The Consultant Pharmacist is published by the
American Society of Consultant Pharmacists.

Clinical Note

Changes in Psychoactive Drug Prescribing Over Four Years in 30 Nursing Facilities

Alvin Sandberg

Objective: To determine what changes, if any, had occurred in the use of the antipsychotic, antidepressant, anxiolytic, and sedative/hypnotic classes of psychoactive drugs in comparison to the results of a study conducted in the same nursing facilities four years earlier.

Study Population: Three thousand, nine hundred and eighty-three residents of 30 nursing facilities in seven states.

Practice Description: Nineteen nursing facilities in eastern Tennessee and 11 additional nursing facilities geographically dispersed throughout the eastern United States.

Methods: Medication administration records were examined for the month of October 1996 and compared to the records from October 1992. A drug was counted as "used" if it had been administered one or more times during the month. Data collected included the actual use of as-needed (p.r.n.) orders. Drugs were categorized according to Drug Facts and Comparisons.

Main Outcome Measurements: Use rates of four classes of psychoactive drugs.

Results: Antipsychotic use was found to be 20.60% in 1996, compared to 19.79% in 1992 in a study conducted by the author and published in The Consultant Pharmacist Vol. 9 No. 12 Dec 1993 pages 1377-1381. Anxiolytic use in 1996 was 19.11%, compared to 21% in 1992. A sedative/hypnotic was used by 4.57% of the residents in 1996 compared to the 1992 usage rate of 7.16%. Antidepressant use was 29.21% in 1996, compared to 17.04% in those same nursing facilities in 1992.

Conclusion: Actual use of anxiolytics and sedative/hypnotics has decreased. These decreases could be interpreted as significant, considering that the observed nursing facility resident turnover of 28% could have resulted in a higher use of those classes of medications; since newly admitted residents are more likely to have initial orders for an antipsychotic, anxiolytic, or sedative/hypnotic during their early adjustment period; and that the current typical nursing facility resident has a higher acuity rating than in years past.

Key Words: Antipsychotic, Antidepressant, Anxiolytic, Sedative, Hypnotic, Drug use, Long-term care, Nursing facility, Psychoactive.

Abbreviations: LTCF = long-term care facility, p.r.n.= as needed

Consult Pharm: 1998;1:77-81.

The actual use of the antipsychotic, antidepressant, anxiolytic, and sedative/hypnotic classes of psychoactive medications is of interest to consultant pharmacists, long-term care facility nursing staff and administration, nursing facility surveyors, and society in general. Federal mandates to reduce the use of psychoactive drugs, especially antipsychotics and anxiolytics, led to an examination of the 1992 rates of use of these four classes of drugs in a study the author published in The Consultant Pharmacist.1

This current study examines use of these agents in the same 30 nursing facilities to determine if any change in utilization had occurred 48 months later. The methodology, researcher, and nursing facilities were identical, with changes in nursing staff and resident population the only variables. Resident turnover was determined to be 28%, and nursing staff turnover 17%. For the study, data from the month of October 1996 was compared to corresponding data from October 1992.

Methods

Drugs were categorized for this study according to the 1995 edition of Drug Facts and Comparison.2 Each drug was counted in its appropriate pharmacologic classification without regard to diagnosis or reason for use. For example, trazadone was counted as an antidepressant even when prescribed for insomnia or for some use other than a depressive disorder. The only drugs omitted from this study were clonazepam, diazepam, and phenobarbital when used for treatment of seizures.

The author manually examined the medication administration records of each resident for the months of October 1996 and October 1992. Computerized records were not used, since the software program was not able to differentiate between medications that had been ordered and administered and those that had been ordered but not administered; manual review was considered more accurate.

The study was conducted in 23 nursing facilities in Tennessee and a group of seven additional nursing facilities geographically located from Florida to Massachusetts. The group of seven was composed of one facility each in Florida, Kentucky, North Carolina, Rhode Island, and Virginia, and two in Massachusetts. None of the nursing facilities were specialized, for example, in Alzheimer's disease, treatment of pressure sores, or treatment of psychiatric disorders. All were "typical" long-term care facilities (LTCFs) with a few skilled beds (usually between 10%Ð20%) ranging in size from 60 to 230 beds. The number of residents reviewed in the 30 nursing facilities totaled 3,983.

An additional group of 12 nursing facilities west of the Mississippi River that were not included in the smaller 1992 study were added to the 1996 study. Addition of these facilities increased the database for future comparisons, and facilitated geographic comparison. Psychoactive use in these 12 facilities (total population 1,347 residents) will be separately compared to psychoactive drug use in the 30 facilities east of the Mississippi River later in this article.

