Psychotropic Drug Prescription in Patients with Dementia: Nursing Home Residents Versus Patients Living at Home

Abstract

Background:

Psychotropic drugs are frequently prescribed in nursing homes (NH). Nonetheless, we hoped that institutionalization decreases the number of psychotropic drug classes prescribed, because NH residents may have more psychosocial interventions than patients living at home.

Objective:

The aim was to compare the type and number of psychotropic drugs prescribed in elderly NH residents with dementia with those in community-living patients.

Methods:

This cross-sectional study included elderly patients (at least 75 years old) with dementia recorded in the National Alzheimer’s data Bank (“Banque Nationale Alzheimer”) during the year 2012 and who were taking at least one psychotropic drug. Psychotropic drugs were classified as follows: antidepressant, anxiolytic, hypnotic, and antipsychotic drugs. Patients were classified into three categories of dementia severity according to the MMSE score.

Results:

Among the 50,932 patients with dementia recorded in the BNA, 40.1% had at least one psychotropic drug prescribed. Most of the patients who were treated by at least one psychotropic drug class had antidepressant therapy (69.0%), whatever their residence type, and 16.1% were treated with antipsychotics. Among the study population, 51.9% of the NH residents and 67.4% of the patients living at home had only one psychotropic drug class prescribed. Living in a NH was significantly associated with the more frequent prescription of anxiolytic, hypnotic, and antipsychotic drugs, and with a greater number of psychotropic drug classes prescribed, whatever the severity of the dementia.

Conclusion:

We underlined the more frequent prescription of psychotropic drugs in NH residents regardless of MMSE scores.

Keywords

Dementia National Alzheimer’s data Bank nursing home psychotropic drug

INTRODUCTION

The proportion of people older than 75 years residing in nursing homes (NH) in France, the United States, or the United Kingdom ranges from 4 to 12% [1]; the mean age is around 84 years old. The main reasons for institutionalization are related to disability:36% of them are deeply dependent and most have at least one disorder of the basic Activities of Daily Living (ADL) [2] or dementia: 70 to 90% of NH residents have dementia [2]. Because of their multiple diseases, older NH residents receive more medications than do non-institutionalized older people: on average, they take 7 to 8 drugs, including inappropriate treatments that may cause adverse events [2 –6].

Psychotropic drugs (benzodiazepines, hypnotics, antidepressants, antipsychotics) are commonly used in NH residents in Western countries [3 , 7–15]. From 50to 80% of the NH residents have at least one prescription for a psychotropic drug [1 , 7–15]. In France [1], like in the United States [16], antipsychotic drugs are widely used for the management of behavioral and psychological symptoms, from 19.1% [1] to 25.7% [16] of NH patients with dementia. However, these psychotropic drugs are potentially deleterious for the elderly as they increase the risk of falls [17], delirium, functional decline [18], and death [19 –21]. Psychotropic drugs therefore need to be prescribed with caution, especially in patients with dementia. It is for this reason that two measures were implemented by the French National Health Authority (HAS): first, professional guidelines on the management of the behavioral and psychological symptoms related to Alzheimer’s disease were published in 2009 [22]; then, a national program to reduce psychotropic prescriptions in demented patients in NH was launched in 2010 [23].

Nonetheless, information on psychotropic drug prescriptions in NH residents according to their demented status in France is still limited; and, to our knowledge, no studies have compared psychotropic drug prescriptions in NH residents with those in elderly patients living at home. We could hope that institutionalization decreased the number of psychotropic drug classes prescribed, because the NH residents may have more psychosocial interventions (psychotherapy or group activities) than patients living at home, to take care of behavioral and psychological symptoms.

Therefore, the aim of this study was to describe and compare the prescription of psychotropic drugs in dementia in elderly (at least 75 years old) NH residents and elderly patients living at home. The study included patients treated with at least one psychotropic drug. We used the data from the BNA database to describe the classes and the number of psychotropic drugs commonly prescribed in these patients with dementia at the first outpatient consultation.

METHODS

Study design and eligible population

This cross-sectional study included all patients recorded in the National Alzheimer’s data Bank (“Banque Nationale Alzheimer”, BNA) during the year 2012. The National Alzheimer’s data Bank was created by the French National Alzheimer Plan 2008–2012 [24]. It prospectively records every patient consulting for a memory complaint (including patients with or without dementia, i.e., Alzheimer’s disease or associated disorders), at the memory centers (CM), at memory resource and research centers (CMRR), or with private specialists (neurologists, geriatricians, or psychiatrists) in France, who agreed to contribute to the BNA database. The BNA was approved by the French national ethics committee (“Commission Nationale Informatique et Libertés”, CNIL). The details of the BNA database have been described elsewhere [24, 25].

