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Psychotropic prescribing in the oldest old attending a geriatric psychiatry service: a retrospective, cross-sectional study

Published online by Cambridge University Press:  18 July 2013

E. Kolshus ,
A. Freyne ,
I. Callanan  and
C. Cooney
E. Kolshus*
Affiliation:
St. Patrick's University Hospital/Trinity College Dublin, Steeven's Lane, Dublin, Ireland
A. Freyne
Affiliation:
Department of Old Age Psychiatry, St. Vincent's University Hospital, Elm Park, Dublin, Ireland
I. Callanan
Affiliation:
Clinical Audit Department, St. Vincent's University Hospital, Elm Park, Dublin, Ireland
C. Cooney
Affiliation:
Department of Old Age Psychiatry, St. Vincent's University Hospital, Elm Park, Dublin, Ireland
*
Address for correspondence: E. Kolshus, Clinical Research Fellow, St Patrick's University Hospital/Trinity College Dublin, Steeven's Lane, Dublin 8, Ireland. Email [email protected]
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Abstract

Objective

More people are living beyond their 90s, yet this group has not been much studied. This study aimed to describe a sample of non-agenarians and centerians attending an old age psychiatry service with a focus on pharmacotherapy.

Methods

Retrospective, cross-sectional survey of patients aged >90 in contact with the Department of Old Age Psychiatry in a university hospital over a 1-year period. Results were compared with the Beers, the Canadian and Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria.

Results

A total of 65 nonagenarians or centerians were identified (mean age 93, 82% female). The majority (65%) resided in a nursing home; dementia was the most common diagnosis (77%), followed by depression (29%). The most commonly prescribed psychotropics were antidepressants (58%), followed by antipsychotics (45%), hypnotics (42%), anti-dementia agents (31%) and anxiolytics (26%). Overall, patients were on a mean of 2.1 (S.D. 1.3, range 0–5) psychotropics and 4.99 (S.D. 2.7, range 0–11) non-psychotropics. Mean Mini Mental State Examination (MMSE) score was 15 (S.D. 8.1). Increasing anticholinergic burden was negatively associated with MMSE scores (B = −1.72, p = 0.013). Residing in a nursing home was associated with a higher rate of antidepressant [OR 5.71 (95% CI 1.9–17.4)], anxiolytic [OR 13.5 (95% CI 1.7–110.4)] and antipsychotic [OR 3.4 (95% CI 1.1–10.4)] use. Potentially inappropriate prescribing included long-term benzodiazepine use (26%) and long-term antipsychotic use (25%).

Conclusions

Our sample had a high psychiatric morbidity burden with high levels of psychotropic use. Ongoing review and audit of psychotropic use in elderly patients can identify potentially inappropriate prescribing in a group vulnerable to high levels of polypharmacy and extended psychotropic use.

Keywords

Cross-sectional studyelderlyinappropriate prescribingnonagenarianpsychotropic drugs
Type
Original Research
Information
Irish Journal of Psychological Medicine , Volume 30 , Issue 3 , September 2013 , pp. 187 - 196
Copyright
Copyright © College of Psychiatrists of Ireland 2013 

