De facto imprisonment and covert medication use in general nursing homes for older people in South East England

BACKGROUND AND AIMS: There is growing interest in ethical issues in nursing home care, including capacity to consent to residence and covert medication use. This study assessed capacity to consent to residence amongst a group of randomly selected residents of non-specialist UK nursing homes and examined the prevalence of de facto imprisonment and covert medication. METHODS: A cross-sectional prevalence study amongst residents in randomly selected non-specialist nursing homes in South East England. 445 residents (97 men and 348 women) were randomly selected from 157 nursing homes. RESULTS: 14% (64) of the residents interviewed lacked the capacity to consent to residence. 6.1% (27) of residents were prevented from leaving but less than half of these lacked the mental capacity to consent to residence and may be therefore, de facto, unlawfully imprisoned. 4.7% (21) of residents on medication had received it covertly in the nursing home. CONCLUSIONS: A significant number of residents in the nursing homes studied did not appear to have the mental capacity to consent to being there, possibly in contravention of the Human Rights Act 1998. There appears to be a small but worrying prevalence of de facto imprisonment, and covert medication use in residents without severe cognitive impairment.     

Mental illness and psychotropic medication use in the nursing home

The authors examined mental illness and psychotropic medications use among nursing home residents. Data were drawn from the Texas Long-Term Care Reimbursement Project, a 1986 study of nearly 2,000 residents in 49 nursing homes. The study measured the use of antipsychotics and other psychotropic medications, physical health conditions, mental illness diagnoses, behavior, and nursing and other direct-care time for sampled residents. The findings indicated that 45% of the sample was receiving an antipsychotic or other psychotropic medication. Although psychotropics were prescribed more extensively for those with a psychiatric diagnosis, nearly one half of persons without a psychiatric diagnosis were receiving psychotropic medications at the time of the survey. Moreover, psychotropics were quite prevalent among those with unstable medical conditions and/or severe activities of daily living impairment. Neither a mental illness diagnosis, evidence of a behavioral problem, nor use of psychotropics was significantly correlated with the amount of nursing or other direct-care time received by residents. The findings raise concerns about the widespread prescribing of these medications, especially among residents who have no supporting psychiatric diagnosis and/or who have physical health conditions making them vulnerable to adverse drug effects.     

Specialized dementia programs in residential care settings

The authors conducted a telephone survey in 7 states to determine the prevalence of residential care specialized dementia programs (RC-SDPs) and to identify a sample of homes (n = 56) for more detailed study. The 56 homes were site visited, and data were gathered on facility administration, therapeutic environment, and characteristics of 259 randomly selected residents. Comparison data from 138 nursing home Special Care Units (NH-SCUs) and 1,340 of their residents were obtained from 4 studies conducted in the same 7 states. RC-SDPs were smaller, provided a more homelike environment, and had a higher proportion of residents paying privately, compared with NH-SCUs. Mean levels of cognitive and physical impairment among residents were higher in NH-SCUs; prevalences of psychotropic medication use and problem behaviors were similar. Among RC facilities, small homes were more homelike, provided fewer structured activities, and charged less than larger facilities. RC-SDPs include 5 types: small, independently operated homes; multiple small homes with joint administration; larger, all-dementia facilities; SDPs operated within larger, exclusively RC facilities; and RC-SDPs in multilevel facilities.     

Australia's use of the Cornell scale to screen for depression in nursing homes

Aim: To examine the utility of the Cornell scale for depression in dementia (CSDD), following its introduction as a routine measure in nursing homes. Methods: The CSDD is administered in Australian nursing homes as section 10 of the Aged Care Funding Instrument. CSDD, cognitive and behavioural ratings, and medication use, recorded in three Sydney nursing homes in 2008–2009 were reviewed. Staff discussed what actions were taken if CSDD scores indicated depression. Results: Of 223 residents, 23% scored >12 on the CSDD, indicating probable depression. Another 21% were possibly depressed and 29% not depressed. The CSDD had not been completed for 27%, commonly because preliminary screening indicated no depression, but sometimes because severe cognitive impairment made various CSDD items impossible to rate. Second CSDD assessments had usually not been made. Conclusion: Nursing homes need to document policies that will ensure best use is made of CSDD findings.     