It was beyond the scope of this study to determine the number of doses and/or the size of the dose. Only the percentage of residents using a given drug was studied. The results do not differentiate between routine and p.r.n. orders. A p.r.n. order was included if it had been administered at least once during the month.

Results

Antipsychotics were used by 20.60% of residents in the 30 nursing facilities, which had a total of 3,983 residents in October 1996. This compared to 19.79% antipsychotic use (Figure 1) among 3,949 residents residing in those same nursing facilities in October 1992, an increase of 4.09%.

Figure 1: Use of Antipsychotics
in 3,983 residents in 30 LTCFs

Sedative/hypnotics use was 7.16% in 1992 and 4.57% in 1996 (Figure 2). Diphenhydramine was used frequently as a hypnotic despite its very strong anticholinergic properties, which sometimes result in urinary retention, confusion, constipation, and worsening of dementia. In comparison to 1992, a larger percentage of new orders in 1996 for a sleep aid were for a sedating antidepressant rather than a short-acting benzodiazepine or a sedative/hypnotic. This decrease of 36.17% in the use of sedative/hypnotics was the largest decline among the four classes of drugs studied.

Figure 2: Use of Sedative/Hypnotics
in 3,983 residents in 30 LTCFs

Anxiolytic use decreased by 10.99% over the four years. They were used by 19.11% of residents in 1996, in comparison to 21.47% in 1992 (Figure 3). Diazepam, clonazepam, and phenobarbital were not counted if they were being used for a seizure disorder. Lorazepam was used most frequently in 1996 and 1992, although it is the benzodiazepine most likely to contribute to antegrade memory loss, according to McDonald and Krishnan of Duke Medical Center. (They recommend oxazepam for older patients based on its metabolic features and side-effect profile.)3

Figure 3: Use of Anxiolytics
in 3,983 residents in 30 LTCFs

Antidepressants were counted without regard to diagnosis (depression, insomnia, enuresis, anxiety, pain, appetite, etc.). Antidepressants have at least 17 different accepted indications other than depression. The most common non-depression uses found in this study were as an appetite stimulant, somnifacient, and anxiolytic, but these occurred less than 12% of the time. In 1996, the group of 30 facilities had a 29.12% use rate compared to 17.04% in 1992 (Figure 4). Although the use of antidepressants has increased in the 30 nursing facilities studied, this class of drugs may remain underutilized considering the many reports of widespread depression in nursing facility populations, and the many uses for these drugs such as an adjunct in relief of chronic pain. Use of the selective serotonin reuptake inhibitors (SSRIs) increased steadily during the four years between reviews, especially for the treatment of depression. SSRIs, as well as nortriptyline, appear to be replacing amitriptyline to a large degree, primarily because of their better side-effect profiles.

Figure 4: Use of Antidepressants
in 3,983 residents in 30 LTCFs

In contrast to this author's findings, Simonson et al. reported only 16% antidepressant use in a study of 3,338 residents in 40 nursing facilities in a study published in The Consultant Pharmacist in December 1996.4 Their national study was not limited to nursing facilities east of the Mississippi. If the 12 facilities west of the Mississippi are included in this study, antidepressant use for the combined 42 facilities (total population 5,202 residents) drops to 27.53%. The western facilities had a use rate east of the Mississippi.

There are clearly differences between this study, the Simonson study reviewed above, and an additional study by Tobias and Pulliam.5 The difference may be due to the fact that in this study a p.r.n. medication was counted if it had been used at any time during the entire month, whereas in the Tobias/Pulliam study a p.r.n. medication was counted only if it had been administered during the five days before the survey date. In addition, in this study a different group of facilities were surveyed, and a sole researcher collected data. The differences between this study, the Simonson study, and the Tobias/Pulliam study may be due to difference in methodology, types of facilities, geographical location of surveyed facilities, and data collection methods.

The number of residents using one or more of the above four classes of psychoactive drugs increased from 1992 to 1996 (Figure 5). The rates were 51.96% in 1996, compared to 48.16% in 1992, exactly 48 months later. This increase of 7.89% is directly due to increased use of antidepressants. If antidepressants are removed from consideration, leaving only the other three classes, the rate of psychoactive drug use was 35.26% in October 1996.