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References

Alanen, HM, Finne-Soveri, H, Noro, A, Leinonen, E (2006). Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland. Age and Ageing 35, 508–513.CrossRefGoogle ScholarPubMed
Alexopoulos, GS, Streim, J, Carpenter, D, Docherty, JP (2004). Using antipsychotic agents in older patients. The Journal of Clinical Psychiatry 65, Suppl. 2. 5–99; discussion 100–102; quiz 3–4.Google ScholarPubMed
Alexopoulos, GS, Katz, IR, Reynolds, CF 3rd, Carpenter, D, Docherty, JP, Ross, RW (2001). Pharmacotherapy of depression in older patients: a summary of the expert consensus guidelines. Journal of Psychiatric Practice 7, 361–376.CrossRefGoogle ScholarPubMed
Banerjee, A (2009). The Use of Antipsychotic Medication for People with Dementia: Time for Action. UK Department of Health: London.Google Scholar
Barker, MJ, Greenwood, KM, Jackson, M, Crowe, SF (2004). Cognitive effects of long-term benzodiazepine use: a meta-analysis. CNS Drugs 18, 37–48.CrossRefGoogle ScholarPubMed
Barrett, A, Kenny, R (2011). Fifty Plus in Ireland 2011. Trinity College Dublin: Dublin.Google Scholar
Blazer, DG (2000). Psychiatry and the oldest old. American Journal of Psychiatry 157, 1915–1924.CrossRefGoogle ScholarPubMed
Beers, MH, Ouslander, JG, Rollingher, I, Reuben, DB, Brooks, J, Beck, JC (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Archives of Internal Medicine 151, 1825–1832.CrossRefGoogle ScholarPubMed
British Medical Association and the Royal Pharmaceutical Society of Great Britain (2011). British National Formulary, 62nd edn. BMJ Publishing Group. British National Formulary: UK.Google Scholar
Brown, MN, Lapane, KL, Luisi, AF (2002). The management of depression in older nursing home residents. Journal of American Geriatrics Society 50, 69–76.CrossRefGoogle ScholarPubMed
Carrillo-Alcala, ME, Bermejo-Pareja, F (2008). Dementia in nonagenarians. Systematic review of population-based studies with Spanish data. Revista de Neurologia 47, 347–354.Google ScholarPubMed
Catic, AG (2011). Identification and management of in-hospital drug-induced delirium in older patients. Drugs and Aging 28, 737–748.CrossRefGoogle ScholarPubMed
Clegg, A, Young, JB (2011). Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing 40, 23–29.CrossRefGoogle ScholarPubMed
Cumming, RG, Le Couteur, DG (2003). Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs 17, 825–837.CrossRefGoogle ScholarPubMed
Fick, DM, Cooper, JW, Wade, WE, Waller, JL, Maclean, JR, Beers, MH (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Archives of Internal Medicine 163, 2716–2724.CrossRefGoogle ScholarPubMed
Finkle, WD, Der, JS, Greenland, S, Adams, JL, Ridgeway, G, Blaschke, T, Wang, Z, Dell, RM, VanRiper, KB (2011). Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults. Journal of American Geriatrics Society 59, 1883–1890.CrossRefGoogle ScholarPubMed
Folstein, M, Folstein, S, McHugh, P (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189–198.CrossRefGoogle ScholarPubMed
Forsell, Y, Winblad, B (1997). Psychiatric disturbances and the use of psychotropic drugs in a population of nonagenarians. International Journal of Geriatrics Psychiatry 12, 533–536.3.0.CO;2-X>CrossRefGoogle Scholar
Forsell, Y, Jorm, AF, von Strauss, E, Winblad, B (1995). Prevalence and correlates of depression in a population of nonagenarians. British Journal of Psychiatry 167, 61–64.CrossRefGoogle Scholar
Formiga, F, Ferrer, A, Perez-Castejon, J, Riera-Mestre, A, Chivite, D, Pujol, R (2009). Mortality-associated factors in nonagenarian. The Nona-Santfeliu Study. Two years of follow-up. Revísta Clinica Española 209, 9–14.CrossRefGoogle ScholarPubMed
Frohnhofen, H, Michalek, C, Wehling, M (2011). Assessment of drug treatment in geriatrics with the new FORTA criteria. Deutsche Medizinische Wochenschrift 136, 1417–1421.CrossRefGoogle ScholarPubMed
Gaboda, D, Lucas, J, Siegel, M, Kalay, E, Crystal, S (2011). No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007. Journal of American Geriatrics Society 59, 673–680.CrossRefGoogle ScholarPubMed
Gallagher, P, Ryan, C, Byrne, S, Kennedy, J, O'Mahony, D (2008). STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. International Journsl of Clinical Pharmacology and Therapeutics 46, 72–83.CrossRefGoogle ScholarPubMed
Green, JL, Hawley, JN, Rask, KJ (2007). Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? The American Journal of Geriatric Pharmacotherapy 5, 31–39.CrossRefGoogle Scholar
Greene, N, Fahy, S, Walsh, C, O'Connell, H (2012). Potentially inappropriate medicines in older patients: comparison of screening tools. Psychiatry Professional 1, 18–22.Google Scholar
Gurvich, T, Cunningham, JA (2000). Appropriate use of psychotropic drugs in nursing homes. American Family Physician 61, 1437–1446.Google ScholarPubMed
Harris, J, Finucane, P, Healy, D, Bakarich, A (2002). Medication use in hospitalized nonagenarians. Internal Medicine Journal 32, 104–107.CrossRefGoogle ScholarPubMed
He, W, Muenchrath, M (2011). 90+ in the United States: 2006–2008. US Census Bureau, American Community Survey Reports. ACS-1.Google Scholar
