily practice to improve lives of PALTC population having SUD.

Screening for and Management of Opioid Use Disorder in Older Adults in Primary Care.

Opioid use disorder (OUD) is commonly seen in older adults in primary care offices. OUD when left untreated, often leads to overdose deaths, emergency department visits, and hospitalizations due to opioid-related adverse effects, especially respiratory and central nervous system depression. Primary care providers are on the front lines of efforts for its prevention, early detection, and treatment. This includes using the lowest doses of opioids for the shortest possible time for management of pain, routine screening, brief intervention, opioid withdrawal management, prescription of naloxone to prevent overdose death, and treatment with medications and psychosocial interventions for OUD. Referral to addiction treatment centers may be needed in complex cases. This review explores the epidemiology, screening, as well as management of OUD as it pertains to the elderly population.

Reforming Management of Behavior Symptoms and Psychiatric Conditions in Long-Term Care Facilities: A Different Perspective.

Despite much attention including national initiatives, concerns remain about the approaches to managing behavior symptoms and psychiatric conditions across all settings, including in long-term care settings such as nursing homes and assisted living facilities. One key reason why problems persist is because most efforts to "reform" and "correct" the situation have failed to explore or address root causes and instead have promoted inadequate piecemeal "solutions." Further improvement requires jumping off the bandwagon and rethinking the entire issue, including recognizing and applying key concepts of clinical reasoning and the care delivery process to every situation. The huge negative impact of cognitive biases and rote approaches on related clinical problem solving and decision making and patient outcomes also must be addressed.

Behavioral disturbance in dementia.

Behavioral disturbances are frequently the most challenging manifestations of dementia and are exhibited in almost all people with dementia. Common behavioral disturbances can be grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep disorders (insomnia, hypersomnia, night-day reversal); psychotic symptoms (delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual disinhibition, aggression). They are often persistent, greatly diminish quality of life of patients and their family caregivers, cause premature institutionalization, and pose a high economic burden on the patient, family, and society. Behavioral disturbances can be prevented and treated with a multifaceted approach that supports dignity and promotes comfort and quality of life of persons with dementia and their family members. Management involves prompt treatment of reversible factors and management of symptoms using primarily individualized nonpharmacological interventions. Pharmacological interventions need to be restricted to behavioral emergencies and for short-term treatment of behavioral disturbances that pose imminent danger to self or others.

Revitalizing the aged brain.

Optimal cognitive and emotional function is vital to independence, productivity, and quality of life. Cognitive impairment without dementia may be seen in 16% to 33% of adults older than 65 years, and is associated with significant emotional distress. Cognitive and emotional well-being are inextricably linked. This article qualifies revitalizing the aged brain, discusses neuroplasticity, and suggests practical neuroplasticity-based strategies to improve the cognitive and emotional well-being of older adults.

Healthy brain aging: a road map.

Optimal cognitive function is vital to independence, productivity, and quality of life, and the debilitation associated with dementias makes them the most feared of conditions related to aging. Effective preventive measures are key components of any response to the potentially overwhelming problem of dementias. Increasing evidence points to the potential risk roles of vascular factors and disorders (eg, midlife obesity, dyslipidemia, diabetes, high blood pressure, cigarette smoking, and cerebrovascular lesions) and the potential protective roles of psychosocial factors (eg, higher education, regular exercise, healthy diet, intellectually challenging leisure activities, and active socially integrated lifestyle) in the pathogenic process and clinical manifestation of dementing disorders. Optimal control of vascular risk factors, secondary prevention of stroke, and manipulation of lifestyle factors have demonstrated efficacy in prevention of stroke and myocardial infarction. Thus, adding dementia prevention and brain function preservation as goals to already existing or planned prevention efforts is appropriate and necessary. Age must be taken into account when assessing the likely effect of such interventions against dementia, which underscores the need to begin prevention efforts early in patients' lives.

Healthy brain aging: what has sleep got to do with it?

Sleep plays an important role in learning, memory encoding, and cognition. Insufficient quantity or quality of sleep leads not only to short-term neurocognitive dysfunction but also to permanent changes to the central nervous system. Sleep disorders are common in the geriatric population. The hypoxemia and sleep fragmentation resulting from obstructive sleep apnea are the most likely pathophysiology responsible for damage to the brain. Because treatment of these sleep disorders can lead to improved cognitive function, it is becoming increasingly important for physicians to be able to correctly recognize and treat these disorders in patients presenting with memory or cognitive complaints.

Rivastigmine for Alzheimer's disease.

Alzheimer's disease is the most common form of neurodegenerative dementia and poses considerable health challenges to both patients and their families. Rivastigmine is a powerful slow-reversible, noncompetitive carbamate cholinesterase inhibitor that is approved for the treatment of mild-to-moderate Alzheimer's disease. Randomized, double-blind, placebo-controlled trials of up to 6 months duration have shown beneficial effects of rivastigmine compared with placebo in measures of cognition and global functioning. Less rigorous but growing data suggest that the beneficial effects may endure for up to 5 years, extend to more advanced stages of Alzheimer's disease and may occur in noncognitive domains, such as activities of daily living and the behavioral symptoms of Alzheimer's disease. Evidence from controlled studies also supports the use of rivastigmine for cognitive and behavioral symptoms in Alzheimer's disease associated with vascular risk factors, dementia with Lewy bodies and Parkinson's disease dementia. Early and continued treatment of Alzheimer's disease with rivastigmine maximizes the observed beneficial effects. The most prominent adverse effect of rivastigmine is centrally mediated cholinergic gastrointestinal events, which can be minimized by slower dose-escalation intervals and administration with a full meal. Therapeutic dosing is 6-12 mg/day given twice daily, with higher doses having the potential for greater benefits.

