Psychotropic and analgesic drug use among old people : with special focus on people living in institutional geriatric care

Old people in general, and those affected by dementia disorders in particular, are more sensitive to drug side effects than younger people. Despite this, the use of nervous system drugs and analgesics among old people is common, and has increased in recent years. Institutional geriatric care accommodates people who need round-the-clock supervision and care, due to somatic, psychiatric, cognitive or behavioral symptomatology. A majority of those living in institutional geriatric care suffers from dementia disorders. This thesis is based on three different data collections. Two large cross-sectional studies, the AC1982 and AC2000 data collections, including all those living in institutional geriatric care in the county of Västerbotten in May 1982 and 2000 respectively (n=3195 and n=3669) and one study, the GERDA/Umeå 85+ data collection, including a sample of very old people, living at home and in institutions (n=546), in the municipalities of Umeå, Sweden and Vaasa and Mustasaari, Finland, in 2005-2006. The use of psychotropic drugs and analgesics was common among old people living in geriatric care and among very old people in general. A higher proportion of people with dementia received certain nervous system drugs, such as antipsychotic drugs. The use of antipsychotic drugs among people with cognitive impairment living in geriatric care was found to be correlated to several behaviors and symptoms that are not proper indications for antipsychotic drug use, and also factors related more to the staff and the caring situation. Over the course of eighteen years, from 1982 to 2000, there has been a manifold increase in the use of antidepressants, anxiolytics and hypnotics in geriatric care, but the use of antipsychotics had decreased slightly. During the same time, the prevalence of several depressive symptoms decreased significantly, correcting for demographical changes. One analysis of calculated numbers needed to treat, however, indicated poor remission rates, suggesting that even better results might be achievable. The prevalence of depressive symptoms among people with moderate cognitive impairment remained unchanged between 1982 and 2000, despite the fact that about 50% were receiving treatment with antidepressants in 2000. One possible explanation might be that depressive symptoms have different etiologies in different stages of a dementia disorder. Approximately a quarter of the people experiencing pain in geriatric care were not receiving any regular analgesic treatment. One possible reason might be misconceptions among the caring staff regarding whether or not the residents were receiving analgesic treatment. Such misconceptions were found to be common. In conclusion, psychotropic and analgesic drug use among old people in geriatric care, and very old people in general, was found to be common and in many cases possibly inappropriate. The use of antipsychotics among people with dementia deserves particular concern, because of the high risk of severe adverse events and the limited evidence for positive effects. The use of antidepressants, on the other hand, might have contributed to a lower prevalence of depressive symptoms among old people

Oropharyngeal dysphagia and associated factors among individuals living in nursing homes in northern Sweden in 2007 and 2013

Background: Swallowing difficulties in the oral cavity or pharynx (i.e., oropharyngeal dysphagia) are a common problem in the aging population, which may result in severe consequences, such as malnutrition, aspiration pneumonia, and mortality. Identifying oropharyngeal dysphagia and its associated factors is essential for establishing better healthcare policies in nursing homes. In this study, we aimed to describe the oropharyngeal dysphagia prevalence among nursing home residents, and to investigate the association between dysphagia and potentially related factors in a large survey of nursing home residents in Sweden, including individuals with various degrees of cognitive impairment. A secondary aim was to compare findings between years on oropharyngeal dysphagia and its associated factors. Methods: This study is based on two cross-sectional surveys performed in 2007 and 2013, including 4,995 individuals living in nursing homes in the Region of Västerbotten, Sweden. Data were collected from caregivers’ reports regarding swallowing ability, nutritional status, chewing ability, and other baseline characteristics, such as cognitive function and activity of daily living (ADL). Data were analyzed using logistic regression models to calculate the odds of the association between oropharyngeal dysphagia and associated factors. Results: Oropharyngeal dysphagia was reported in 14.9% (95% CI: 13.9–16.0) of the nursing home residents. An adjusted model revealed that oropharyngeal dysphagia was associated by severe cognitive impairment (OR: 1.56, 95% CI: 1.14–2.12) and ADL independence (OR: 0.81 95% CI: 1.82–2.66) among nursing home residents. We also identified the following as independently associated factors of dysphagia: reduced nutritional status (OR: 1.84, 95% CI: 1.49–2.27), artificial nutrition (OR: 6.33, 95% CI: 2.73–14.71), and clinical signs of aspiration (OR: 10.89, 95% CI: 8.40–14.12). Conclusions: Oropharyngeal dysphagia was reported among approximately 15% nursing home residents and was associated with cognitive impairment and ADL capability. Furthermore, reduced nutritional status and artificial nutrition were also associated with oropharyngeal dysphagia. Implementing routine protocols in nursing homes may help detect oropharyngeal dysphagia and manage oropharyngeal dysphagia among residents

Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder

Background and Objective: Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder. Methods: In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively. Results: The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis. Conclusions: The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder

Potentially inappropriate medications in relation to length of nursing home stay among older adults