The patients included in our study were at least 75 years old on the first of January, 2012, because this is the lower age limit for admission to a geriatric department in France. They had at least one evaluation using the Mini-Mental State Examination (MMSE) in 2012. All of the included patients had dementia (Alzheimer’s disease or associated disorders) diagnosed before or in 2012. In this study, we distinguished between two groups of patients: patients institutionalized in NH and patients who were living at home (alone, with his/her spouse, in his/her family, or with home help).

Patients who suffered from mild cognitive impairment (without dementia) and patients who changed the type of residence during the year 2012 were not included. We also excluded patients who were not taking a psychotropic drug.

Data collection

All of the data were recorded at the first outpatient consultation during the year 2012. All of the data came from the BNA. Concerning the data which were analyzed in this present study, there was no missing data because they are necessarily required to validate the BNA patient’s file. The following socio-demographic data were collected: age, gender, current residence, education level, psychosocial intervention (speech therapy, physiotherapy, occupational therapy, psychotherapy, group activities, other interventions), financial help for disability (“Allocation Personnalisée à l’Autonomie, APA” in France), and legal protection (guardianship).

We recorded the following clinical data: etiology of the dementia (Alzheimer’s, behavioral frontotemporal, vascular, mixed dementia, dementia with Lewy bodies, Parkinson dementia, semantic dementia, progressive aphasia, and other dementia), MMSE score, specific treatment for Alzheimer’s disease (cholinesterase inhibitor, memantine, or both), and the different psychotropic drugs classes prescribed. The treatment information came from a written medical prescription for all patients.

Psychotropic drugs were classified as follows: antidepressant, anxiolytic, hypnotic, and antipsychotic drugs. Anxiolytic drugs were benzodiazepine and anti-histaminic drugs. Hypnotic drugs included drugs such as zolpidem and zopiclone, which belong to the benzodiazepine class but have a more specific hypnotic effect than the other benzodiazepine drugs.

Patients were classified into three categories of dementia severity according to the total MMSE score: mild dementia for MMSE ≥20, moderate dementia for 10 ≤ MMSE <20, and severe dementia forMMSE <10.

Statistical analyses

Categorical variables were expressed as counts and percentages. Continuous variables were expressed as means and standard deviations. Comparisons between the two defined groups of patients (elderly NH residents with dementia versus elderly patients with dementia who were living at home) were done with the Student’s t test for continuous variables and the chi-square (χ²) test for categorical variables. Stratified comparisons between these two groups of patients were also done according to the severity of the dementia (MMSE classes). An interaction between the number of psychotropic drug classes and the type of dementia was searched because several types of dementia have more behavioral and psychological disorders than the others, and so may need a greater number of psychotropic drugs. Moreover, an interaction between the number of psychotropic drug classes and specific treatment for Alzheimer’s disease was also searched because these specific treatments could improve behavioral symptoms.

The associations between clinical or socio-demographic data and the patients’ type of residence (NH residents versus patients living at home) were analyzed with a multivariable model using logistic regression for all patients to take into account potential confounding variables and to know if the patients’ residence was independently associated with the number of psychotropic drugs prescribed. Age, gender, and all potential confounders with a p-value <0.20 in bivariate analyses were introduced into the multivariable model. The correlations between variables were analyzed and the least relevant variables were excluded. Log-linearity was checked for continuous covariates. A backward selection procedure was then applied to obtain the final model.

Results were expressed using odds-ratios (ORs) and their 95% confidence intervals (CI). A p-value below 0.05 was considered statistically significant. SAS 9.1 (SAS Institute Inc., Cary, North Carolina) was used for all analyses.

RESULTS

Among the 171,656 patients who consulted at a CMRR, CM, or a private specialist contributing to the BNA in 2012, 50,932 were eligible. Among these, a total of 4,500 out of 8,046 NH patients (55.9%) and 16,908 out of 42,886 community-living patients (39.9%) were taking one or more psychotropic medication classes. Among the 50,932 eligible patients, 21,408 patients (40.1%) had at least one psychotropic drug prescribed and were included in our cross-sectional study (Fig. 1). Among these, 16,908 (79%) were living in the community and 4,500 (21%) were institutionalized in NH.