Diagnosis and treatment of Alzheimer's disease.

Alzheimer's disease (AD) is a chronic neurodegenerative disorder and the most common cause of dementia. It is one of the principal causes of disability and decreased quality of life among older adults. Progress in our clinical knowledge of AD has led to more reliable diagnostic criteria and accuracy, and research efforts are expanding to uncover the earliest manifestations and even the presymptomatic phases of the disease. The diagnosis of AD is primarily one of inclusion and usually can be made using standardized clinical criteria. There is currently no cure for AD. Current treatment focuses on establishing an early accurate clinical diagnosis, early institution of cholinesterase inhibitors and/or N-methyl-D-aspartate (NMDA) receptor-targeted therapy. Treating medical comorbidities and dementia-related complications, ensuring that appropriate services are provided, addressing the long-term well-being of caregivers, and treating behavioral and psychological symptoms with appropriate nonpharmacologic and pharmacologic interventions also are important. The initiating and propagating pathologic processes and the anatomic location of the earliest changes will become new targets of research and therapeutic development. A possible precursor of AD, mild cognitive impairment (MCI), is under investigation as a possible therapeutic starting point for disease-modifying interventions. This article provides a research update of current understanding in the diagnosis and treatment of AD and in emerging areas of interest such as MCI, detection of AD in the predementia phase, and neuroimaging in AD.

Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment.

Disability, characterised by the loss of ability to perform activities of daily living (ADL), is a defining feature of dementia that results in growing caregiver burden and the eventual need for alternative care or nursing home placement. Functional decline in patients with dementia can also result from causes other than dementia, such as comorbid medical and psychiatric illnesses and sensory impairment. ADL consists of instrumental ADL (IADL) [complex higher order skills, such as managing finances] and basic ADL (BADL) [self-maintenance skills, such as bathing]. Assessment of IADL and BADL is recommended to establish a diagnosis of dementia. Functional assessment also helps the healthcare provider to offer appropriate counselling regarding safety concerns and need for custodial care. Functional capacity measures have been used increasingly in pharmacological trials of patients with Alzheimer's disease (AD) and related dementias, although at the present time these measures are generally not primary outcome measures. Functional impairment is not a uniform construct; rather, it is multifaceted and can be measured with various clinical instruments. Many scales have been validated for use in patients with AD for characterising functional impairment and evaluating the efficacy of treatment. Research to date indicates that cholinesterase inhibitors have the potential for modest but meaningful beneficial effects on ADL in patients with mild-to-moderate AD. Memantine also has promising beneficial effects on functional abilities in persons with moderate-to-severe AD. Assessment of ADL as a primary efficacy measure using a validated scale that is non-gender biased and cross-nationally relevant is recommended in new treatment trials of patients with AD and related dementias.

Herbals and botanicals in geriatric psychiatry.

There is high prevalence of herbal medicine use among elderly people. Most patients do not reveal their herbal use to their physicians and pharmacists. The authors describe some commonly used herbal remedies in terms of their potential benefits and known adverse effects. The review also highlights the potentially serious risk of herb-drug interactions and discusses communication issues and regulatory concerns associated with use of herbal medicines. Health practitioners should remember to include herbal use history in their routine drug histories and remain informed of the beneficial and harmful effects of these treatments.

Use of psychopharmacologic agents in the elderly.

Most psychiatric disorders in elderly patients are amenable to treatment, provided that intervention is thorough and intensive. Appropriate and judicious use of psychopharmacologic agents has a potential for dramatically improving the quality of life and functional status of many elderly patients with psychiatric disorders. The decision to prescribe a psychopharmacologic agent in elderly patients is a serious and complex issue. Several basic principles need to be followed (Table 6). Although some strides have been made in the last decade regarding safety and efficacy of many psychopharmacologic agents in elderly [table: see text] patients, for many psychopharmacologic agents, large randomized controlled studies to evaluate efficacy and safety in elderly patients are lacking. Sparse data are available regarding the long-term effects of psychopharmacologic agents in elderly patients. Important gaps remain in our knowledge concerning the optimal duration of treatment for most psychiatric disorders in elderly patients. The treatment data deficiency is most striking among the oldest old (patients aged 85 and older), frail medically ill elderly patients (such as nursing home residents), and ethnic minority groups. Future research should focus on these and other relevant issues related to the use of psychopharmacologic agents in elderly patients.

Buspirone in Alzheimer's disease.

Anxiety symptoms are experienced by the majority of patients with Alzheimer's disease. Generalized anxiety disorder may occur in 5-6% of patients with Alzheimer's disease. Anxiety symptoms may underlie agitation and aggression. Anxiety and agitation cause significant morbidity, caregiver distress and may even precipitate institutionalization. Benzodiazepines, although frequently used to treat anxiety and agitation in patients with Alzheimer's disease, should be avoided because of the high morbidity associated with their use. Disturbances in serotonergic neurotransmission may underlie anxiety symptoms and agitation. Preliminary evidence suggests that buspirone may be a good non sedating alternative to treat Alzheimer's disease patients with persistent anxiety symptoms and agitation-aggression. Effective doses reported range from 15 to 60 mg/day is generally well-tolerated. Large, randomized controlled trials are needed to confirm the potential benefits of buspirone for anxiety symptoms and other behavioral disturbances in Alzheimer's disease patients.