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Psychotropic medication consumption patterns observed in residential care facilities for the elderly

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Psychotropic medication consumption patterns observed in residential care facilities for the elderly

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Content PSYCHOTROPIC MEDICATION CONSUMPTION PATTERNS OBSERVED IN RESIDENTIAL CARE FACILITIES FOR THE ELDERLY by Jeannette Diem-Trang Vuong A Thesis Presented to the LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In P artial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY December 1992 Copyright 1992 Jeannette Diem-Trang Vuong U M I Number: EP58998 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Rjonsmng UMI EP58998 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 UNIVERSITY OF SOUTHERN CALIFORNIA LEONARD DAVIS SCHOOL OF GERONTOLOGY University Park Los Angeles, CA 90089 ^ 42^ V444 This thesis, written by ^ ______________________Jeannette Diem-Trang Vuong___________ _ under the director of h er Thesis Committee, and approved by all its members, has been presented to and accepted by the Dean of the Leonard ‘ Davis School of Gerontology, in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN GERONTOLOGY_________ Dean Date OûûujJ' 1 7 ^ /HZ-______ THESIS COMMITTEE Chairman 1 1 DEDICATIONS This thesis is dedicated to my parents, Nghiem and Le-Oanh Vuong, and my brother, Eric Vuong, who have provided me with tremendous love and support in pursuing my dream s to become a geriatric pharm acist. They have shown me th a t three of the most im portant values in life are family, commitment, and honest hard work. This thesis is especially dedicated to my grandfather, Giap Xa Vuong, whose stroke in the mid-1980’s led me to become interested in learning about the field of aging and to commit myself to helping older adults. Ill ACKNOWLEDGEMENTS There are m any individuals whom I would like to thank for their assistance during my work on this thesis. First, I would like to thank Dr. Bradley Williams for generously providing me with his time and wisdom during the development of this thesis. I highly adm ire and respect Dr. Williams for his work in the geriatric pharm acy field, and I thank him for his encouragements, advice, and the opportunity to work with and learn from him. Second, I would like to thank Dr. Eileen Crimmins, the second reader of this thesis, for her insightful and useful suggestions and comments. I appreciate Dr. Crimmins for teaching me the statistical background and research methods which were necessary for this thesis. Third, thanks to Adrienne Pixley, May Ng, and especially Paula Lackie for their assistance in instructing me in some parts of the computer statistical work. Fourth, thanks to the researchers of the project: Bradley Williams, Mike Nichol, Jeff McCombs, Beverly Lowe, Peter Yoon, and Loren Lipson. They each played an integral part in either the project proposal, collection, coding, or analysis of the data in this thesis. J IV Fifth, I would like to thank Dr. Williams, the Hartford Foundation, U.S.C. Schools of Pharmacy and Medicine, and the Andrus Gerontology Center for allowing me to use the data from their project for this thesis' secondary data. Sixth, I would like to thank all my friends and acquaintances for their encouragements, support, and well wishes in finishing this thesis. Lastly, special thanks to my parents and brother whose encouragements and prodding throughout my work on this thesis have carried me to its completion. TABLE OF CONTENTS Page DEDICATIONS .................................................................................... ii ACKNOW LEDGEM ENTS.................................................................. iii LIST OF T A B L E S ............................................................................... viii CHAPTER 1 -- INTRODUCTION The P u r p o s e ........................................................................................ 1 Reasons for Consideration of the Thesis T o p i c .......................... 1 Outline of this T h e s i s ....................................................................... 3 CHAPTER 2 - LITERATURE REVIEW Outline of Chapter 2 .......................................................................... 4 Geriatric Drug U s e .............................................................................. 5 Drugs, the Aging Body, and P h arm aco k in etics.......................... 8 Polypharmacy and the Elderly ................................................ 10 Psychotropic Medications and Their Side E ffe c ts ................. 11 Psychotropic Drug Utilization within the N ursing Home E nvironm ent............................................ 16 Residential Care Facilities ............................................................ 22 Issue: Psychotropic Medication Utilization in Residential Care Facilities ......................................................... 26 I VI TABLE OF CONTENTS (continued) Page CHAPTER 3 - METHODOLOGY AND SAMPLE M eth o d o lo g y .................... 28 S a m p le ........................................................................................... 