The mean age (±standard deviation SD) of the included patients was 83.6±4.7 years old and 71.5% were women. Sixty percent of the patients suffered from Alzheimer’s disease. The mean (±SD) MMSE score was 16.8±6.1 out of 30. The characteristics of the total study population are listed in Table 1.

Differences between NH residents and patients living at home

In bivariate associations, living in a NH was significantly associated with old age [OR = 1.14 (1.13–1.15), p < 0.001], female gender [OR = 1.78 (1.65–1.93, p < 0.001], a lower likelihood of Alzheimer’s disease[OR = 0.81 (0.76–0.87), p < 0.001], severe dementia [OR = 2.44 (2.24–2.67), p < 0.001], fewer psychosocial interventions [OR = 0.75 (0.71–0.81), p < 0.001], more financial help (APA) [OR = 4.15 (3.81–4.52), p < 0.001], and more frequent legal protection [OR = 4.45 (3.89–5.09), p < 0.001] (Table 1). Others characteristics according to the patient’s residence (NH residents versus patients living at home) and their bivariate associations are shownin Table 1.

Concerning the specific treatments for Alzheimer’s disease, patients living in NH were less frequently treated than patients living at home [OR = 0.90 (0.84–0.96), p = 0.003]; in particular, they were less likely to be given cholinesterase inhibitors alone [OR = 0.77 (0.72–0.82), p < 0.0001] than were patients living at home. However, they were more likely to be given memantine alone [OR = 1.38 (1.28–1.49), p < 0.001] or both treatment classes [OR = 1.20 (1.06–1.35), p = 0.003].

Concerning the MMSE score, patients living in NH had significantly a lower score (14.3±6.2) than patients living at home (17.4±5.9) [OR = 0.93 (0.93–0.94), p < 0.001]. Concerning MMSE classes, patients living in NH were more frequently classed in the severe dementia group than patients living at home [OR = 2.44 (2.24–2.67), p < 0.001].

Psychotropic drug prescription

Most of the patients who were treated by at least one psychotropic drug class had antidepressant therapy (14,775 (69.0%)), whatever their residence type; 7,941 patients (37.1%) were treated with anxiolytic drugs, 3,730 (17.4%) with hypnotics, and 3,444 (16.1%) with antipsychotics (Table 2).

Among the study population, 51.9% (2,334) of the NH residents with dementia and 67.4% (11,394) of the patients living at home with dementia had only one psychotropic drug class prescribed (antidepressant, anxiolytic, hypnotic, or antipsychotic drug) (Table 2).

Patients living in NH were significantly more likely to be treated with anxiolytics [OR = 1.55 (1.45–1.66), p < 0.001], hypnotics [OR = 1.55 (1.43–1.69), p <0.001], and antipsychotics [OR = 2.21 (2.04–2.39), p < 0.001]. The prescription of antidepressants in NH residents was similar to that in patients living at home [OR = 0.95 (0.89–1.02), p = 0.166] (Table 2).

Patients living at home were more likely to be treated with only one psychotropic drug class [OR = 0.52 (0.49–0.56), p < 0.001] (Table 2). In contrast, the prescription of two psychotropic classes [OR = 1.46 (1.36–1.56), p < 0.001] or three and more psychotropic drug classes [OR = 2.41 (2.17–2.68), p < 0.001] was significantly more frequent in NH residents(Table 2).

The same differences concerning the number of psychotropic drug classes between NH residents and patients living at home were observed regardless of the MMSE score classes (Table 3).

An interaction was found between the number of psychotropic drug classes and the type of dementia (Alzheimer’s disease versus other dementia): patients with Alzheimer’s disease had significantly fewer psychotropic drug classes than did patients with another dementia [OR = 0.88 (0.83–0.93), p < 0.001]. However, in the overall population, the relationship between the type of residence and the number of psychotropic drugs prescribed was the same [for one psychotropic drug class: OR = 0.52 (0.49–0.56), p < 0.001] as in the two sub-groups of patients: patients with Alzheimer’s disease [for one psychotropic drug class: OR = 0.51 (0.46–0.55), p < 0.001] on the one hand, and patients with another dementia [for one psychotropic drug class: OR = 0.55 (0.49–0.61), p < 0.001] on the other hand. There was no interaction between the number of psychotropic drug classes and specific treatments for Alzheimer’s disease [OR = 0.95 (0.89–1.00), p = 0.06].

