ANTIDEPRESSANT PRESCRIBING IN US NURSING HOMES BETWEEN 1996 AND 2006 AND ITS RELATIONSHIP TO STAFFING PATTERNS AND USE OF OTHER PSYCHOTROPIC MEDICATIONS, HANLON JT, HANDLER SM, CASTLE NG. JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION, 2010; 11 (JUNE): 320-324
Background: Few studies have examined factors associated with antidepressant prescribing in older nursing home residents.
Objective: The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropicmedications in the same cohort.
Design: Longitudinal.
Settings: Settings were 12,556 US nursing homes in 1996 and 2006.
Data Sources: Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF)..
Results: Antidepressant prescribing significantly increased from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders, registered nurses, or nurse aides in a facility, as well as the coprescribing of sedative/hypnotics. Factors found to be protective of increasing antidepressant prescribing (i.e., decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility, or coprescribing of antianxiety or antipsychotic agents.
Conclusions: Prescribing of antidepressants has increased dramatically in the past decade in older nursing home residents and seems to be associated with certain staffing characteristics and the coprescribing of psychotropic medications. Further research is needed to determine if antidepressants are appropriately prescribed, and if overuse is determined, develop interventions to improve the quality of prescribing of these medications in older nursing home residents.
Kevins' Comments: Depression is common, affecting nearly two million of the 35 million persons over age 65. Another five million older adults may have milder degrees of depression. If untreated, depression can become more severe and lead to suicide. Depression is especially common in nursing homes. One has to question whether the marked increase in use of antidepressants reported in this study is related to better recognition and treatment of depression in this setting, or whether providers are overprescribing these medications. Antidepressant drugs are not without the potential for side effects such as an increased incidence of falls, heart rhythm disturbances, and electrolyte disorders. The Center for Medicare and Medicaid Services (CMS) recently included antidepressants in the list of potentially unnecessary medications (F-tag 329). This article does not address the appropriateness of prescribing antidepressants, but since most cases do not fit criteria for major depression where urgent intervention is important, should we also consider lifestyle interventions that have an evidence-base to support their efficacy? Exercise is beneficial in both major and milder forms of depression. Visits from a mental health nurse have been demonstrated to be very effective. Purposeful activities, social engagement, and spiritual practices have been demonstrated to be effective in preventing or ameliorating mild depression.
VITAMIN D AND RISK OF COGNITIVE DECLINE IN ELDERLY PERSONS, LLEWELLYN DJ, LANG IA, ET AL. ARCHIVES OF INTERNAL MEDICINE 2010;170 (JULY 12):1135-1141
Background: To our knowledge, no prospective study has examined the association between vitamin D and cognitive decline or dementia.
Methods: We determined whether low levels of serum25-hydroxyvitamin D (25[OH]D) were associated with an increased risk of substantial cognitive decline in the InCHIANTI population–based study conducted in Italy between 1998 and 2006 with follow-up assessments every three years. A total of 858 adults 65 years or older completed interviews, cognitive assessments, andmedical examinations and provided blood samples. Cognitive decline was assessed using theMini-Mental State Examination (MMSE), and substantial decline was defined as three ormore points. The Trail-Making Tests A and B were also used, and substantial decline was defined as the worst 10%of the distribution of decline or as discontinued testing.
Results: The multivariate adjusted relative risk of substantial cognitive decline on the MMSE in participants who were severely serum 25(OH)D deficient (levels <25nmol/L) in comparison with those with sufficient levels of 25(OH)D was 1.60. Multivariate adjusted random-effects models demonstrated that the scores of participants who were severely 25(OH)D deficient declined by an additional 0.3 MMSE points per year more than those with sufficient levels of 25(OH)D. The relative risk for substantial decline on Trail-Making Test B was 1.31 among those who were severely 25(OH)D deficient compared with those with sufficient levels of 25(OH)D. No significant association was observed for Trail-Making Test A.
Conclusions: Low levels of vitamin D were associated with substantial cognitive decline in the elderly population studied over a 6-year period, which raises important new possibilities for treatment and prevention.
Kevins' Comments: Vitamin D deficiency is highly prevalent in our society and has been linked to heightened risk of a number of disorders including osteoporosis, falls, cancer, and vascular disease. Most of these studies have been observational, which means that vitamin D deficiency was observed with a higher frequency in persons with the above mentioned conditions.
However, this does not necessarily mean cause and effect—in other words, this does not prove that vitamin D deficiency caused the disease. It is known that vitamin D levels are directly related to sunlight exposure and physical activity and lower levels are related to obesity. So it is quite possible that vitamin D deficiency is related to an unhealthy lifestyle (lack of physical activity, poor nutrition, and less time outdoors)—lower levels of vitamin D could be a marker for unhealthy status rather than the cause of it. However, we now know that vitamin D supplementation has been shown in some studies to reduce risk of falls and may have favorable effects on mood. Now we have the first prospective study demonstrating an association between low levels of vitamin D and cognitive decline. Will this add fuel to the current controversy related to vitamin D supplementation?
