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Age and Ageing Advance Access originally published online on June 28, 2006
Age and Ageing 2006 35(5):508-513; doi:10.1093/ageing/afl065
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© The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland

Hanna-Mari Alanen1, Harriet Finne-Soveri2, Anja Noro2 and Esa Leinonen1,3

1 University of Tampere Medical School, University of Tampere, FIN-33014 Tampere, Finland
2 STAKES, Centre for Health Economics CHESS, FIN-00530 Helsinki, Finland
3 Department of Psychiatry, Tampere University Hospital, FIN-33380 Pitkäniemi, Finland

Address correspondence to: H.-M. Alanen. Tel: (+358) 3 215611. Fax: (+358) 3 2156164. Email: hanna-mari.alanen{at}uta.fi

Received 6 November 2005; accepted in revised form 23 May 2006


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 
Background: there is a paucity of information about the use of antipsychotic medication in long-term care, especially among the oldest-old residents.

Objective: to analyse the factors associated with the use of antipsychotic medication among nonagenarian residents in long-term institutional care.

Design: a retrospective study was designed from cross-sectional data, gathered in the period 1 January 2003 to 30 June 2003, in Finland. Data were extracted from the Resident Assessment Instrument database, based on Minimum Data Set 2.0 assessments.

Setting: data were provided by 23 hospital-based institutions and 43 residential homes.

Subjects: residents aged ≥90 years were included, consisting of 1,334 resident assessments.

Results: almost a third of the residents received one or more antipsychotic medication. In the logistic regression analysis, factors associated with the use of antipsychotics among nonagenarian residents were as follows: socially inappropriate or disruptive behavioural symptoms [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.36–2.54], concomitant anxiolytic medication (OR 1.83, 95% CI 1.39–2.42), recurring anxious complaints (OR 1.61, 95% CI 1.17–2.22), recurring physical movements (OR 1.43, 95% CI 1.08–1.91) and unsettled relationships (OR 1.35, 95% CI 1.15–1.57). A good sense of initiative or involvement was significantly less likely to be associated with antipsychotics (OR 0.86, 95% CI 0.80–0.94). There were no associations between any psychiatric diagnoses or symptoms and the use of antipsychotics.

Conclusions: antipsychotic medication use in nonagenarians in long-term institutions was common and seemed in many cases to be associated with residents’ negative attitudes to others. Querulous residents received antipsychotics more commonly than those with good social skills. Clearly defined indications may not be fulfilled in many cases, and an evaluation of treatment may be lacking. These may indicate that in Finland, there could be a considerable gap between antipsychotic medication recommendations and actual clinical practice.

Keywords: antipsychotic agent, long-term institutional care, nonagenarian, Minimum Data Set, elderly


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 
The oldest old (≥85 years) are the fastest growing age group in the population throughout the developed world. It has been estimated that the prevalence rate of centenarians in industrialised countries is 0.5–1 per 10,000 [1, 2]. The number of octogenarians has grown 4-fold, nonagenarians 8-fold and centenarians >20-fold from 1950 to 1990 [2]. In 2003 in Finland, 1.6% of the population was aged ≥85 years [3], and 18.4% of them were permanently in long-term institutional care including nursing homes and hospitals [4].

Antipsychotics are widely used in nursing homes in the UK and the US [5, 6]. Oborne and coworkers stated that 24.5% of residents in nursing homes in the UK used antipsychotics (estimated appropriate use 18%) [5]. The corresponding rate in the US study was 27.6% (appropriate 19%) [6]. Less than half of residents in that study received antipsychotics in accordance with nursing home prescribing guidelines. However, an outcome of >40% antipsychotic treatment has been reported among residents with dementia in residential placements when psychological and environmental interventions have been ineffective [7].