Multivariable associations between clinical or sociodemographic data and the patients’ type of residence (NH residents versus community-living patients)

In multivariable analysis, living in an NH was significantly associated with a greater number of psychotropic drug classes, old age, female gender, a lower likelihood of Alzheimer’s disease, severe dementia, and fewer psychosocial interventions (Table 4).

DISCUSSION

This cross-sectional study showed that 40.1% of outpatients older than 75 years old with dementia, who consulted at a CMRR, CM, or a private specialist contributing to the BNA during the year 2012, had at least one psychotropic drug class prescribed. Among these patients treated with at least one psychotropic drug class, 21% were NH residents and 79% were living in the community. A greater proportion of NH patients with dementia were given multiple psychotropic drugs (at least two drugs) than was the case for patients living at home with dementia, whatever the severity of the dementia. Among patients who were treated with at least one psychotropic drug class, those living in NH were more likely to be given anxiolytic, hypnotic, and antipsychotic medication.

Certain limitations of the present work should be addressed. First, despite the large size of our population, the BNA database is not an exhaustive record of memory consultations in France, especially for private specialists. Data concerning the medical written prescription of psychotropic drugs are declared by the doctor who takes care of the demented patient, and are thus less reliable than data from the French health insurance system, which provide proof of the drug’s delivery. Inherent to the BNA database constraints, we were not able to distinguish between regular and pro re nata medications. Moreover, the data correspond to the prescription of psychotropic drugs and do not necessarily reflect the consumption of drugs by the patient. Second, the patients with dementia who contributed to the BNA may not be representative of patients with dementia overall, because the BNA does not include patients outside the care system who are not able to have consultations as outpatients. Most of these patients outside the care system might be older patients, with more severe dementia (and thus with a low MMSE score), severe physical dependency, and more severe behavioral symptoms. It is easily conceivable that these patients are different comparing with patients who are able to have an outpatient consultation. Because of the study design, we could not compare BNA patients with patients not referred to the BNA. Both these limitations could under-estimate the prevalence of the psychotropic drug prescription in these patients. Third, as our study was cross-sectional, we could not evaluate modifications in psychotropic drug prescription during the patient’s follow-up. Fourth, because of the study design, we had no data relating to the patient’s history (for example, how long the disease has been present) or data about the history of psychotropic drug prescriptions. Finally, for reasons inherent to the BNA database, we had no data or scores concerning behavioral disorders. Behavioral data would be useful to compare NH residents with community-living patients. In fact, behavioral symptoms could be more frequent in NH because they may have been the reason motivating the admission into the NH. Moreover, NH residents may have fewer relatives seeing them, and admission to a NH may cause depression, agitation, and anxiety leading to the prescription of psychotropic drugs. This last limit of our study could overestimate the psychotropic drug prescription in NH residents compared with community-living patients with dementia.

In the literature, previous studies did not compare psychotropic drug prescription for dementia between NH residents and patients living at home, but focused only on psychotropic drug prescription in NH. These studies underlined the high prevalence of psychotropic drugs prescription in old institutionalized patients with dementia [7 , 27]. The high frequency of psychotropic drug prescriptions in NH residents with dementia is well known. The prevalence in our study was obviously lower than that in a previous French study [1], because this included all NH patients. In this previous work, the authors underlined that approximately 70% of the patients included had at least one psychotropic drug prescribed. This difference could obviously be explained by the fact that NH patients who consulted at centers contributing to the BNA database may not be representative of all NH patients with dementia in that they are more likely to attend memory clinics or have consultations with private-sector specialists and as a result, their prescriptions might have been more likely to comply with French National Health Authority (HAS) guidelines [22, 23]. Moreover, NH patients who are not able to have an outpatient consultation may have more behavioraldisorders.

Almost all of the studies highlighted the high prevalence and the deleterious effects of antipsychotic drugs. In the literature, the prescription of antipsychotic drugs is controversial [9 , 27]. Antipsychotic drugs are known to be potentially deleterious for the elderly, as they increase the risk of falls [17], hip fracture [28], delirium, functional decline [18], and death [16, 19]. These deleterious effects are not well explained in the literature and are aggravated by polymedication and old age [16, 19]. The prescription of non-recommended treatments may be the consequence of inadequate resources to implement other non-pharmacological interventions recommended by the HAS guidelines [22, 23].