Vitamin D deficiency as measured by 25-hydroxyvitamin D levels is especially prevalent in older adults. So what are we to do? Should measurement of blood vitamin D levels be routine? Should supplementation be routine? These questions will likely be answered for us this summer at a national consensus conference convened by the National Institutes of Health. Most experts agree that vitamin D intake in most older adults is inadequate. Food sources of vitamin D are few (fish and fortified foods such as milk, juice, cereal). Many older adults have little sun exposure. In addition, the skin of older adults is less efficient at converting vitamin D in the skin to vitamin D3, the active form of vitamin D. Many are wary of sun exposure related to skin cancer risk and use sunblocks that interfere with synthesis of vitamin D3. Interestingly, the ultraviolet band of light responsible for production of vitamin D3 is also responsible for skin cancer and accelerated aging of the skin. Most geriatricians now recommend at least 1000 units of vitamin D per day and many are recommending doses of 2000-4000 units per day. Doses in this range or higher should only be used with a physician’s supervision, as some individuals may be at risk for elevated blood calcium levels, vitamin D toxicity, and even a higher risk for bone fractures. Since vitamin D is a fat soluble vitamin, many doctors prescribe it once a month to those in nursing homes and assisted living communities
PERCEPTIONS AND PERFORMANCE OF FUNCTION AND PHYSICAL ACTIVITY IN ASSISTED LIVING COMMUNITIES, GALIK E, ET AL. JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION 2010; 11 (JULY): 406-414
Objectives: The purpose of this study was to describe residents' self-efficacy and outcome expectations with regard to function and physical activity (PA); to measure functional performance and time in PA; to evaluate the fit between the resident and the environment; and to evaluate knowledge, beliefs, and care behaviors of nursing assistants (NAs) in four different assisted living (AL) communities.
Design: This was a descriptive study using baseline data from an ongoing intervention study, Testing the Impact of a Function Focused Care Intervention, Res-Care-AL.
Setting: Four assisted living communities in Maryland.
Participants: A total of 171 residents and 96 NAs consented, passed eligibility, and were included in this study.
Measurements: Descriptive data were obtained from NAs and residents. Resident data also included self-efficacy and outcome expectations associated with functional tasks and exercise, social support for exercise, and subjective and objective information about function and physical activity. NA data included self-efficacy and outcome expectations, knowledge, and performance of function-focused care.
Results: Residents were mostly female, white, and widowed; needed some assistance with activities of daily living; and engaged in very little PA based on subjective and objective reports. NAs were mostly female and black, had more than a decade of nursing experience, strong confidence but limited knowledge of function-focused care, and performed this care in 76% of observed care interactions. There were no site specificdifferences among NAs with regard to beliefs, knowledge, or performance of function-focused care. There were site-specific differences in residents with regard to self-efficacy for functional ability; functional performance; social supports for exercise from experts; and from family, person-environment fit, and PA based on subjective surveys. There were no differences noted based on actigraphy.
Conclusions: Residents in AL communities engage in very limited amounts of PA and staff in these sites could benefit from ongoing education about how to increase PA among residents and help them adhere to current guidelines for PA so as to optimize overall health status.
Kevin's Comments: This study is limited by the fact that it only observed physical activity in four Maryland assisted living communities. More and more senior living providers are promoting and providing physical fitness programs. However, it is well recognized that most older adults do not participate in regular fitness activities. In the over 65 age group, only 25% of men and 18% of women engage in regular exercise. Exercise has been shown to have substantial benefits no matter how old a person is or what shape they are in. Barriers to participation may include: pain, fear of having an adverse effect on a medical condition, fear of falling, fatigue, shortness of breath, lack of time, and lack of access to equipment and/or a facility. Helping older adults overcome these barriers is essential.
Education should address the fact that fitness activities, with proper instruction, are one of the best ways to manage pain. Exercise has benefits for just about every major medical condition including hypertension, diabetes, heart disease, and arthritis. Fatigue and shortness of breath usually improve with better conditioning. By making fitness activities a priority, 30 minutes on most days of the week is not hard to achieve. Expensive exercise equipment is not necessary—a good pair of walking shoes is all it takes to get started. Strength training can be initiated with relatively inexpensive dumbbells or stretch bands, but even soup cans or water bottles can be used as an alternative. A wonderful free guide entitled Exercise and Physical Activity for Older Adults is available from the National Institute on Aging at www.nia.nih.gov.
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