Dartmouth Institute, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
Sanitas Mayores, Barcelona, Spain.
J Am Geriatr Soc. 2019 Jul;67(7):1444-1453. doi: 10.1111/jgs.15855. Epub 2019 Mar 8.
BACKGROUND/OBJECTIVE: In nursing homes across the world, and particularly in Spain, there are concerns that psychotropic medications are being overused. For older Spanish nursing home residents who had dementia, we sought to evaluate the association between applying interventions designed to reduce inappropriate psychotropic medication use and subsequent psychotropic use.
Retrospective, propensity score-matched, controlled, patient-level observational analysis.
A total of 45 nursing homes in Spain.
A total of 1653 nursing home residents, aged 70 to 99 years, who had dementia and were prescribed an antipsychotic, anxiolytic, or antidepressant medication, 606 of whom received an intervention; the remainder served as propensity score-matched controls.
Team Rounds, Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria, or a Patient Decision Aid.
At 2 and 4 weeks following intervention: change from baseline drug class-specific milligram-equivalent daily dose (MEDD); at 2 weeks: patient falls and restraint use.
Within each intervention/drug-class cohort, intervention patients and matched controls had similar baseline demographic characteristics, Charlson scores, lengths of admission, and drug class-specific MEDDs. Compared to controls, patients exposed to Team Rounds experienced a 23.3% (95% confidence interval [CI] = 13.9%-32.8%) reduction in antipsychotic and a 23.1% (95% CI = 18.3%-28.0%) reduction in anxiolytic MEDDs; those exposed to Patient Decision Aids had a 24.8% (95% CI = 15.6%-33.9%) reduction in antipsychotic and a 31.8% (95% CI = 25.5%-38.2%) reduction in anxiolytic MEDDs; and those exposed to STOPP/START application had a 27.7% (95% CI = 22.4%-33.0%) reduction in antipsychotic and a 39.5% (95% CI = 35.5%-43.5%) reduction in anxiolytic MEDDs. Intervention-associated antidepressant MEDD reductions were statistically significant but less dramatic. Interventions were associated with higher rates of medication discontinuation, but not higher rates of deaths, patient falls, or physical restraints.
We found strong evidence that the interventions we studied were associated with reduced psychotropic use without commensurate harms, suggesting that such interventions should be incorporated into Spanish nursing home care models. Public reporting of psychotropic medication use in Spanish care homes may encourage care homes to regularly monitor psychotropic medication use and implement such instruments. J Am Geriatr Soc, 2019.
背景/目的：在全球范围内的养老院中，尤其是在西班牙，人们普遍担心精神药物的使用过度。对于患有痴呆症的西班牙养老院的老年居民，我们评估了应用旨在减少不适当的精神药物使用的干预措施与随后的精神药物使用之间的关联。
回顾性、倾向评分匹配、对照、患者水平的观察性分析。
西班牙共 45 家养老院。
共 1653 名年龄在 70 至 99 岁之间、患有痴呆症并开有抗精神病药、抗焦虑药或抗抑郁药的养老院居民，其中 606 名接受了干预措施；其余的则作为倾向评分匹配的对照组。
团队查房、老年人用药筛选工具（STOPP）/正确治疗提醒工具（START）标准、或患者决策辅助工具。
干预后 2 周和 4 周：与基线相比，药物类别特异性毫克等效日剂量（MEDD）的变化；在 2 周时：患者跌倒和约束使用。
在每个干预/药物类别队列中，干预患者和匹配的对照组在基线人口统计学特征、Charlson 评分、住院时间和药物类别特异性 MEDD 方面具有相似性。与对照组相比，接受团队查房的患者抗精神病药的 MEDD 降低了 23.3%（95%置信区间 [CI] = 13.9%-32.8%），抗焦虑药的 MEDD 降低了 23.1%（95% CI = 18.3%-28.0%）；接受患者决策辅助工具的患者抗精神病药的 MEDD 降低了 24.8%（95% CI = 15.6%-33.9%），抗焦虑药的 MEDD 降低了 31.8%（95% CI = 25.5%-38.2%）；接受 STOPP/START 应用的患者抗精神病药的 MEDD 降低了 27.7%（95% CI = 22.4%-33.0%），抗焦虑药的 MEDD 降低了 39.5%（95% CI = 35.5%-43.5%）。干预相关的抗抑郁药 MEDD 降低具有统计学意义，但幅度较小。干预措施与更高的药物停药率相关，但与更高的死亡率、患者跌倒或身体约束无关。
我们发现有力的证据表明，我们研究的干预措施与减少精神药物使用相关，而没有相应的危害，这表明应将这些干预措施纳入西班牙养老院护理模式。西班牙养老院中精神药物使用的公开报告可能会鼓励养老院定期监测精神药物的使用情况并实施这些工具。美国老年学会杂志，2019 年。
