Daniel E. Everitt

A Randomized Trial of a Program to Reduce the Use of Psychoactive Drugs in Nursing Homes

BACKGROUND Although psychoactive medications have substantial side effects in the elderly, these drugs are used frequently in nursing homes. Few interventions have succeeded in changing this situation, and little is known about the clinical effects of such interventions. METHODS We studied six matched pairs of nursing homes; at one randomly selected nursing home in each pair, physicians, nurses, and aides participated in an educational program in geriatric psychopharmacology. At base line we determined the type and quantity of drugs received by all residents (n = 823), and a blinded observer performed standardized clinical assessments of the residents who were taking psychoactive medications. After the five-month program, drug use and patient status were reassessed. RESULTS Scores on an index of psychoactive-drug use, measuring both the magnitude and the probable inappropriateness of medication use, declined significantly more in the nursing homes in which the program was carried out (experimental nursing homes) than in the control nursing homes (decrease, 27 percent vs. 8 percent; P = 0.02). The use of antipsychotic drugs was discontinued in more residents in the experimental nursing homes than in the control nursing homes (32 percent vs. 14 percent); the comparable figures for the discontinuation of long-acting benzodiazepines were 20 percent vs. 9 percent, and for antihistamine hypnotics, 45 percent vs. 21 percent. In the experimental nursing homes residents who were initially taking antipsychotic drugs showed less deterioration on several measures of cognitive function than similar residents in the control facilities, but they were more likely to report depression. Those who were initially taking benzodiazepines or antihistamine hypnotic agents reported less anxiety than controls but had more loss of memory. Most other measures of clinical status remained unchanged in both groups. CONCLUSIONS An educational program targeted to physicians, nurses, and aides can reduce the use of psychoactive drugs in nursing homes without adversely affecting the overall behavior and level of functioning of the residents.

Treatment for glaucoma: adherence by the elderly.

OBJECTIVES The purpose of this study was to determine the extent of nonadherence to treatment for glaucoma among elderly patients. METHODS This was a retrospective cohort study of 2440 patients older than age 65 who were enrolled in the New Jersey Medicaid Program and who were newly initiated on a topical agent for the treatment of glaucoma. Two patient-specific measures of nonadherence were employed: (1) no filled prescription for any glaucoma medication over a 12-month period after the initiation of therapy and (2) number of days without therapy for glaucoma during this 12-month period. RESULTS By the first measure, 569 patients (23%) were found to be nonadherent. The mean number of days without therapy during the study year was 112. Factors associated with nonadherence included the use of glaucoma medication requiring more than 2 administrations per day and the presence of multiple other medications in the patients drug regimen. Patients started on multiple glaucoma medication were more adherent than those started on a single agent. Age and sex were not found to be predictors of nonadherence. CONCLUSIONS Substantial nonadherence was found to be common in this population. More attention to the issue of nonadherence could result in important benefits in the preservation of sight.

Medicaid data as a resource for epidemiologic studies: Strengths and limitations☆

Large claims databases from third-party insurance programs such as Medicaid have attracted the interest of epidemiologists because of their enormous size and apparent comprehensiveness. Over 20 million people are covered by the various state Medicaid programs and most states maintain detailed computerized records of all reimbursed health care encounters on a recipient-specific basis. For states covering medication costs, data on drug exposures are particularly complete and accurate. However, Medicaid claims data also have many limitations that can pose major methodological difficulties. Foremost among these is the uneven validity and completeness of the diagnoses appearing on claims. Likewise, the unique identification of specific program participants is not straightforward, although useful approaches can often be developed to track individuals over time. Consideration of the limitations as well as the possible strengths of claims-based data makes it possible to choose appropriate study hypotheses as well as to attempt solutions, where possible, to the biases of this methodology.

Resident Behavior and Staff Distress in the Nursing Home

Newly enacted Federal regulations have focused increasing attention on the use of psychoactive drugs and on the treatment of disruptive behavior in the nursing home. To study the interaction between resident behavior and staff distress in nursing homes, we measured the frequency of seven types of behavior problems among 346 residents of intermediate care facilities who were receiving some form of psychoactive medication. Nurses were interviewed on two shifts to determine their perception of the frequency and severity of each behavior in each patient as well as the level of distress it caused among caregivers. The most common behavior problems noted were agitation (42%), withdrawal (33%), and noisiness (27%). Only half of the reported instances of behavior disorders were considered distressful by nursing home staff. While physical abuse caused distress 92% of the time and verbal abuse 90% of the time, wandering was seen as distressful to staff only 50% of the time. Nearly a third of “wandering” patients were restrained; they produced less distress than non‐restrained wanderers.

