Original Research Report

Social Engagement and Antipsychotic Use in Addressing the Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities

Canadian Journal of Nursing Research 0(0): 1–9 ! The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0844562117726253 journals.sagepub.com/home/cjn

Nasrin Saleh1, Margaret Penning2, Denise Cloutier3, Anastasia Mallidou1, Kim Nuernberger4, and Deanne Taylor5

Abstract Objectives: The use of antipsychotics, mainly to address the behavioral and psychological symptoms of dementia (BPSD), remains a common and frequent practice in long-term care facilities (LTCFs) despite their associated risks. The objective of this study was to explore the association between social engagement (SE) and the use of antipsychotics in addressing the BPSD in newly admitted residents to LTCFs. Methods: A cross-sectional study was undertaken using administrative data, primarily the Resident Assessment Instrument Minimum Data Set (Version 2.0) that collected between 2008 and 2011 (Fraser Health region, British Columbia, Canada). The data analysis conducted on a sample of 2,639 newly admitted residents aged 65 or older with a diagnosis of Alzheimer’s disease or other dementias as of their first full or first quarterly assessment. Multivariate logistic regression analyses were undertaken to predict antipsychotic use based on SE. Results: SE was found to be a statistically significant predictor of antipsychotic use when controlling for sociodemographic variables (odds ratio (OR) ¼ .86, p < .0001, confidence interval (CI) [0.82, 0.90]). However, the association disappeared when controlling for health variables (OR ¼ .97, p ¼ .21, CI [0.97, 1.0]). Conclusion: The prediction of antipsychotic use in newly admitted residents to LTCFs by SE is complex. Further research is warranted for further examination of the association of antipsychotic use in newly admitted residents to LTCFs. Keywords long-term care facilities, residential care, social engagement, antipsychotics

Background Demand on long-term care facilities (LTCFs) in Canada is increasing due to the rise of life expectancy and the number of persons with dementia. In 2011, 5 million Canadians were 65 years of age or older, which is expected to double by the year 2036 (Canadian Nurses Association, 2013). Almost one million Canadians will be living with dementia by the year 2036 compared to 450,000 in 2012 (Canadian Life and Health Insurance Association, 2012). This is presenting major challenges to policy makers and the health-care system and requiring a shift of priorities, adapting innovative approaches to keep older adults healthy and independent.

1

School of Nursing, University of Victoria, British Columbia, Canada Department of Sociology and Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada 3 Department of Geography and Institute on Aging and Lifelong Health, University of Victoria, British Columbia, Canada 4 British Columbia Trajectories in Care Project, University of Victoria, British Columbia, Canada 5 Research and Knowledge Translation, Interior Health Authority, Research Affiliate, Fraser Health Authority, British Columbia, Canada 2

Corresponding Author: Nasrin Saleh, School of Nursing, University of Victoria, 2833 Dufferin Avenue, Victoria, British Columbia, Canada V8R 3L6. Email: [email protected]