The treatment data deficiency is most striking among the oldest-old and frail medically ill elderly patients [8]. According to the Expert Consensus Guidelines (US 2004), antipsychotics in the elderly are indicated for disorders with psychotic symptoms, that is schizophrenia, mania with psychosis, agitated dementia with delusions, psychotic major depression and delusional disorders [9]. On the contrary, experts do not recommend antipsychotics for irritability and hostility in the absence of a major psychiatric syndrome, non-psychotic major depression, generalised anxiety disorder, hypochondriasis or insomnia/sleep disturbance without a major psychiatric syndrome. Atypical antipsychotics have been recommended for behavioural and psychiatric symptoms in dementia [9], even though the evidence of their effectiveness is still scanty [10]. An increased risk of serious cerebrovascular adverse events (CVAEs) and mortality has also been associated with the use of atypical antipsychotics in older patients with dementia [11]. Regulators in Europe and the US now warn of the risks and off license use of these drugs [12, 13]. However, some recent studies have reported that older patients with dementia who take atypical antipsychotics have a CVAE risk similar to that of those taking typical antipsychotics [14].

The aim of this study was to analyse the use of antipsychotic medications and associated factors among nonagenarian residents in long-term institutional care in Finland. We hypothesised that the use of antipsychotic medication would be common among nonagenarians in institutions and would be associated with psychotic and behavioural symptoms of dementia.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 
The data were drawn from the Resident Assessment Instrument (RAI) database consisting of Minimum Data Set (MDS) assessments version 2.0 for long-term care facilities. The RAI database is located in STAKES (National Research and Development Centre for Welfare and Health, Finland). The assessments extracted originated from 23 hospital-based long-term care institutions (69 wards) and 43 residential homes (190 wards) in 26 municipalities located in different parts of Finland. Every resident aged ≥90 years was included in the extracted set. Data from altogether 1,334 residents were gathered. All the units were classified for elderly care and none for psychiatric care.

The extracted data set covered the period from 1 January to 30 June in 2003. The 6-month follow-up periods embedded in the database were originally designed for scientific, administrative and organisational purposes, and this time period was adopted for the present analysis. In the time period, each resident was assessed only once and there were no exclusion criteria or refusals. Units providing assessments to the RAI database collaborate on a voluntary basis. The total number of assessments represents ~20% of the Finnish long-term institutional care population in 2003.

The MDS assessment includes demographic information such as age, gender, marital status, place of admission, length of stay and history of psychiatric and medical illnesses. The diagnoses (ICD-10) for the assessments were taken from medical records, as recorded by the treating physicians [mostly general practitioners (GPs)]. Due to the high prevalence of dementia in long-term care facilities and in order to ascertain the prevalence of psychiatric disorders not linked to dementia, the psychiatric diagnoses available in the data were reclassified into a hierarchical order as follows: (i) all residents with any diagnosed form of dementia, (ii) residents without dementia and with schizophrenia, (iii) residents without dementia and without schizophrenia but with diagnoses of mood disorders and (iv) residents without all the above diagnoses but with diagnosis of anxiety. Actual medical diagnoses were gathered, such as stroke, deep venous thrombosis, hip fracture, diabetes and cardiovascular diseases.

The personnel performing the MDS assessments on each of the wards had received minimum 20-h standardised education that included assessments step-by-step according to the training manual [15] and the use of software [16].

MDS assessment questionnaires consist of nearly 400 variables that have been proven valid and reliable in several countries [17, 18]. Five of the MDS items from different sections are combined to form the Cognitive Performance Scale (CPS, scale 0–6, where 0 equals intact cognition and 6 equals very severe decline) for measuring cognition [19–21]. The CPS is very reliable compared with Mini-Mental State Examination (MMSE) [21] and the Test for Severe Impairment (TSI) [20, 21]. Four of the MDS items are combined to form the Activity of Daily Living (ADL) hierarchy scale (scale 0–6, where 0 equals normal functional capacity and 6 equals very severe decline) for measuring physical function. On the Depression Rating Scale (DRS, scale 0–14), at least 3 points refer to probability of depression [22].