31 D ata Collection D e sc rip tio n ...................................................... 31 Operationalization of V a ria b le s............................................... 34 Statistical P ro c e d u re s ................................................................ 36 Limitations of S tu d y ................................. 37 CHAPTER 4 - RESULTS AND FINDINGS Characteristics of the Baseline Sample Population: RCFE Residents Age 65 and Above .................................. 39 RCFE Residents with a Prim ary Diagnosis of a M ental Condition or a Nervous System Disorder . . . . 42 Differences Among RCFE Residents in Different Size F a c ilitie s .......................................................................... 50 Drug Consumption Among RCFE Residents Using Psychotropic M ed icatio n s...................................................... 51 Psychotropic Drug Orders Prescribed For a Prim ary Diagnosis of a M ental Condition or Nervous System D is o r d e r ............................................... 59 Psychotropic Drug Consumption by T y p e .............................. 71 vil TABLE OF CONTENTS (continued) Page CHAPTER 5 - DISCUSSION AND CONCLUSION D is c u s s io n ..................................................................................... 75 C o n c lu sio n ..................................................................................... 84 R E FE R E N C E S................................................................................. 89 APPENDIX A ................................................................................. 93 APPENDIX B 95 [ I I APPENDIX C 97 ! LIST OF TABLES V lll Page Table 1 Demographic Characteristics of RCFE Residents in Sample P o p u la tio n ............................................ 43 Table 2 Demographic Characteristics of RCFE Residents by Facility S iz e ......................................................... 44 Table 3 Demographic Characteristics of RCFE Residents by Activity of Daily Living L e v e l ........................ 45 Table 4 Percentage of Prim ary Diagnoses of a M ental Condition of a Given T y p e ..................................... 47 Table 5 Percentage of Prim ary Diagnoses of a Nervous System Disorder of a Given T y p e ........................ 48 Table 6 Percentage of Prim ary Diagnoses of a Dementia Related D ia g n o s is ................................................... 49 Table 7 Percentage of RCFE Residents with Activity of Daily Living Level by Facility S i z e .................... 52 Table 8 Percentage of RCFE Residents with a M ental Condition Diagnosis of a Given Type by Facility S i z e .................................. 53 Table 9 Percentage of RCFE Residents with a Nervous System Disorder Diagnosis of a Given Type by Facility S i z e .................................. 54 Table 10 Percentage of RCFE Residents with a Dementia Related Diagnosis by Facility Size . . 55 Table 11 Percentage of Psychotropic Drug Orders Per Class Among RCFE Psychotropic Drug Users . . . . 60 IX LIST OF TABLES (continued) Page Table 12 Percentage of Psychotropic D rug Orders Per Class Among Male and Female RCFE Psychotropic Drug Users .................................. 61 Table 13 Percentage of Psychotropic Drug Orders P er Class Among W hite and Non white RCFE Psychotropic Drug Users .................................. 62 Table 14 Percentage of Psychotropic Drug Orders P er Class Among RCFE Psychotropic Drug Users of Different Age G r o u p s .............. 63 Table 15 Percentage of Psychotropic Drug Orders Per Class For RCFE Psychotropic Drug Users with Different Activity of Daily Living L e v e ls.......................................................... 64 Table 16 Percentage of Psychotropic Drug Orders Per Class For RCFE Psychotropic Drug Users of Different Facility Sizes ..................................... 65 Table 17 Percentage of Psychotropic Drug Orders Per Class Prescribed For a M ental Condition Diagnosis of a Given T y p e .............. 68 Table 18 Percentage of Psychotropic Drug Orders Per Class Prescribed For a Nervous System Disorder Diagnosis of a Given Type ................................. . . . 69 Table 19 Percentage of Psychotropic Drug Orders Prescribed with and without a Prim ary Diagnosis of a M ental Condition or a Nervous System Disorder . . . . 70 Table 20 Percentage of Psychotropic Drug Orders by Class and within C la s s .................... 73 CHAPTER 1 - INTRODUCTION The Purpose The purpose of this thesis is to provide a description of the residents who live in residential care facilities for the elderly w ithin the greater Los Angeles area and sections of Orange County in term s of their demographic characteristics and their psychotropic medication consumption patterns. This descriptive analysis examines the residents' age, sex, race, activity of daily living level, prim ary diagnosis, and the m any different classes and types of psychotropic medications which the residents consume. Reasons for Consideration of the Thesis Topic In 1989, the U.S. Subcommittee on H ealth and Long-Term Care estim ated th a t there were over a million older Americans residing within residential care facilities (RCF), otherwise known