2 Since the early 1990s, LTCFs have moved from a medical model focusing on treatment toward a social model of care emphasizing a home-like environment. Moreover, the culture change movement in LTCFs, based on the philosophy of person-centered care, focuses on well-being and quality of life as defined by the resident. However, the prevalence of antipsychotic use in LTCFs remains high (Fischer, Cohen, Forrest, Schweizer, & Wasylenki, 2011), mainly to address the behavioral and psychological symptoms of dementia (BPSD) that include aggression, agitation, restlessness, wandering, hoarding, sleep disturbances, psychosis, delusions, hallucinations, and sundowning (Cohen-Mansfield, Marx, & Rosenthal, 1989). Recently, British Columbia (BC) Ministry of Health reviewed antipsychotic use in LTCFs and recommended its use for the treatment of BPSD under several conditions (MoH, 2011). These conditions include weighing the risks against the benefits, using those drugs as a last resort, obtaining informed consent prior to use, and following the clinical guidelines of a low dose, slow titration, and over a short period with close monitoring. Yet, the review illustrated that over half (50.3%) of the residents were prescribed antipsychotics between April 2010 and June 2011, an increase of 37% within a decade (MoH, 2011), with similar increases reported across Canadian health authorities. While newly admitted residents are more likely than other residents to be prescribed at least one antipsychotic during the first 90 days of admission (Huybrechts, Rothman, Silliman, Brookhart, & Schneeweiss, 2011), antipsychotic use can be as twice as high in residents with BPSD (Alanen, Finne-Soveri, Noro, & Leinonen, 2006). Antipsychotic use in older adults, particularly with dementia, is associated with multiple side effects (Perucca & Gilliam, 2012) such as increased risks of mortality, falls, and hip fractures. Furthermore, antipsychotics may worsen cognition and increase sedative load (Perucca & Gilliam, 2012) that, in turn, may reduce the level of social engagement (SE). SE is considered essential to the psychological and physical well-being (Bennett, 2002) of older adults in LTCFs due to challenges within the setting in keeping older adults active and stimulated. Scholars have proposed that SE might be an alternative to antipsychotics use (Mallidou, Oliveira, & Borycki, 2013). Socially engaging residents has positive health outcomes, such as a protective effect on mortality (Bennett, 2002; Kiely, Simon, Jones, & Morris, 2000), and improved function and cognition (Chen et al., 2013). SE is also associated with decreased symptoms of depression (Lou, Chi, Kwan, & Leung, 2013) and is an indicator of quality of life, as it relates to positive emotions, sense of purpose, and life satisfaction. Conversely, lonely older adults often have low self-rated health and low life satisfaction.

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Design and Method Design and Sample This is a cross-sectional study using administrative data. Data from the Resident Assessment Instrument Minimum Data Set (RAI-MDS, Version 2.0) and the Continuing Care Information Management System were collected between 2008 and 2011 in the Fraser Health region, BC, Canada (accessible population). Fraser Health operates 7,800 residential care beds and has systematically collected RAI-MDS data on residents since 2007. The RAI-MDS has been rigorously tested for reliability and validity in Canada and internationally (Hawes et al., 1995; Lawton et al., 1998; Mor et al., 2003), enabling comparison between countries and institutions. Trained clinicians complete the MDS 2.0 upon resident admission and ideally every 3 months thereafter. It also is completed if changes in health status are experienced by residents. In this study, all measures were drawn from assessments undertaken 90 days following admission to LTCFs. Our initial sample included 10,763 newly admitted residents (from January 1, 2008, to December 31, 2011), aged 65 or older. The final study sample included 2,639 residents who upon admission or in their first full or quarterly assessment had a diagnosis of dementia and who had at least one LTC assessment within 90 days of admission (Figure 1).

Dependent Variable The dependent variable is antipsychotic use, which was defined as the use of atypical and typical antipsychotic agent(s). It was coded into a binary variable: did not receive antipsychotic drugs ¼ 0 and received antipsychotics (one drug at least once, regardless of the numbers of drugs or days the drug is received) in the past 7 days prior to the assessment date ¼ 1.

Independent Variable The independent variable was SE, which within the context of LTCFs, was defined as those who have ‘a high sense of initiative and involvement and can respond adequately to social stimuli in the social environment, participate in social activities and interact with other residents and staff’ (Achterberg et al., 2003, p. 213). SE was measured using the Index of Social Engagement (ISE), an observational scale that measures the positive social behavior of residents. It includes six dichotomous items reflecting whether the resident is at ease interacting with others, with planned or structured activities, doing self-initiated activities, establishing their own goals, pursuing involvement in facility life, and accepting invitations into most group activities. The ISE has shown

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19,194 residents aged ≥ 65 years

10,763 residents admitted between Jan1, 2008 - Dec 31, 2011

2,936 with a diagnosis of AD or other dementias

N= 2,639 clients with at least one LTC assessment at least 90 days following admission

Figure 1. Participant selection process and sample.

good internal consistency with Cronbach’s a of .72 (Lou et al., 2013) and interrater reliability with an average of k of .58 (Hawes et al., 1995). For this study, we dichotomized the ISE scores: low level of SE with scores 0 to 3 ¼ 0 and high level with scores 4 to 6 ¼ 1.