Hilleret, H, Falconnet, C, Le Saint, L, Perrenoud, JJ, Michel, JP, Vogt-Ferrier, N (2008). Prescribing psychotropic drugs to patients aged 80 and over. Revue Médicale Suisse 4, 2405–2408, 2410–1.Google ScholarPubMed
Hovstadius, B, Hovstadius, K, Astrand, B, Petersson, G (2010). Increasing polypharmacy – an individual-based study of the Swedish population 2005–2008. BMC Clinical Pharmacology 10, 16.CrossRefGoogle ScholarPubMed
Huber, M, Kolzsch, M, Rapp, MA, Wulff, I, Kalinowski, S, Bolbrinker, J, Hofmann, W, Scholze, J, Drager, D, Kreutz, R (2012). Antipsychotic drugs predominate in pharmacotherapy of nursing home residents with dementia. Pharmacopsychiatry 45, 182–188.Google ScholarPubMed
Kolanowski, A, Fick, DM, Campbell, J, Litaker, M, Boustani, M (2009). A preliminary study of anticholinergic burden and relationship to a quality of life indicator, engagement in activities, in nursing home residents with dementia. Journal of the American Medical Directors Association 10, 252–257.CrossRefGoogle ScholarPubMed
Lagnaoui, R, Moore, N, Moride, Y, Miremont-Salame, G, Begaud, B (2003). Benzodiazepine utilization patterns in Alzheimer's disease patients. Pharmacoepidemiology and Drug Safety 12, 511–515.CrossRefGoogle ScholarPubMed
Laursen, TM (2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research 131, 101–104.CrossRefGoogle ScholarPubMed
Lee, PE, Gill, SS, Freedman, M, Bronskill, SE, Hillmer, MP, Rochon, PA (2004). Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review. BMJ 329, 75.CrossRefGoogle ScholarPubMed
Lesen, E, Carlsten, A, Skoog, I, Waern, M, Petzold, M, Borjesson-Hanson, A (2011). Psychotropic drug use in relation to mental disorders and institutionalization among 95-year-olds: a population-based study. International Psychogeriatrics 23, 1270–1277.CrossRefGoogle ScholarPubMed
Lonergan, E, Britton, AM, Luxenberg, J (2007). Antipsychotics for delirium. Cochrane Database Systemic Review. John Wiley & Sons Ltd: NY, USA.CrossRefGoogle ScholarPubMed
Mangoni, AA, Jackson, SH (2004). Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology 57, 6–14.CrossRefGoogle ScholarPubMed
McLeod, PJ, Huang, AR, Tamblyn, RM, Gayton, DC (1997). Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 156, 385–391.Google ScholarPubMed
Morandi, A, Jackson, JC, Ely, EW (2009). Delirium in the intensive care unit. International Review of Psychiatry 21, 43–58.CrossRefGoogle ScholarPubMed
Nybo, H, Petersen, HC, Gaist, D, Jeune, B, Andersen, K, McGue, M, Vaupe, J, Christensen, K (2003). Predictors of mortality in 2,249 nonagenarians – the Danish 1905-Cohort Survey. Journal of American Geriatrics Society 51, 1365–1373.CrossRefGoogle Scholar
O'Mahony, D (2011). Prevention of Adverse Drug Events (ADEs) in Hospitalised Older Patients (http://clinicaltrials.gov/ct2/show/NCT01467128). Accessed 12 September 2012.Google Scholar
Peltz, CB, Corrada, MM, Berlau, DJ, Kawas, CH (2011). Incidence of dementia in oldest-old with amnestic MCI and other cognitive impairments. Neurology 77, 1906–1912.CrossRefGoogle ScholarPubMed
Prasad, K, Gupta, H, Bharath, S, Prakash, O, Sivakumar, PT, Kumar, CN, Varghese, M (2009). Clinical practice with antidementia and antipsychotic drugs: audit from a geriatric clinic in India. Indian Journal of Psychiatry 51, 272–275.Google ScholarPubMed
Ravaglia, G, Morini, P, Forti, P, Maioli, F, Boschi, F, Bernardi, M, Gasbarrini, G (1997). Anthropometric characteristics of healthy Italian nonagenarians and centenarians. British Journal of Nutrition 77, 9–17.CrossRefGoogle ScholarPubMed
Rao, RL, Schears, RM (2010). Prescription use and survival among nonagenarians presenting to the ED. The American Journal of Emergency Medicine 28, 348–353.CrossRefGoogle ScholarPubMed
Seitz, D, Purandare, N, Conn, D (2010). Prevalence of psychiatric disorders among older adults in long-term care homes: a systematic review. International Psychogeriatrics 22, 1025–1039.CrossRefGoogle ScholarPubMed
Vaupel, JW, Zhang, Z, van Raalte, AA (2011). Life expectancy and disparity: an international comparison of life table data. BMJ Open 1, e000128.CrossRefGoogle ScholarPubMed
Wastesson, JW, Parker, MG, Fastbom, J, Thorslund, M, Johnell, K (2011). Drug use in centenarians compared with nonagenarians and octogenarians in Sweden: a nationwide register-based study. Age and Ageing 41, 218–224.CrossRefGoogle ScholarPubMed
Wehling, M (2011). Guideline-driven polypharmacy in elderly, multimorbid patients is basically flawed: there are almost no guidelines for these patients. Journal of American Geriatrics Society 59, 376–377.CrossRefGoogle ScholarPubMed
Wen, Z, Bi-Rong, D, Chang-Quan, H, Zhen-Chan, L, Yuan, Z, Hong-Mei, W, Yan-Ling, Z, Hui, W, Ping, H (2010). Depression and hypertension among Chinese nonagenarians and centenarians. Interantional Journal of Geriatrics Psychiatry 25, 554–561.CrossRefGoogle ScholarPubMed
WHO (2004). International Statistical Classification of Diseases and Health Related Problems. WHO: Geneva.Google Scholar
Wolff, JL, Starfield, B, Anderson, G (2002). Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine 162, 2269–2276.CrossRefGoogle ScholarPubMed
Woods, SW (2003). Chlorpromazine equivalent doses for the newer atypical antipsychotics. The Journal of Clinical Psychiatry 64, 663–667.CrossRefGoogle ScholarPubMed