Figure 5: Residents taking medication from
one or more psychoactive categories

More residents used drugs from two or more of the four psychoactive categories-18.08% in 1996, compared to 15.41% in 1992-an increase of 17.33% (Figure 6). This again is due to increased use of antidepressants. Only 6.82% of the 3,983 residents in the 30 nursing facilities used two or more of the psychoactive drugs if antidepressants were not included.

Figure 6: Residents taking medication from
two or more psychoactive categories

In this study, when two or more medications from the above four classes of drugs were prescribed, the combination of an antipsychotic and an antidepressant was most common. This was not true in 1992. This combination was used by 5.25% of residents in 1996, compared to 2.94% of residents in 1992. This increase again reflected increased utilization of antidepressants. Combination of an antidepressant and an anxiolytic was second in 1996, being used by 4.65% of the residents in 1996 and 3.65% in 1992. The third most common combination was that of an antipsychotic and an anxiolytic. That percentage of use was 2.73% of residents in 1996, compared to 3.04% of residents surveyed in 1992.

Statistical Summary

Antipsychotics-20.60% (compared to 19.79% in 1992)

Anxiolytics-19.11% (compared to 21.47% in 1992)

Antidepressants-29.12% (compared to 17.04% in 1992)

Sedative/hypnotics-4.57% (compared to 7.16% in 1992)

51.96% used a drug from one or more of the above classes (compared to 48.16% in 1992)

18.08% used drugs from two or more of the above classes (compared to 15.41% in 1992)

Expansion of this study to include nursing facilities west of the Mississippi River facilitated comparison based on geographic location. The 1,347 residents in the 12 nursing facilities located west of the Mississippi River had lower usage rates in all categories, compared to the 3,983 residents in the 30 nursing facilities east of the Mississippi River. Antipsychotic use was 12.03% compared to 20.60%, respectively. Anxiolytic use was 11.58%, compared to 19.11%. Sedative/ hypnotic use was 3.64%, compared to 4.57%. Antidepressant use was also lower in the western group at 23.16%, compared to 29.12% in 1996 among the eastern group of nursing facilities. Use of one or more of the four psychoactive groups was 36.30% in the West, compared to 51.96% in the East.

Conclusion

Use of anxiolytics and sedative/hypnotics has declined. The decrease by 10.99% to 36.17%, depending on the particular class of psychoactive medication, could be significant, considering the fact that observed nursing facility resident turnover of 28% could easily have resulted in a higher use of these classes of drugs. One could say the same about the 20.6% use of antipsychotics in 1996 compared to 19.79% in 1992, since many of the new residents were on an antipsychotic, anxiolytic and/or sedative-hypnotic upon admission, and, in general were observed to be of a higher level of acuity than in previous years, according to nursing facility administration and staff.

Decreased utilization of psychoactive drugs with significant adverse side-effect profiles, such as anxiolytics, highly anticholinergic amitriptyline, and sedative/hypnotics, has certainly resulted in significant monetary savings, as well as an improvement in quality of life. Savings are not necessarily measured using the cost of drugs employed (the newer psychoactive medications are more expensive), but rather in funds not spent on unnecessary drugs, treatment of adverse drug reactions (confusion, incontinence, etc.), drug administration, or drug-related fractures and falls.

At the 1996 ASCP Annual Meeting, Executive Director Tim Webster referred to the Fleetwood Project's estimation: consultant pharmacists save over $3 billion a year by preventing the occurrence of drug-related problems-for all classes of drugs, not just the classes of psychoactives discussed here. Savings must also address the incalculable benefit to dignity and quality of life for those residents who function better due to decreased use of anxiolytic and sedative/ hypnotic medications.

References

1. Sandberg AM. Use of four classes of psychoactive drugs in long-term care facilities. Consult Pharm 1993;8(12)1377-81.

2. Drug Facts and Comparisons. 1995. ed. St. Louis: Facts and Comparisons; 1995.

3. McDonald W, Krishnan KR. Pharmacologic management of the symptoms of dementia. Am Fam Phys 1990:123-32.

4. Simonson W. National Antidepressant Drug-Use Evaluation in Nursing Facilities. Consult Pharm 1996; 11(12):1328Ð38.

5. Tobias DE, Pulliam CC. General and psychotherapeutic medication use in 372 nursing facilities: a national survey. Consult Pharm 1994;9(4)449-461.


Alvin M. Sandberg, BS,FASCP is Senior Consultant Pharmacist, MediLife Pharmacy, Cleveland, Tennessee

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The Consultant Pharmacist is published by the
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