Control Variables Sociodemographic (i.e., gender, age, marital status, guaranteed income supplement (GIS), education) and healthrelated (i.e., aggression, cognition, depression, burden of illness, delirium, and communication problems) variables were included as control variables. Gender was binary coded with female (0) and male (1). Age was recoded into eight 5-year age categories: 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, 90 to 94, 95 to 99, 100 to 104 years old. Marital status was coded into four categories: married, separated/divorced, single/ never married, and widowed. GIS, a monthly nontaxable benefit provided to low-income old age security recipients was coded into two categories: received GIS ¼ 1 and did not receive GIS ¼ 0. Education was a three-level ordinal variable: less than high school ¼ 0, high school completed ¼ 1, and more than high school ¼ 2. Aggressive behavior is considered the most disturbing and distressing (verbal or physical) actions displayed by residents in LTCFs (Voyer et al., 2005) that could harm or threaten another person. Aggression was measured by the Aggressive Behavior Scale (ABS) based on the occurrence of verbal or physical abuse, socially disruptive behavior, and resistance to care. The ABS has shown

internal consistency with as between .79 and .93 (Perlman & Hirdes, 2008) and concurrent validity. Responses were coded into three levels: no aggression ¼ 0, mild to moderate level of aggression with ranges from 1 to 4 ¼ 1, and high level of aggression with range values of 5 or more ¼ 2. Cognition includes ‘abilities such as use of symbols and abstractions, acquiring new information, and adapting to changing situations’ (Williams & Kemper, 2010, p. 43). It was measured using the Cognitive Performance Scale (CPS) that combines information on memory impairment, level of consciousness, and executive function. CPS has been found to provide a valid measure of the cognitive status of residents living in LTCFs and has been validated against the MiniMental State Examination with a a coefficient of .75 (Ahn & Horgas, 2013). CPS scores range from 0 (intact) to 6 (very severe impairment). We recoded the CPS scores into a binary variable: not severely impaired with values 0 to 3 ¼ 0 and severely impaired with values 4 to 6 ¼ 1. Depression was measured by the Depression Rating Scale (DRS), consisting of making negative statements; persistent anger with self or others; expression (including nonverbal) of what appear to be unrealistic fears; repetitive health complaints; repetitive anxious complaints (nonhealth related); sad, pained, worried facial expression; and crying and tearfulness. The DRS demonstrated good internal consistency of .87 (Achterberg et al., 2003). The DRS scores were rerecoded into a binary variable based on the DRS cut-point of 3: absence of depression (scores 4 2) ¼ 0 and presence of depression (scores 5 3) ¼ 1 (Achterberg et al., 2003). Burden of illness was assessed by the 9-item Changes in Health, End-Stage Disease, and Symptoms and Signs Scale (CHESS) that measures instability in health and is a strong predictor of mortality (Hirdes, Frijters, & Teare, 2003), with higher scores predictive of adverse outcomes such as mortality, hospitalization, pain, caregiver stress, and poor self-rated health. Six items of CHESS (vomiting, dehydration, decrease in food or fluid, weight loss, shortness of breath, and edema) were summed ranging from 0 to 2; and three items (decline in cognition, decline in activity of daily living-ADL, and end-stage disease) we summed ranging from 0 (no instability) to 5 (high level of instability). Then, we recoded the first six items as no health instability ¼ 0, minimal health instability ¼ 1, and low-health instability ¼ 2. The higher levels of CHESS were then recoded as moderate health instability ¼ 3, high-health instability ¼ 4, and very high health instability ¼ 5 and were reflective of a ‘high burden of illness’ due to the presence of a significant level of instability. For our analyses, CHESS scores were recoded into a binary variable: low burden of illness

4 in which we combined the scores of 0 to 2 and recoded as 0 and high burden of illness which a combined scores of 3 to 5 that were recoded to 1. Data were selected that assessed six delirium symptoms: easily distracted, periods of altered perception, disorganized speech, periods of restlessness, periods of lethargy, and mental function that varies over the course of the day. Each symptom was scored as not present ¼ 0, present but not of recent onset ¼ 1, and present that appears different from usual level of functioning ¼ 2. Then, following Voyer and colleagues (2008), we coded the absence of delirium symptoms as 0) and we combined the scores of 1 and 2 and gave it a score of 1, which indicates positive presence of delirium. Communication problems were measured by three items: making oneself understood (1 ¼ sometimes understood; 2 ¼ rarely or never understood), speech clarity (1 ¼ unclear speech; 2 ¼ no speech), and ability to understand others (1 ¼ sometimes understand; 2 ¼ rarely or never understands). The scores were summed into single scores, ranging from 0 to 3, with a higher score reflecting greater difficulty communicating with and understanding others.