Systemic Effects of Medications Used To Treat Glaucoma

Medications used to treat glaucoma can have clinically important systemic effects in some patients; these effects may not be recognized in elderly patients who have chronic medical problems and who are taking several systemic medications. Beta-blocking ophthalmic agents are generally safe, but can be absorbed systemically to induce bronchospasm, worsen heart block, decompensate congestive heart failure, or create central nervous system effects in some patients. Reports of adverse systemic effects from miotics, such as pilocarpine, are rare, although cardiovascular decompensation has been seen in patients with acute angle closure who were given excessive doses before surgery. Topical sympathomimetic agents such as epinephrine may increase ventricular extrasystoles and have, on occasion, caused severe hypertensive reactions. Nearly 50% of patients taking carbonic anhydrase inhibitors must discontinue their use because of various adverse constitutional and central nervous system symptoms. Although these drugs are not usually part of internal medicine regimens, they can produce adverse effects that mimic primary disease in nonocular organ systems.

Neuroleptic drug exposure and treatment of parkinsonism in the elderly: a case-control study.

PURPOSE Despite the widespread use of neuroleptic medications for the elderly, little is known about the frequency of treatment for drug-induced parkinsonian syndromes in this age group, particularly with L-dopa-type drugs, which are more appropriate for the treatment of true idiopathic Parkinsons disease. PATIENTS AND METHODS We identified 3,512 patients aged 65 to 99 enrolled in a large state Medicaid program who were newly prescribed a drug to treat parkinsonian symptoms. Controls were comparable program enrollees of similar age who had not been prescribed an antiparkinsonian drug. In a case-control study, we evaluated the use of neuroleptic drugs in the 90 days before initiation of antiparkinsonian therapy. RESULTS Patients taking neuroleptics were 5.4 times more likely to begin antiparkinsonian medication than were nonusers (95% confidence interval [CI] 4.8 to 6.1). They also had a greater than two-fold increase in risk of beginning therapy with a dopaminergic drug specific for idiopathic Parkinsons disease, not generally indicated for treatment of drug-induced parkinsonism (adjusted odds ratio 2.2, 95% CI 1.9 to 2.7). Clear dose-response relationships were demonstrated, as were differences among neuroleptics. Among all patients started on dopaminergic drugs in this population, 37% of such therapy was attributable to prior neuroleptic use. Continuation of the neuroleptic persisted in 71% of patients so treated. CONCLUSION Neuroleptic use is a common cause of extrapyramidal dysfunction in the elderly, and the side effect is frequently treated by adding an anticholinergic or dopaminergic drug to the regimen. The use of anticholinergic drugs presents risks of additional drug side effects; the use of dopaminergic drugs, generally not appropriate for drug-induced parkinsonian syndrome, suggests that extrapyramidal neuroleptic side effects may often be mistaken for idiopathic Parkinsons disease in older patients.

Changing surgical antimicrobial prophylaxis practices through education targeted at senior department leaders.

Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p less than .001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over

Identifying and Preventing Family-Mediated Abuse and Neglect of Elderly Persons

26,000 each year, or

Pygmalion in the nursing home. The effects of caregiver expectations on patient outcomes.

47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.

Rosiglitazone and Hepatic Failure

Unexplained trauma, neglected medical problems, failure to thrive, malnutrition, and misuse of medications may be manifestations of family-mediated abuse and neglect of the non-institutionalized elderly person. Physicians frequently overlook or misdiagnose this form of family violence. Access to these persons, assessment, and intervention are facilitated by focusing on the unmet care needs of the elderly person and by moving to meet those needs. Issues of intervention can be clarified by categorizing abuse or neglect as occurring in situations in which the dependency and care needs of the elderly person are paramount or in which the pathologic behavior of the abuser is most evident. The provision of specific support services or legally mandated separation of the elderly person and the abuser can be attempted but the elderly persons right to refuse any intervention must be recognized.