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The efficacy of antipsychotics in the treatment of physical aggressive behavior in patients with dementia in nursing homes.

ABSTRACT: Patients with dementia often suffer from behavioral changes. A common behavioral change is acute physical aggressive behavior which is the most distressing change. This can lead to harm, which is especially problematic in nursing homes. Despite the serious safety concerns, antipsychotics are often prescribed to combat this problem. This article is aimed to review the evidence of the efficacy of utilizing antipsychotics in acutely treating physical aggressive behavior in patients with dementia in nursing homes. Therefore, a systematic literature search was performed. The results demonstrated that a meta-analysis confirmed statistically significant reduction in physical aggression when risperidone was compared to placebo. However, a randomized controlled trial showed no change in physical aggressive behavior between quetiapine and placebo. More research is needed to fully investigate the benefits of physical aggressive behavior and safety concerns of all the antipsychotics in patients with dementia in nursing homes.

SUBMITTER: Nawzad S

PROVIDER: S-EPMC9118396 | biostudies-literature | 2022

REPOSITORIES: biostudies-literature

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The efficacy of antipsychotics in the treatment of physical aggressive behavior in patients with dementia in nursing homes.

Nawzad Sina S Cahn Wiepke W Abdullah-Koolmees Heshu H

Therapeutic advances in psychopharmacology 20220516

Patients with dementia often suffer from behavioral changes. A common behavioral change is acute physical aggressive behavior which is the most distressing change. This can lead to harm, which is especially problematic in nursing homes. Despite the serious safety concerns, antipsychotics are often prescribed to combat this problem. This article is aimed to review the evidence of the efficacy of utilizing antipsychotics in acutely treating physical aggressive behavior in patients with dementia in ...[more]

PMID: 35600754

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Project description:ImportanceOff-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use.ObjectiveTo quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS.Design, setting, and participantsThis investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from November through December 2016.ExposuresThe OASIS educational program targets all NH staff (direct care and nondirect care) using a train-the-trainer model. The program goals were to reframe challenging behaviors of residents with cognitive impairment as the communication of unmet needs, to train staff to anticipate resident needs, and to integrate resident strengths into daily care plans.Main outcomes and measuresThis study used an interrupted time series model of facility-level prevalence of antipsychotic medication use, other psychotropic medication use (antidepressants, anxiolytics, and hypnotics), and behavioral disturbances to evaluate the intervention's effectiveness in participating facilities compared with control NHs in Massachusetts and New York. The 18-month preintervention (baseline) period was compared with a 3-month training period, a 6-month implementation period, and a 3-month maintenance period.ResultsThis study included 93 NHs enrolled in the OASIS intervention (27 of which had a high prevalence of antipsychotic use) compared with 831 nonintervention NHs. Among OASIS facilities, prevalences of atypical antipsychotic prescribing were 34.1% at baseline and 26.5% at the study end (absolute reduction of 7.6% and relative reduction of 22.3%) compared with a drop of 22.7% to 18.8% in the comparison facilities (absolute reduction of 3.9% and relative reduction of 17.2%). In the OASIS implementation phase, NHs experienced a reduction in antipsychotic use prevalence among OASIS facilities (-1.20%; 95% CI, -1.85% to -0.09% per quarter) greater than that among non-OASIS facilities (-0.23%; 95% CI, -0.47% to 0.01% per quarter), resulting in a net OASIS influence of -0.97% (95% CI, -1.85% to -0.09%; P = .03). A difference in trend was not sustained in the maintenance phase (difference of 0.93%; 95% CI, -0.66% to 2.54%; P = .48). No increases in other psychotropic medication use or behavioral disturbances were observed.Conclusions and relevanceAntipsychotic use prevalence declined during OASIS implementation of the intervention, but the decreases did not continue in the maintenance phase. Other psychotropic medication use and behavioral disturbances did not increase. This study adds evidence for nonpharmacological programs to treat behavioral and psychological symptoms of dementia.

Project description:ObjectiveTo estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.Data sources and study settingA national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.Study designRetrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.Data collection/extraction methodsHospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.Principal findingsWe found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.ConclusionsThese findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Project description:BACKGROUND:Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient's best interest, assessment of capacity to consent, and on the patient's own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards. METHODS:Using a questionnaire, we studied the decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 (72%) patients treated in nursing homes to the 84 (28%) nursing home patients treated in the hospital. RESULTS:The patients' capacity to consent was considered prior to treatment in 197 (92%) of the patients treated in nursing homes and 56 (67%) of the patients treated in hospitals (p < 0.001). The answers indicate that capacity to consent can be difficult to assess. Patients that were considered capable to consent, were more often involved in the decision-making in nursing homes than in hospital (90% vs. 52%). Next of kin and other health personnel were also more rarely involved when the nursing home patient was treated in hospital. Whether advance care planning had been carried out, was more often unknown in the hospital (69% vs. 17% in nursing homes). Hospital doctors expressed more doubt about the decision to admit the patient to the hospital than about the treatment itself. CONCLUSIONS:This study indicates a potential for improvement in decision-making processes in general, and in particular when nursing home patients are treated in a hospital ward. The findings corroborate that nursing home patients should be treated locally if adequate health care and treatment is available. The communication between the different levels of health care when hospitalization is necessary, must be better. TRIAL REGISTRATION:ClinicalTrials.gov NCT01023763 (12/1/09) [The registration was delayed one month after study onset due to practical reasons].

Project description:ObjectiveTo determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes.DesignCluster randomised controlled trial.Setting60 clusters (single independent nursing home units) in 18 nursing homes within five municipalities of western Norway.Participants352 residents with moderate to severe dementia and clinically significant behavioural disturbances randomised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment (33 clusters; n = 175) or to usual treatment (control, 27 clusters; n = 177).InterventionParticipants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol, with paracetamol (acetaminophen), morphine, buprenorphine transdermal patch, or pregabaline. The control group received usual treatment and care.Main outcome measuresPrimary outcome measure was agitation (scores on Cohen-Mansfield agitation inventory). Secondary outcome measures were aggression (scores on neuropsychiatric inventory-nursing home version), pain (scores on mobilisation-observation-behaviour-intensity-dementia-2), activities of daily living, and cognition (mini-mental state examination).ResultsAgitation was significantly reduced in the intervention group compared with control group after eight weeks (repeated measures analysis of covariance adjusting for baseline score, P < 0.001): the average reduction in scores for agitation was 17% (treatment effect estimate -7.0, 95% confidence interval -3.7 to -10.3). Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms (-9.0, -5.5 to -12.6) and pain (-1.3, -0.8 to -1.7), but the groups did not differ significantly for activities of daily living or cognition.ConclusionA systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia. Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population. Trial registration ClinicalTrials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008-007490-20.

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The efficacy of antipsychotics in the treatment of physical aggressive behavior in patients with dementia in nursing homes.

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The efficacy of antipsychotics in the treatment of physical aggressive behavior in patients with dementia in nursing homes.

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