Background: To investigate the use of potentially inappropriate medications and their relation to the length of nursing home stay among older adults. Methods: Questionnaire surveys using the Multi-Dimensional Dementia Assessment scale were sent out to all nursing homes in Västerbotten county in northern Sweden in 2007 and 2013. In total, 3186 adults (1881 from 2007 and 1305 from 2013) ≥65 years old were included and 71.8% of those had cognitive impairment. Potentially inappropriate medications were identified using drug-specific quality indicators according to Swedish National Board of Health and Welfare. Results: Potentially inappropriate medications were used by 48.0% of the 2007 study sample and by 28.4% of the 2013 study sample. The prevalence of glibenclamide use 2007 and antipsychotic drug use 2013 increased linearly (β = 0.534E− 3, 95% CI: 0.040E− 3-0.103E− 2, p = 0.034 and β = 0.155E− 2, 95% CI: 0.229E− 3-0.288E− 2, p = 0.022, respectively) with the length of nursing home stay. No significant association was found between the prevalence of propiomazine, codeine, long-acting benzodiazepines, anticholinergics, NSAIDs, tramadol or the total use of potentially inappropriate medications and the length of stay in nursing homes in 2007 or 2013. Antipsychotics were the most commonly prescribed of the drug classes investigated and used by 22.6% of the residents 2007 and by 16.0% of the residents 2013. Conclusions: These results indicate that treatment with potentially inappropriate medications is common among older adults living in nursing homes, but it seems to be related to the length of nursing home stay only to a smaller extent. Drug treatment should regularly be reviewed and followed-up among nursing home residents regardless of their length of nursing home stay, in order to prevent unnecessary adverse events

Clinically relevant drug-drug interactions among elderly people with dementia

Purpose: Increased numbers of drugs and changes in pharmacokinetic and pharmacodynamic parameters among elderly people contribute to increased prevalence of adverse drug reactions. Drug-drug interactions (DDIs) are an important reason for admission to hospital and elderly people with dementia are particularly vulnerable. The aims of the present study were to assess the occurrence and characteristics of clinically relevant DDIs and to investigate potential risk factors associated with DDIs among elderly people with dementia. Methods: People 65 years with dementia, admitted to two hospitals in Northern Sweden, were included. The medical records of 458 patients were reviewed. Clinically relevant DDIs were identified using the Janusmed interactions database. Pharmacological classification was conducted using Stockley's classification system. Results: A total of 401 DDIs were identified among 43.2% of the study population, of which 98.5% had interactions that may require dose adjustment and 7.6% had drug combinations that should be avoided. Pharmacodynamic interactions were most common, of which furosemide-citalopram (n=35) were most frequently observed. Omeprazol-citalopram (n=25) was the most common drug combination among pharmacokinetic interactions. Citalopram and warfarin were the most commonly involved drug substances. An association was found between a higher number of medications being prescribed and having at least one DDI. Conclusion: Clinically relevant drug-drug interactions are prevalent among elderly people with dementia living in Northern Sweden. Drug-drug interactions should be identified in order to manage and prevent adverse outcomes. This is particularly important among this group of people especially when multiple medications are being prescribed

Antipsychotic Drugs and Hip Fracture : Associations Before and After the Initiation of Treatment

Objective: To study the association between antipsychotic drug treatment and hip fracture, before and after the initiation of treatment. Design: Nationwide cohort study. Setting and Participants: In this study based on several Swedish registers, all individuals age ≥65 years who filled prescriptions for antipsychotic drugs in 2007–2017 were matched 1:1 by sex and age with controls, resulting in a cohort of 255,274 individuals. Measures: Associations between antipsychotic drug treatment and hip fracture were investigated using multivariable conditional logistic regression models and flexible parametric survival models for nonproportional hazards, starting 1 year before the first prescription was filled and extending to 1 year thereafter. Results: The studied cohort had a mean age of 81.5 (standard deviation, 8.1) years; 152,890 (59.9%) individuals were women. Antipsychotic drug use was associated with an increased risk of hip fracture in all studied time frames, before and after the initiation of treatment. The risk was highest 16–30 days before the initiation of treatment (odds ratio 9.09; 95% confidence interval 7.00–11.81). The pattern was consistent in subgroup analyses of users of conventional and atypical antipsychotics, men and women, as well as in younger old and older old participants. The association with hip fracture was not influenced by antipsychotic drug dose. Conclusions and Implications: The association between antipsychotic drug use and the risk of hip fracture was observed before the initiation of antipsychotic treatment. This finding suggests that factors other than exposure to antipsychotic drugs are responsible for the increased risk of hip fracture in the treatment group

Psychotropic drug use among older people with major neurocognitive disorder : a cross-sectional study based on Swedish national registries

Aim: Psychotropic medications include many drugs that may be inappropriate for older individuals with cognitive impairment. In Sweden, many people become registered in the Swedish Dementia Registry when they are diagnosed with major neurocognitive disorder (NCD). In this study, we aim to describe psychotropic drug use and associated factors among older Swedish people with major NCD. Methods: This study included 38,251 people ≥ 65 years from the Swedish registry for cognitive/dementia disorders diagnosed during 2007–2017. Drug use was defined as one or more filled prescription(s) recorded in the Swedish Prescribed Drug Register during 1 July to 31 December 2017. Associations between psychotropics and age, sex, diagnosis date, Mini-Mental State Examination score and major NCD subtype were analysed through multiple logistic regression. Results: We found that 12.0% of the individuals filled at least one prescription for antipsychotics, 22.0% for anxiolytics, 23.0% for sedatives or hypnotics, 43.2% for antidepressants and 56.7% for antidementia drugs. In brief, psychotropic use was associated with female sex, higher age, longer time since diagnosis and specific subtypes of major NCD; the strongest association was found between antipsychotics and Lewy body dementia (odds ratio 2.40, 95% confidence interval 2.04–2.82). Conclusion: Psychotropic drugs were frequently dispensed among older Swedish people with major NCD. The use of antipsychotics and medications with sedative properties warrants concern, especially among those with Lewy body dementia who are severely sensitive to antipsychotics. A more restrictive prescribing pattern regarding these medications might reduce the risk of drug-related problems in this vulnerable group of people