Data Analysis Data were analyzed using SAS (9.2). Descriptive analysis was completed and included cross-tabulation evaluated with Wald2. Variables meeting minimal significance (p < .25) were included in the multivariate analysis. Covariates were removed from the model if they are nonsignificant and not a confounder. Therefore, models contained only significant covariates and confounders. The criterion to establish statistical significance for the multivariate analysis was an a of .05. We conducted logistic regression in a series of three nested models exploring the effect of SE on antipsychotic use. We first entered the variable SE followed by the sociodemographic characteristics, and finally, health-related variables.

Results The average age of the study participants was just under 84 years (Table 1). Half of the sample was widowed, 60.4% received GIS, and 52.3% had less than a high school education. Antipsychotics receivers were males (43.8%), younger (mean age ¼ 82.6 years), and married (46.6%), GIS no-recipients (41.2%) and were mildly aggressive (53.3%) or severely aggressive residents (72.5%). An interesting finding is that 31.8% of residents who had no aggressive behavior received antipsychotics, while 27.5% of participants with severe aggressive behavior did not receive antipsychotics. Furthermore, residents who received antipsychotics had a lower mean level of SE (X ¼ 2.2, SD ¼ 1.7), experienced

Canadian Journal of Nursing Research 0(0) cognitive issues (.75, SD ¼ .43), depression (X ¼ .25, SD ¼ .43), delirium (X ¼ 2.55, SD ¼ 2.02), burden of illness (X ¼ .07, SD ¼ .25), and communication problems (X ¼ .66, SD ¼ .96). We used logistic regression analyses to predict antipsychotic use based on the SE level while we controlled for sociodemographic- and health-related variables (Table 2). In both Model 1 and Model 2, a greater level of engagement was associated with a lower level of antipsychotic use (odds ratio (OR) ¼ .85, p < .0001, confidence interval (CI) [0.81, 0.89]) and (OR ¼ .86, p < .0001, CI [0.82, 0.90]), respectively. In addition, findings showed that older age (OR ¼ .96, p < .0001, CI [0.95, 0.97]) and widowhood rather than married (OR ¼ .76, p < .01, CI [0.63, 0.93]) were associated with lower likelihood of antipsychotic use. In Model 3, controlling for both sociodemographicand health-related indicators, SE and widowhood were no longer significantly associated with antipsychotics use (OR ¼ .97, p ¼ .21, CI [0.91, 1.0]) and (OR ¼ .84, p ¼ .09, CI [0.68, 1.0]), respectively. However, age (OR ¼ .97, p < .0001, CI [0.95, 0.98]) and several health status indicators remained statistically significant predictors. Notably, residents with moderate or severe aggressive behavior were 1.8 times and 3.2 times more likely to receive antipsychotics (OR ¼ 1.8, p < .0001, CI [1.5, 2.2] and OR ¼ 3.2, p < .0001, CI [2.1, 4.7]), respectively. Furthermore, residents diagnosed with depression or delirium were 1.3 times (OR ¼ 1.3, p < .05, CI [1.0, 1.6]) or 1.2 times (OR ¼ 1.2, p < .0001, CI [1.1, 1.3]) more likely to receive antipsychotics, respectively.

Discussion The aim of this study was to explore the association between SE and antipsychotic use in addressing BPSD in residents newly admitted to LTCFs. Several noteworthy factors were associated with antipsychotic use. Consistent with other studies, females (65.8% in our sample) live longer than males and are more likely to receive LTC services. Also, consistent with the study of Kamble et al. (2008), the likelihood of receiving antipsychotics was lower for female than male residents (38.5% vs. 43.8%); and as Krueger et al. (2009) found, the percentage of residents receiving antipsychotics decreased with age (the lowest percentage of those receiving antipsychotics aged 585). However, gender was not statistically significant when controlling for other sociodemographic factors and health-related variables. Conversely, age remained statistically significant when controlling for both sociodemographic characteristics and health indicators. Prior to the introduction of controls for factors such as aggression, depression, and delirium, SE was found to have an inverse association with antipsychotic use, with

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Table 1. Characteristics of Residents Receiving and Not Receiving Antipsychotics.