as board and care homes (U.S. Subcommittee on H ealth and Long-Term Care and U.S. Select Committee on Aging, 1989). As the 20th century approaches its end, the num ber of older adults living in RCFs is expected to climb, paralleling the growth of the elderly (age 65 and over) population. Although m any studies have been conducted with a 2 focus on elderly residents of nursing homes, relatively few studies have focused on elderly residents of RCFs. An older individual residing in residential care facility (RCFE) has been described as "a person ‘on the border', too frail to live safely independent and unsupervised but insufficiently ill" to live in a nursing home (Williams and Lipson, 1989). Although an elderly resident is usually capable of determ ining his or her activities, he or she is very likely to be dependent on the facility's staff for the adm inistration of his or her medications. Since the medications are centrally stored in an office, the resident has little, if any, control over the taking or not taking of his or her medications (other th an to outright refuse). As a result, the resident may have little knowledge regarding drugs in term s of their benefits and side effects and is at risk of abusing the drugs (Williams and Lipson, 1989). By examining the patterns of psychotropic medication consumption, this thesis is able to provide some insight into the health status of RCFE residents and illustrate some of the differences in medication consumption patterns of residents of different age groups, sexes, races, activity of daily living levels, prim ary diagnoses, and facility sizes. Outline of the Thesis The introductory chapter (Chapter 1) states the purpose of this thesis. Reasons for consideration of the thesis topic are also presented. The literature review chapter (Chapter 2) provides a background on geriatric drug usage, pharmacokinetics, polypharmacy, and psychotropic medications. In addition, findings from earlier studies on psychotropic medication consumption patterns in America’ s nursing homes are presented. Psychotropic medication utilization by RCFE residents is also discussed in this chapter. The methodology and sample chapter (Chapter 3) describes the m anner in which the data were collected for the original study and describes the sample used. In addition, variables used in this thesis’ data analysis are introduced and operationalized. The statistical m anipulations used to analyze the data and the lim itations of the study are also discussed. The results chapter (Chapter 4) states the findings derived from data analyses using SAS (SAS Institute, 1985). In addition, data tables are presented. The discussion and conclusion chapter (Chapter 5) discusses the m eanings and implications of the findings from the data analyses. 4 CHAPTER 2 - LITERATURE REVIEW Outline of Chapter 2 The population today is rapidly aging as a result of a decline in mortality, greater longevity, lower birth rates, and greater medical technology. As of 1985, approximately 11% of the nation’s population was made up of older adults age 65 and over. T hat is an estim ated 25 million older Americans! It is expected th a t this figure will more th an double to 55 million (or 18% of the nation’ s population) by the year 2030. These demographic changes point to greater usage of prescription drugs, and therefore, greater risks for "incidence of drug misuse and abuse, adverse reactions, and drug interactions" involving the elderly (Moore and Teal, 1985). Due to the growing size of the elderly population, greater attention has been focused on the necessity for appropriate drug usage by older individuals. In order to understand the vulnerability of older adults to adverse drug reactions, the first section in this chapter discusses geriatric drug usage and some of the differences in drug handling and usage between older adults and younger adults. The second and third sections in this section discuss pharmacokinetics and polypharmacy, respectively, which are believed 5 to be im portant factors in the elderiys greater susceptibility to adverse drug reactions. The fourth section introduces psychotropic medications, potentially the most dangerous category of drugs taken by the elderly because of its influence on the brain and resultant side effects. ; The fifth section introduces residential care facilities, a housing ' environment which has grown in the last two decades and m ay play a major role in housing this nation’s growing aging population. In order to get an idea of the psychotropic medication problems in a long-term care setting, studies which have been conducted regarding psychotropic medication consumption patterns in nursing homes are discussed in the sixth section of this chapter. The issue of psychotropic medication consumption patterns in RCFEs is brought up in the last section of this chapter. It raises questions concerning the residents of RCFEs, a population which has been little researched until recently. t I Geriatric Drug Use j Drug utilization is a major issue in the lives and health of the elderly. Of the m any factors which may affect the medication consumption p attern of the elderly, their health status is one of the 6 m ost influential. Due in