Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden
Drugs - Real World Outcomes
Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden
Cecilia Lenander 0 1 2 3 4
Patrik Midlo¨v 0 1 2 3 4
Nina Viberg 0 1 2 3 4
John Chalmers 0 1 2 3 4
Kris Rogers 0 1 2 3 4
A˚ sa Bondesson 0 1 2 3 4
Key Points 0 1 2 3 4
0 Department of Medicines Management and Informatics , Region Ska ̊ne, Kristianstad , Sweden
1 Department of Clinical Sciences in Malmo ̈, Lund University , Jan Waldenstro ̈ms gata 35, 205 02 Malmo ̈ , Sweden
2 & Cecilia Lenander
3 The George Institute for Global Health, University of Sydney , Sydney , Australia
4 Department of Public Health Sciences, Karolinska Institutet , Solna , Sweden
Background Antipsychotics form a class of drugs that should be used with caution among elderly people because of a high risk of adverse events. Despite the risks and modest effects, their use is estimated to be high, especially in nursing homes. Objective The aim was to explore the effects of medication reviews on antipsychotic drug use for elderly primary care patients and describe the extent of, and reasons for, the prescription of antipsychotics. Methods In this cross-sectional study in primary care in Ska˚ne, Sweden, patients aged C75 years living in nursing homes or in their own homes with home care were included. The effects of medication reviews were documented, as were the use of antipsychotics and the differences in characteristics between patients receiving or not receiving antipsychotics. Results A total of 1683 patients aged 87.6 (±5.7) years were included in the analysis. Medication reviews reduced the use of antipsychotics by 23% (p 0.001) in this study. Of the 206 patients using antipsychotics, 43% (n = 93) had an approved indication, while for 15% (n = 32) the indication was not given. Antipsychotic drug use was more common with increasing number of drugs (p = 0.001), and in nursing home residents (p \ 0.01). It was also more frequent in patients with cognitive impairment, depressive symptoms or sleeping problems. Conclusion The use of antipsychotic drugs is high in elderly patients in nursing homes. They are often given for indications that are not officially approved or are poorly documented. Medication reviews appear to offer one useful strategy for reducing excessive use of these drugs.
1 Introduction
In 2010, the Swedish National Board of Health and
Welfare published a report with quality indicators concerning
the treatment of elderly patients [
1
]. The report points to
antipsychotics as a medication group that should be used
with caution among elderly people. Prescription of
antipsychotics should be limited to patients with psychotic
events and potentially to aggressive patients with dementia
according to the Swedish National Board of Health and
Welfare [
1
]. Antipsychotic drugs carry a high risk of
adverse events, such as extra-pyramidal symptoms,
cognitive impairment, sedation and orthostatic hypotension as
well as an increased risk of stroke and premature death in
patients with dementia [
2
]. The use of antipsychotics for
treatment of behavioural and psychological symptoms in
dementia (BPSD) is still high. This is despite warnings
from, for example, the US Food and Drug Administration
(FDA), concerning the use of antipsychotics in patients
with dementia [
3
]. Moreover, the evidence for the efficacy
of antipsychotics for treating BPSD is at best modest for
aggression and very weak for other symptoms [
4
].
Prescription of antipsychotics for elderly patients with
multiple co-morbidities seems to be high and often for
indications that are not officially approved. A Swedish
study from 2004 [
5
], supported by the findings from other
studies [
2, 3, 6, 7
], reported that 25–30% of patients in
nursing homes were given antipsychotics, often without a
clear indication.
Medication reviews provide a possible strategy to
improve the situation. A medication review is a method to
analyse, review and follow-up an individual’s drug therapy.
The review is done in a structured and systematic way,
according to local guidelines and routines [
8
], and can be
performed in hospitals, in primary care or in nursing
homes. Medication reviews can be discussed at a
multiprofessional meeting or left as a note to the doctor, with or
without patient participation. Medication reviews should,
according to the Swedish National Board of Health and
Welfare, be performed in patients aged C75 years who
have five or more medications. Furthermore, for patients
moving to a nursing home, medication reviews should be
performed in connection with this and thereafter annually
[
9
]. The aim of the present study was to assess the effects
of medication reviews on antipsychotic drug use in elderly
patients. We also wished to explore the extent of, and
justification for, the prescription of antipsychotics for
elderly patients in everyday practice and whether there
were significant differences (...truncated)