Daily medication use in nursing home residents with advanced dementia

Abstract

Objectives: To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia.

Design: Prospective cohort study.

Setting: Twenty-two Boston-area NHs.

Participants: NH residents with advanced dementia (N=323).

Measurements: Data from residents' records were used to determine the number or daily medications, specific drugs prescribed, and use of drugs deemed "never appropriate" in patients with advanced dementia. Resident characteristics associated with the use of more daily medications and drugs deemed inappropriate were examined.

Results: Residents were prescribed a mean of 5.9 +/- 3.0 daily medications, and 37.5% received at least one medication considered "never appropriate" in advanced dementia. Acetylcholinesterase inhibitors (15.8%) and lipid-lowering agents (12.1%) were the most common inappropriate drugs. Twenty-eight percent of residents took antipsychotics daily. Modest reductions in most daily medications occurred only during the last week of life. Factors independently associated with taking more daily medications included older age, male sex, non-white race, dementia not due to Alzheimer's disease, better cognition, cardiovascular disease, acute illness, and hospice referral. Factors independently associated with greater likelihood of taking inappropriate medications included being male, shorter NH stay, better functional status, and diabetes mellitus, whereas a do-not-hospitalize order was associated with a lower likelihood.

Conclusion: Questionably beneficial medications are common in advanced dementia, even as death approaches. Several characteristics can help identify residents at risk for greater medication burden. Medication use in advanced dementia should be tailored to the goals of care.

Figure 1

Proportion of nursing home residents with advanced dementia using selected non-psychotropic medications during the last year of life. The number of residents available for analysis at each interval were: 0-7 days, N=164 (7 decedents were outside the nursing home during the last week of life); 8-90 days, N=177; 91-180 days, N=128; 181-270 days, N=81 and 271-365 days, N=67.

Figure 2

Proportion of nursing home residents with advanced dementia using selected psychotropic medications and opioids during the last year of life. The number of residents available for analysis at each interval were: 0-7 days, N=164 (7 decedents were outside the nursing home during the last week of life); 8-90 days, N=177; 91-180 days, N=128; 181-270 days, N=81 and 271-365 days, N=67.