p art to rising age, the elderly’s declining health status is attributed to the increase in the incidence of chronic diseases. More th an 80 percent of the elderly have a t least one chronic disease (Simonson, 1984). To nam e a few, they include arthritis, diabetes, and stroke. These diseases m ay range in their level of severity. In order to deal w ith these chronic problems, the elderly use prescription medications, nonprescription medications, and other, nondrug item s, to relieve their suffering and to manage the problems. As individuals age, there is a greater tendency for them to take m ultiple medications simultaneously. In the 1977 N ational H ealth Care Expenditure Study which was adm inistered by the U.S. D epartm ent of H ealth and H um an Services (DHHS), results indicated th a t 4.3 was the m ean num ber of prescription medications (both new prescriptions and refills) obtained by noninstitutionalized people in the United States (U.S. D epartm ent of H ealth and H um an Services, 1981). Of this noninstitutionalized population, those age 65 and over obtained a m ean num ber of 10.7 prescription medications annually (Simonson, 1984). In 1984, the American Association of Retired Persons’ (AARP) health survey reported th a t 24% of men and women over the age of 65 "take more th an three prescription drugs a day. 7 compared w ith only 9% in the 45-64 age range" (McKim and M ishara, 1987). These figures indicate th a t older individuals consume more prescription medications th an younger individuals. There are two reasons why older adults tend to consume more medications th an younger adults. First, as mentioned earlier, older adults are more likely to increase the num ber of medications consumed as a result of acquiring diseases and chronic conditions. Second, drug prescribing patterns of physician indicate th a t the elderly are prescribed more th an their younger counterparts. M akinodan, Jam es, Inamizu, and Chang (1981) found th a t the elderly were prescribed hypnotics and laxatives a t a higher rate th an the younger population (cited in McCormack and O’ Malley, 1986). Along w ith greater medication consumption, the elderly are more vulnerable to experiencing adverse drug reactions th an younger adults. Goldberg and Roberts (1983) found th a t "the elderly are three to seven tim es more susceptible th an younger people to adverse drug reactions" (cited in McCormack and O’Malley, 1986). The num ber of adverse drug reactions for 80 years-old adults was double th a t of those in their fifties. It was suggested th a t the elderiys greater susceptibility to adverse drug reactions is due to polypharmacy and altered pharmacokinetics (cited in McCormack and O’ Malley, 1986). 8 The following two sections define pharmacokinetics and polypharmacy and their relation to older adults. Drugs^ the Aging Body, and Pharmacokinetics There are m any factors which can complicate the usage of drugs by the elderly. One of these is the fact th a t the body tissues of older people are reduced and this reduction influences the way in which they respond to drugs. Another factor is th a t m any elderly have more than one major or m inor physical disease at the same time. Lastly, poor nutrition among the elderly may be a contributing factor to drug reactions (McKim and M ishara, 1987). M any age-related changes in the body have been dem onstrated to affect the pharmacokinetics of drugs. Pharmacokinetics, the "movement of drugs", is the study of mechanisms involved in transporting a drug to and from its action site where it affects the body’s functions and processes. The strength of the drug effect is dependent upon the am ount of drug th a t arrives at the action site (McKim and M ishara, 1987). Studies have shown th a t the process of drug absorption is delayed in the elderly. The change in the rate of absorption is due to factors such as the decreased rate of the drug passing through the 9 stomach, the reduction of acidity in the stomach, and the diminished strength of the intestinal wall muscles (McKim and M ishara, 1987). Changes in the drug distribution throughout the body are determ ined by an older individual’ s sm aller body size, the increase in fat tissue as a percentage of total body weight and corresponding decrease in body w ater percentage, and the decrease in percentage of drug th a t is protein (albumin) bound (due to a reduction in album in production). Changes in drug metabolism involve reductions in liver (hepatic) blood flow, hepatic mass, and hepatic enzyme activity (Simonson, 1984). In the elderly, there is a decrease in kidney function, and therefore, a slowing of medication excretion. As a result, the drug’ s concentration is inclined to be high in the bloodstream and there is greater chance for drug effect and toxicity (Simonson, 1984). Due to the decline in kidney function w ith age, the safety m argin between the therapeutic dose and the toxic dose of drugs is narrow. An older person, who receives a dose considered "normal" or appropriate for a younger person, is likely to accumulate the drug w ithin the body if the drug is given over a long duration (Simonson, 1984). . J 10 Polypharmacy and the Elderly One medication consumption pattern