In addition, MDS questionnaire includes evaluations of several possible indicators of psychiatric and behavioural symptoms such as wandering, verbally or physically abusive, socially disruptive behaviour or resisting care (Table 1). The evaluation is based on the observations made by the personnel according to the instructions in the manual over a 7-day period during assessment. The condition is coded for whether present or not. Mood and behaviour, sense of initiative/involvement and unsettled relationship items are given in detail in Table 2. The usability of the variables has been tested and validated [23, 24].


View this table:
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  		Table 1.. Use of antipsychotic medications by diagnosis, psychotropic medication and behavioural and psychiatric symptoms in 2003 in Finnish nonagenarian residents in institutions (n = 1,334)

 

View this table:
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  		Table 2.. Use of antipsychotic medications by individual items of Minimum Data Set (MDS) in 2003 in Finnish nonagenarian residents in institutions (n = 1,334)

 

All statistical analyses were performed using SAS version 8.2 (SAS Institute, Cary, NC, USA). Socio-demographic factors were tested using either chi-square test or Student’s t-test. Variables (Table 1) and individual items of entities (Table 2) were dichotomised to 0 or 1. The associations between them and antipsychotic use were then tested using chi-square test. Then, a summary scale was formed in which the new dichotomic variable was 0 if no signs in any individual item of entities ‘sense of initiative/involvement’ or ‘unsettled relationships’ (Table 2) were found and was 1 if any of them was present. These new variables were likewise first tested separately with chi-square test. Statistically significant (P<0.05) factors according to these tests were included in the logistic regression model. The statistical analyses were performed stepwise.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 
Univariate results
The mean age of the sample was 92.9 years (±2.7) (range 90–107), and 88% were women. Of the residents, 5.5% had a previous history of mental illness and 1.5% of them had arrived from a psychiatric hospital. The prevalences of psychiatric diagnoses were as follows: dementia 58.6%, depression 11.5%, anxiety disorders 2.2% and schizophrenia 1.0%. The prevalence of moderate or severe cognitive impairment (CPS 3–6) was 71.4%, whereas it was 19.5% for mild cognitive impairment (CPS 1–2), and 8.8% were assessed to be without any sign of cognitive impairment at all.

The proportion of residents prescribed one or more antipsychotics was 29.5% of the study population. There were no associations between the use of antipsychotics and age or gender. Of the residents, 49.3% of those with previous psychiatric history used antipsychotics. The proportion of residents prescribed antidepressants was 33.8%, anxiolytics 26.4% and hypnotics 33.7%. Twenty-eight per cent received no psychotropic medication.

A third (32.6%) of residents with a diagnosis of dementia received antipsychotics. In residents with moderate to severe cognitive impairment (CPS 3–6), the proportion of antipsychotics use was 31.8%, 28.1% with mild cognitive impairment (CPS 1–2) and 10% in cognitively intact subjects (P<0.0001). Residents who had some psychiatric diagnosis (except dementia) used antipsychotics more often (39.9%) than those without (27.6%) (P<0.0004). The comparisons of antipsychotic use between the groups with and without diagnosis, medications and symptoms are given in Table 1 and other behavioural items in Table 2.

Among medical diagnoses, the most striking associations between the use of antipsychotics were found with hip fracture (37.4%, P<0.0027) and deep venous thrombosis (52.4%, P<0.021). In the residents with a diagnosis of stroke (11.9%), the prescription rate of antipsychotics was (in univariate analysis) lower than without this diagnosis. No statistically significant associations of antipsychotic use were found in residents with diabetes mellitus or cardiovascular diseases. Moreover, impaired hearing and vision were not associated with the use of antipsychotics. Residents who were bedridden all or most of the time (26.9%) received antipsychotics (29.8%) as frequently as the rest of the population.