Variables Social engagement X (SD) Sociodemographic variables Female Male Age X (SD) Marital status Married (ref) Separated/divorced Single/never married Widowed GIS recipient Yes No (ref) Education Less than high school High school Postsecondary (ref) Health-related variables Aggression No aggression Moderate Severe Cognition X (SD) Depression Delirium Burden of illness Communication problems

n ¼ 2,639 n (%) or X (SD)

Percentage received antipsychotics or X (SD) 2.2 (1.7)

1737 (65.8%) 902 (34.2%) 83.9 (6.8)

669 (38.5%) 395 (43.8%) 82.6 (6.8)

948 216 96 1264

442 97 40 436

(37.6%) (8.6%) (3.8%) (50.0%)

(46.6%) (44.9%) (41.7%) (34.5%)

Percentage did not receive antipsychotics or X (SD) 2.7 (1.8) 1068 (61.5%) 507 (56.2%) 84.8 (6.6) 506 119 56 828

(53.4%) (55.1%) (58.3%) (65.5%)

1000 (39.6%) 1524 (60.4%)

387 (38.7%) 628 (41.2%)

613 (61.3%) 896 (58.8%)

1321 (52.3%) 633 (25.1%) 570 (22.6%)

531 (40.2%) 254 (40.1%) 230 (40.4%)

790 (59.8%) 379 (59.9%) 340 (59.6%)

1677 (66.4%) 687 (27.2%) 160 (6.3%)

533 366 116 .75 .25 2.55 .07 .66

(31.8%) (53.3%) (72.5%) (.43) (.43) (2.02) (.25) (.96)

1144 321 44 .65 .13 1.53 .06 .44

(68.2%) (46.7%) (27.5%) (.48) (.34) (1.82) (.23) (.83)

Note. GIS ¼ guaranteed income supplement.

residents who were more socially engaged being less likely to receive antipsychotics. When accounting for these health indicators, however, the association between SE and antipsychotic use was no longer significant. This may reflect the stronger effect of health indicators on the residents’ behavior and thus on antipsychotic use and the ability of the residents to socially engage. Likewise, antipsychotics are mainly used to treat BPSD that are associated with declines in cognition (Hersch, & Falzgraf, 2007). Indeed, as determined by Foebel and colleagues (2015), our results suggest that residents with dementia and with behavioral symptoms are more likely to receive antipsychotics. Our findings support those of Kamble and colleagues (2008) who reported a strong association between the behavioral and functional characteristics of residents and antipsychotic use in LTCFs. Depression, an important risk factor for low levels of SE in newly admitted residents, is more likely to be

treated with antipsychotics in residents with BPSD (Alanen et al., 2006). It is unclear if SE decreases or increases in the weeks and months after admission, but there is a strong association between depression and SE in newly admitted residents. As Achterberg and colleagues (2003) explain, symptoms of depression (anxiety, withdrawal, and loss of interest) can act as obstacles for engaging socially. Moreover, delirium is an acute medical condition, manifesting in behavioral changes that are sometimes misdiagnosed as BPSD, and treated with antipsychotics. Communication problems and burden of illness were statistically insignificant, although aggressive behaviors tend to occur in the later stages of dementia, when verbal communication is severely compromised. Ultimately, the relationship between SE and antipsychotic use is complex, as both SE and antipsychotic use are likely to be influenced by resident health status.

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Table 2. Nested Logistic Regression Analysis of Predictors of Use of Antipsychotic Drugs.

n Variable Social engagement Gender (Female ¼ ref) Male Age Marital status (married ¼ ref) Separated/divorced Single, never married Widowed GIS (no ¼ ref) Education (postsecondary ¼ ref) Less than high school High school Aggression (0 ¼ ref) Moderate Severe Cognition Depression Delirium Burden of illness Communication problems

OR .85

Model 1

Model 2

Model 3

2,639

2,524a

2,524a

95% CI [.81, .89]

p

Social Engagement and Antipsychotic Use in Addressing the Behavioral and Psychological Symptoms of Dementia in Long-Term Care Facilities.

Objectives The use of antipsychotics, mainly to address the behavioral and psychological symptoms of dementia (BPSD), remains a common and frequent pr...
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