Health status and assessed need for a cohort of older people admitted to nursing and residential homes

OBJECTIVE: to investigate dependency and health status of a cohort of older people admitted for long term nursing or residential care and to compare these findings with assessments conducted by social services departments prior to placement. DESIGN: retrospective cohort study. SETTING: residential, nursing and dual registered homes within Nottingham Health Authority boundaries. SUBJECTS: 205 residents placed over 3 months. MAIN OUTCOME MEASURES: levels of disability, cognitive impairment and behavioural disturbance identified by assessment before and after admission. RESULTS: cognitive impairment and physical disability were significantly higher in nursing homes, although a third of residents in residential care had substantial physical disability. In nursing homes, a quarter of residents had low dependency needs but these had greater cognitive impairment than those in residential homes with the same level of dependency. Most residents had some degree of behavioural disturbance (particularly in nursing homes) and more severe disturbance was associated with greater cognitive impairment and more depressed mood, but not physical disability. A moderate level of agreement was found between preadmission and follow-up assessments of health status. CONCLUSIONS: a case-mix which includes higher dependency residents in residential homes and lower dependency residents in nursing homes is likely to reflect changes in the health status of residents following placement but also suggests that a range of placement criteria were used together, rather than individual indicators of need. Although pre-placement measures of disability and dependency were supported by follow-up assessments, it is essential that the needs of residents in long-term care are adequately monitored and managed, in particular those in residential care with higher dependency needs.     

Dependency in older people recently admitted to care homes

OBJECTIVE: to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care. METHOD: we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication. RESULTS: 50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder. DISCUSSION: the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.     

A Psychogeriatric Outreach Service to Nursing Homes in Sydney

Objective: To describe nursing home referrals to a multidisciplinary psychogeriatric outreach service. Methods: Retrospective case note audit of all nursing home referrals to a psychogeriatric outreach service in Sydney during 1996. Results: Of 106 referrals (mean age 76.9 years) from 22 nursing homes, 101 (95%) were assessed in the home. Behavioural problems were identified in 87 referrals (82%), usually being associated with chronic organic brain syndromes including dementia (n = 75, 86%). Aggressive behaviours (45%), agitation (32%), uncooperativeness (17%) and vocally disruptive behaviour (16%) were the most frequently identified problems. Depression was diagnosed in 33 referrals (31%), often comorbid with dementia (n = 16). Multiple diagnoses were present in 58 (55%) referrals. The most frequent treatment recommendations related to the use of nursing interventions (73%), psychotropic medication (70%), behavioural programs (29%) and family involvement (29%). Admission to the acute psychogeriatric ward occurred in 18 cases (17%). Conclusion: Psychogeriatric services should provide adequately staffed outreach teams to nursing homes.     

Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia

OBJECTIVES: To evaluate the effect of regularly scheduled administration of analgesic medication on behavior, emotional well-being, and use of as-needed psychotropic medications in nursing home residents with moderate-to-severe dementia. DESIGN: Randomized, double-blind, placebo-controlled, crossover trial. SETTING: Nursing-home based. PARTICIPANTS: Twenty-five nursing home residents with moderate-to-severe dementia. INTERVENTION: Participants received 4 weeks of acetaminophen (3,000 mg/d) and 4 weeks of placebo. MEASUREMENTS: Behavior and emotional well-being were assessed using Dementia Care Mapping, an observational method that quantifies time spent in behaviors across 26 domains (e.g., social interaction, unattended distress) and assesses emotional state while behaviors are being observed. Agitation was measured using the Cohen-Mansfield Agitation Inventory. As-needed psychotropic medication use was aggregated from medication logs. RESULTS: Participants spent more time in social interaction, engaged with media, talking to themselves, engaged in work-like activity, and experiencing unattended distress when they received acetaminophen than they did when they received placebo. Participants also spent less time in their rooms, less time removed from the nursing home unit, and less time performing personal care activities when they received acetaminophen. There were no effects on agitation, emotional well-being, or as-needed psychotropic medication use. CONCLUSION: Untreated pain inhibits activity in nursing home residents with moderate-to-severe dementia. Pain treatment in this group may facilitate engagement with the environment.     