Multivariate results
Logistic regression modelling identified factors that were significantly independently associated with the use of anti- psychotics among nonagenarian residents in 2003: socially inappropriate or disruptive behavioural symptoms [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.36–2.54], concomitant anxiolytic medication (OR 1.83, 95% CI 1.39–2.42), recurring anxious complaints (OR 1.61, 95% CI 1.17–2.22), recurring physical movements (OR 1.43, 95% CI 1.08–1.91) and unsettled relationships (OR 1.35, 95% CI 1.15–1.57) (Table 3). Those with a good sense of initiative or involvement were significantly less likely to be taking antipsychotics (OR 0.86, 95% CI 0.80–0.94). In multivariate analysis, the significance of association between antipsychotic drug use and any dementia, cognitive impairment or any psychiatric diagnosis disappeared.


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  		Table 3.. Results of logistic regression analysis explaining antipsychotic drug use in 2003 among Finnish nonagenarian residents in institutions (n = 1,334)

 


   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Conclusions
 Key points
 Conflicts of interest
 References
 
The residents in this study represent the upper end of age in the institutionalised elderly population. Because of the high age, the proportion of women and residents with some cognitive impairment was high. Studies on antipsychotic drug use frequency in such high age populations are rare. There are some reports about antipsychotic use in ‘younger’ elderly as well as in special groups such as patients with dementia [7, 25]. Elderly men have been reported to receive more antipsychotics than women [26]. However, in the present study, there was no difference between genders in antipsychotic use.

The main finding this study on 1,334 nonagenarian residents was the relatively high level of antipsychotic prescribing in long-term care: 30% received antipsychotic medication. This finding concurs with Hosia-Randell and Pitkälä in 2005 [27], who stated that 31.3% of nonagenarian residents in nursing homes in Helsinki were taking antipsychotics. Accordingly, the present result is in line with the previous findings of study groups of Oborne (24.5%) and Briesacher (27.6%), even though the residents in the present study were older [5, 6]. In the study by Lindesay et al., 2003 [26], the proportion (17%) of antipsychotics used in nursing home residents aged >85 years seemed to be smaller. In contrast, only 5% of Swedish nonagenarians received antipsychotics [28]. However, three quarters of them were living in their own homes.

Cognitive impairment was associated with behavioural problems and use of antipsychotic medication in the UK [25]. Börjesson-Hanson et al. [29] reported that the prevalence of dementia among institutionalised subjects aged 95 years was 78%. However, in the present study, only 58.6% of nonagenarian residents had diagnosis of dementia, but ~90% had cognitive impairment of some degree. This discrepancy is due to the fact that the cause of cognitive impairment in this age group is only infrequently ascertained. Approximately one-third of residents with a diagnosis of dementia received antipsychotics, but logistic regression model did not reveal significant differences in antipsychotic use between residents with dementia or cognitive impairment and the rest of the study population. Thus, in this oldest-old population, cognitive impairment is so common that its role alone in necessitating antipsychotic treatment may not be as crucial as in younger age groups.

Around 15% of the residents in this study had some major psychiatric diagnosis (other than dementia), and 40% of them used antipsychotics. This seemed to be higher than that reported in Sweden, where 9% of 85-year-old population (not in institutions) who had some psychiatric diagnosis (24.3%) were using antipsychotics [30]. In the present study, the prevalence of antipsychotic use among those residents suffering from anxiety disorders was higher (62%) than in the rest of the population (28.8%). In the logistic regression model, however, the difference was no longer significant. Among residents with schizophrenia, the use of antipsychotics only tended to be higher (54%) than in other residents even in the univariate model. Briesacher et al. [6] in 2005 stated that those using antipsychotics compared with non-users were more likely to have schizophrenia, delusional disorders, hallucinations and anxiety. This contradicts the present findings of no associations between major psychiatric diagnoses or symptoms (delusions and hallucinations) and the use of antipsychotics. The difference between the studies may be due to the fact that the residents in the US study were about 10 years younger than in the work in hand. Productive psychiatric symptoms in the oldest old may no longer be prominent even in major psychiatric disorders.