Fewer previous studies have highlighted the prevalence and the characteristics of the prescription of anti-depressant, hypnotic, or anxiolytic drugs in institutionalized patients with dementia [7 , 30]. These studies had a smaller number of patients than our study, and they did not compare psychotropic drug prescriptions in NH patients with those in patients living at home. Most did not focus exclusively on patients with dementia, and as a result did not take into account the prescription of drugs for Alzheimer’s disease in the analysis of overall prescriptions of psychotropic drugs. To our knowledge, ours is the first study to take these different aspects of psychotropic drug prescription into account. In addition, it is the first study to include such a large number of patients, and thus provides a clear picture of patients with dementia who are able to consult at the CMRR, CM, or private specialists in France. In our study, the prescription of anti-depressants in NH residents with dementia was similar to that in patients living at home with dementia, and was high in both groups: among patients treated with at least one psychotropic drug class, 69.0% had an anti-depressant drug. This high prevalence could be explained by the high prevalence of dementia-related depression, and was probably also linked to the HAS guidelines [22], which recommend the prescription of an anti-depressant drug if depression occurs. Like previous studies [7 , 30], our study showed that hypnotics and anxiolytics were frequently prescribed. Unfortunately, for reasons inherent to the BNA database, we cannot know why these drugs were prescribed: perhaps these NH patients were more likely than community-living patients to have insomnia or anxiety. Several explanations could be done: NH residents may have fewer relatives seeing them, admission to a NH might cause emergence of depression, anxiety, or insomnia because it modifies their lifestyle.

We demonstrated that patients living in NH were less often treated with an anti-Alzheimer drug. This relationship could explain why demented NH residents had a greater number of psychotropic drugs. In fact, it is well known that cholinesterase inhibitors and memantine are safe and effective treatments to delay the onset of the behavioral and psychological symptoms of dementia and reduce the severity of some symptoms [31 –37]. However, we did not find an interaction between the number of psychotropic drug classes and the treatment of Alzheimer’s disease. So, it is unlikely that fewer anti-Alzheimer drugs in NH explain the greater number of psychotropic drugs in NHresidents.

Other factors could explain the higher prevalence of psychotropic drug prescription in NH residents compared to community-living patients. First, fewer psychosocial interventions were performed in NH. Only group activities and psychotherapy were more frequent in NH than in community in our study. Nonetheless, HAS guidelines implement these non-pharmacological interventions to reduce the number of psychotropic drug prescribed [22 , 38]. Second, the presence of patients with more severe dementia in NH than in community (confirmed by significant lower MMSE score in NH residents) could also explain the higher prevalence of psychotropic drug prescription in NH. In fact, patients with severe dementia may have greater behavioral symptoms and need a larger number of psychotropic drug classes. However, stratification analyses by MMSE classes showed that this higher prevalence of psychotropic drug prescription in NH was true regardless of the MMSE classes (defining mild, moderate, or severe dementia). Third, the difference concerning psychotropic drug could also be explained by a larger prevalence of vascular, mixed, Parkinson, or Lewy body dementia in NH than in the community. These types of dementia potentially lead to more behavioral symptoms than Alzheimer’s disease [39].

In conclusion, this cross-sectional study based on data from the BNA database for the year 2012 underlined the high prevalence of psychotropic drug prescription, regardless of the MMSE classes. The prescription of anxiolytic, hypnotic, and antipsychotic drugs was more frequent in NH residents than in patients living in the community with dementia. The same association existed regardless of the treatment prescribed for Alzheimer’s disease. Inherent to the BNA database constraints, patients outside the care system were not included, and thus it could underestimate the prevalence of the psychotropic drug prescription. The aim of this work was to provide information to physicians on the high prevalence of psychotropic prescription in patients with dementia, especially in NH residents, and to try to promote non-pharmacological interventions to manage behavioral disorders. Interventions should aim at reducing and optimizing psychotropic drug prescriptions. Our results need to be completed by a longitudinal study to evaluate modifications in psychotropic drugs prescriptions during the patient’s follow-up.

Footnotes

ACKNOWLEDGMENTS

We thank all the CMRR, CM and private specialists who contributed to the National Alzheimer’s data Bank (“Banque Nationale Alzheimer”).

We thank Roland Chevrier from the Banque Nationale Alzheimer.

We thank Karim Tifratène (“Banque Nationale Alzheimer”, Public Health Department, Nice, France) for the review of the article.

We thank Pr Ménard, Pr Trunet and Pr Maisonneuve (French National Alzheimer Plan 2008–2012).

We thank Philip Bastable, a native English speaker, for reviewing the English in the manuscript.

Authors’ disclosures available online ().

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