Happy pills in nursing homes in Belgium: A cohort study to determine prescribing patterns and relation to fall risk

BackgroundMental problems are common in nursing homes, and the medical answer to these conditions is largely pharmacological. However, frail elderly people are particularly vulnerable to psychotropic-related adverse effects. This study documents the current use of psychotropics in Flemish nursing homes, and examines the relation to fall risk.MethodsThis is a cohort study in 651 nursing home residents in 53 nursing homes in Flanders, Belgium. The use of antidepressants, anxiolytics, sedatives, and antipsychotics was registered from the patients' medication charts. The incidence of subsequent falls was registered for a period of 6 months.ResultsIn this cohort, 74.8% of nursing home residents without dementia used at least one psychotropic drug; almost 20% used an antipsychotic, approximately 40% used one or more antidepressants; and approximately 60% used one or more benzodiazepines or benzodiazepine-related drugs. The most prescribed antipsychotic was risperidone (35.1%); the most common benzodiazepine was lormetazepam (54.8%); and the most frequent antidepressants were citalopram/escitalopram (38.9%) and trazodone (24.9%). The use of psychotropics was mostly chronic. Falls were registered in 24.1% of participants; they were mainly associated with antidepressant use (odds ratio 1.38), and especially with trazodone (odds ratio 1,94).ConclusionDespite recommendations against chronic use and a growing body of evidence showing the risk of side effects, the use of psychotropic drugs currently is still alarmingly high in Flemish nursing home residents without dementia. Strategies to optimize prescribing are discussed.     

The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective

OBJECTIVES: To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation. DESIGN: A retrospective cross-sectional study SETTING: Nursing homes in five US states and selected nursing homes in Denmark, Iceland, Italy, Japan, and Sweden. PARTICIPANTS: Residents in nursing homes in five US states and the aforementioned countries during 1993-1996. MAIN OUTCOME MEASURES: Using data collected using the Minimum Data Set, logistic regression provided estimates of the legislative effects on the use of antipsychotics and antianxiety/hypnotics while simultaneously adjusting for potential confounders. The occurrence of falls was evaluated similarly. RESULTS: Prevalence of antipsychotic and/or antianxiety/ hypnotic use varied substantially across countries. After adjustment for differences in age, gender, presence of psychiatric/neurologic conditions, and physical and cognitive functioning, residents in Denmark, Italy, and Sweden were at least twice as likely to receive these drugs (Denmark Odds Ratio (OR)=2.32; 95% Confidence Intervals (CI), 2.15-2.51; Italy OR=2.05; 95% CI, 1.78-2.34; Sweden OR=2.50; 95% CI, 2.16-2.90); in Iceland, the risk was increased to greater than 6 times (OR=6.54; 95% CI, 5.75-7.44) that of the US. Residents were less likely to fall in Italy, Iceland, and Japan compared with the US, despite more extensive use of psychotropic medication, whereas residents in Sweden and Denmark were more likely to fall. CONCLUSIONS: Policy has had an impact on the prescribing of psychotropic medication in US nursing homes compared with other countries, but it is unclear if this is translated into better outcomes for residents.     

Physical restraint use and cognitive decline among nursing home residents.

OBJECTIVE: This study investigated the association between physical restraint use and decline in cognition. DESIGN: Cohort analytic study describing changes in resident characteristics. SETTING: Eight nursing homes, both urban and suburban, operated by a proprietary corporation in a large metropolitan area. PARTICIPANTS: 437 nursing home admissions, with 201 remaining at 1 year. MAIN OUTCOME MEASURES: Cognitive status was measured by geropsychiatrists, using the Folstein Mini-Mental State Exam, during a psychiatric evaluation of the resident. Daily restraint use was documented from nursing orders. Observations were made at 2 weeks, 10 weeks, and 1 year. RESULTS: Restraint use alone and in combination with neuroleptic use was associated with poor cognition. Other variables associated with poor cognitive scores were: ADL impairment, poor adaptive behavior, and longer time in the nursing home. The use of neuroleptics alone was not significant. Variables which were associated with good cognitive status were: being non-ambulatory but without dementia and having strong social support. CONCLUSIONS: These findings raise the possibility that restraint use may contribute to cognitive impairment, specifically among residents who have moderate to no cognitive impairment at admission; however, the findings do not exclude an alternative explanation that residents undergoing cognitive decline are more likely to be put in restraints. Further research is needed to understand whether factors which can be manipulated contribute to cognitive decline.     

Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units

OBJECTIVES: To explore the extent of and factors associated with male nursing home residents who wander. DESIGN: Cross-sectional design with secondary data analyses. SETTING: One hundred thirty-four nursing home facilities operated by the Department of Veterans Affairs. PARTICIPANTS: Fifteen thousand ninety-two nursing home residents with moderate or severe cognitive impairment admitted over a 4-year period. MEASUREMENTS: Selected variables from the Minimum Data Set included ratings recorded at residents' admission to the nursing home (cognitive impairment, mood, behavior problems, activities of daily living, and wandering). RESULTS: In this sample of residents with moderate or severe cognitive impairment, the proportion of wanderers was found to be 21%. Wanderers were more likely to exhibit severe (vs moderate) cognitive impairment, socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion or ambulation, and dependence in activities of daily living related to basic hygiene. A sizable proportion of wanderers were found to be wheelchair users (25%) or were wanderers with dual dementia and psychiatric diagnoses (23%), characteristics that are not well documented in the literature. CONCLUSION: These results support previous clinical understanding of wanderers to be those who are more likely to exhibit more-severe cognitive impairment. Based on a statistical model with variables generated from prior research findings, classification as a wanderer was found to be associated with other disruptive activity such as socially inappropriate behavior and resisting care. Two understudied populations of wanderers were documented: wheelchair wanderers and those with comorbid dementia and psychiatric diagnoses. Future longitudinal studies should examine predictors of wandering behavior, and further research should explore the understudied subpopulations of wheelchair and dual-diagnosis wanderers who emerged in this study.     

Mental illness and the use of restraints in nursing homes.

Using data from 441 newly admitted nursing home residents, we examined whether the diagnoses of mental illnesses, as well as other resident characteristics, were associated with use of physical restraints in both high restraint and low restraint use homes. Predictors of restraint use during both the first month and the first year of admission were inability to transfer and having a combination of severe ADL and cognitive impairment. Other predictors were wandering, inability to dress, symptoms of depression, and severity of cognitive impairment.     

Withdrawal of haloperidol, thioridazine, and lorazepam in the nursing home: a controlled, double-blind study.

BACKGROUND: Ongoing regimens of haloperidol, thioridazine, and lorazepam are commonly administered to manage behavior problems in nursing home residents. Nevertheless, there is controversy over whether periodic drug withdrawal should be attempted when those medications are prescribed. This study addressed that issue by examining the effects of discontinuing treatment with haloperidol, thioridazine, and lorazepam among residents of a large suburban nursing home. METHODS: In a double-blind, crossover study, half of 58 nursing home residents (43 women and 15 men with a mean age of 86 years) continued to take the psychotropic medication they had been prescribed, whereas the other half were tapered to placebo. After 6 weeks of taking placebo or original drug, patients were tapered to the reverse schedule and remained on it for 6 weeks. Assessments included informant ratings by the nursing staff who completed the Brief Psychiatric Rating Scale and the Cohen-Mansfield Agitation Inventory. RESULTS: Analyses comparing residents taking placebo to those taking medication after completion of the first phase showed no impact of drug therapy discontinuation on their behavior. Similarly, using the crossover design to compare residents' behaviors while taking placebo vs. taking drugs, withdrawal of medication had no impact on Cohen-Mansfield Agitation Inventory or Brief Psychiatric Rating Scale scores. CONCLUSIONS: Results of this work suggest that longterm use of haloperidol, thioridazine, and lorazepam in nursing homes to manage agitation should be closely monitored for their efficacy. Furthermore, routine attempts at drug withdrawal should be considered for most residents taking psychotropic medication.     

Tracking the Cognition of Nursing Home Residents

Although estimates place the prevalence of dementia in nursing home residents at approximately 50%, the longitudinal course of cognition and cognitive impairment in nursing home residents are not well understood. Using data from 33 long-term care residents, patterns of performance on the Mini-Mental State Examination across multiple quarterly administrations were examined. Results show that four distinct patterns were evident: declining, stable, improving, and inconsistent performance. Although a number of residents exhibited declines in performance across multiple administrations, the performance of the majority of residents either remained stable or improved. Few clinical correlates of patterns of performance were observed in this cohort. These results have implications for providers working in nursing homes and raise important questions for future research.