In univariate analyses, medical diagnoses such as hip fracture and deep venous thrombosis were associated with more frequent antipsychotic use. However, residents with a diagnosis of stroke were prescribed less antipsychotics. In the multivariate model, however, all these differences disappeared.

In the logistic regression model, only five aspects were associated with increased frequency of antipsychotic use: socially disruptive behavioural symptoms, concomitant anxiolytic medication, recurring anxious complaints, recurring physical movements and unsettled relationships, all of which would be inappropriate indications for antipsychotic use. However, these findings concur with those of Briesacher and coworkers [6] in 2005, who stated that non-aggressive behavioural problems, such as restlessness (51.7%), unsociability (34.2%), uncooperativeness (30.4%) and indifference to their surroundings (25.1%), were common among residents receiving inappropriately prescribed antipsychotics.

Antipsychotic drug use among nonagenarians with concomitant use of anxiolytics was decidedly high. More than one in four (26%) of the Finnish nonagenarian residents in this study received anxiolytics, and 44% of them received concomitant antipsychotics. Of the nonagenarians, only 2% suffered from anxiety disorders, and despite the fact that these disorders had seldom been properly diagnosed, the symptoms were frequently registered. In old age, anxiety has been reported to be associated with female sex, stressful life events, insufficient network and having no regular visitors [31, 32].

Individuals who had good sense of initiative or involvement were less likely to receive antipsychotic medication. They could interact easily with others and were involved in group activities and responded positively to new activities. It is unlikely that these residents were less cognitively impaired and therefore possessed more social skills because forcing the CPS scale into the final regression model, the protecting power of the social skills did not deteriorate. It may be that antipsychotics are used in many cases to relieve symptoms associated with the lack of social contacts or poor life satisfaction.

Potential limitations in this study include its retrospective nature and the limitations of the MDS to reveal the lack of indications for the use of antipsychotics, their dosages and duration and also the inability to distinguish between new atypical antipsychotics and typical neuroleptics that are not included in the assessment. These issues warrant further study. Moreover, OBRA‘87 (The Omnibus Budget Reconciliation Act of 1987) guidelines [33] concerning the appropriateness of antipsychotic drug treatment were not specifically checked in this study. Although MDS items have demonstrated good to excellent reliability, these studies have not been performed specifically on the oldest old. Moreover, these data did not include any severity or frequency assessment of psychotic or behavioural symptoms. One limitation in this study is the nature of the sample: the view is restricted to the population in long-term institutional care. Although half of those aged ≥95 years reside in nursing homes, this sample cannot be representative of very old persons living in the community.


   Conclusions
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
Key points
 Conflicts of interest
 References
 
Antipsychotic medication use in nonagenarians in long-term institutions was common and seemed in many cases to be associated with the residents’ negative attitudes to others. However, it may be possible to make a reliable distinction of these attitudes from behavioural symptoms. In this study, clearly defined indications may not be fulfilled in many cases, and an evaluation of treatment may be lacking. Thus, there seems to be a considerable gap between antipsychotic medication recommendations and clinical practice. The risk of inappropriate use of antipsychotics might be especially high in those residents who were querulous or had staff–resident friction. More attention should be paid to the appropriate use of antipsychotics among this frail population. There is a need to redress this balance to ensure that the prescribing of antipsychotics in very old people is done according to the guidelines.


   Key points
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 Key points
Conflicts of interest
 References
 

  • Almost a third of nonagenarian residents received one or more antipsychotic medication.
  • Querulous residents received antipsychotics more commonly than those with good social skills.
  • There were no associations between any psychiatric symptoms or diagnoses including dementia and the use of antipsychotics.


   Conflicts of interest
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
References
 
There are no conflicts of interest to declare.


   Acknowledgements
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 
The authors thank interRAI for the use of the MDS instruments in data collection.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Conclusions
 Key points
 Conflicts of interest
 References
 

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