often seen among the elderly is polypharmacy. Polypharmacy, which may be defined as the excessive and unnecessary usage of medication, includes the usage of medication no longer appropriate for an older individual’s present condition, the use of multiple medications having sim ilar effects, the interaction of medications which m ay have contradictory physiological effects, the usage of inappropriate medications, the adm inistration of inappropriate dosages, and the usage of m ultiple medications a t one tim e (Simonson, 1984). There are m any consequences of polypharmacy. The risk of adverse drug reactions occurring is the most common and serious consequence for older adults. Because bodies undergo a variety of age-related changes which can affect the pharmacokinetics of medications, older persons are a t greater risk th an younger persons of experiencing adverse drug reactions. Twenty-one percent of adults age 70 and over experience adverse side effects as compared to less th an three percent of adults age 20 to 29 years old (Weedle, Poston, and Parish, 1988). Furtherm ore, these adverse drug reactions can lead older adults to become dehydrated, incontinent, delirious, or fall (Ouslander, 1986). In addition, the reduction of homeostasis in older 11 adults puts them a t risk of suffering side effects, because drugs may disrupt the regulation of their body tem perature and m ay cause them to experience postural hypotension, a common drug side effect (McCormack and O’ Malley, 1986). Psychotropic Medications and Their Side Effects Psychotropic drugs cause m any adverse drug reactions. Over the years, physicians have prescribed psychotropic medications in order to m anage the m any behavioral and m ental disorders observed in some older individuals. However, some studies (Ray, Federspiel, and Schaffner, 1980; U.S. Senate, 1976) suggest th a t psychotropic drugs are m isused and overprescribed (cited in Dunkle, Petot, and Ford, 1986). It is the intention of this section to provide a background on psychotropic drugs, their actions, and side effects in order to get a clearer idea of how harm ful they can be to older adults. Psychotropic drugs include antidepressants, antipsychotics, anxiolytics, and sedatives/ hypnotics. The psychotropic drug category is one of many drug groups belonging under the classification of central nervous system drugs, a category which encompasses all drugs which act on the brain. Psychotropic drugs are potentially the most dangerous of the central nervous system drugs because they act 12 prim arily on the brain and not only cause severe side effects but also serious m ental im pairm ent (Bums and Phillips on, 1986). Confusion is a common drug-induced effect and is a result of increased brain sensitivity to blood levels after taking such drugs as sedatives and tranquilizers. In addition to the confusional state, the elderly are likely to experience depression, incontinence, drowsiness, m orning hangover, and/ or dem entia with the use of psychotropic drugs (Bum s and Phillipson, 1986). The elderly are also vulnerable to postural hypotension, the sudden reduction in blood pressure associated with the change from sitting position to standing position, as well as dizziness and fainting spells which are induced by tranquilizers, antidepressants, and m any nonpsychotropic dm gs. The effects result from the presence of less efficient pressure receptors in the arterial walls (Bum s and Phillipson, 1986). In 1981, H indm arsh found th a t benzodiazepines, a form of hypnotics and minor tranquilizers, produce adverse effects in normal subjects on the movements requiring some skill component. Both the short-acting and long-acting benzodiazepines dism pted the skilled performance (e.g. driving) of the subjects. Due to the sedative effects of the benzodiazepines, the central nervous system ’s level of activity 13 was reduced and the equilibrium between sensory and motor system was disturbed. Not only did benzodiazepines have sedative effects which im paired psychomotor performance and memory processing ability, their effects were exacerbated when combined with other sedatives and alcohol (Bum s and Phillipson, 1986). Diazepam and lorazepam, which are frequently used benzodiazepines, have been reported by Subhan in 1984 to "act upon the process of memory retention rath er than registration or recall" (Bum s and Phillipson, 1986). Among their m any paradoxical effects, benzodiazepines can cause people to "become tense, sleepless, antagonistic and prone to aggressive outbursts” instead of calming them as expected (Bum s and Phillipson, 1986). Neuroleptics are another type of psychotropic dm g. They are considered major tranquilizers (antipsychotics) and are specifically given to people who have schizophrenia or are in psychotic states of high excitement and euphoria. Not only do neuroleptics have paradoxical effects of exacerbating anxiety and aggression, they also produce adverse side effects such as serious im pairm ent of movement (if they are adm inistered over a long duration), stiffness, and trem ors which are all characteristic of Parkinson’s disease as well as "restless ’ jitters’ and involuntary movements distorting the face, m outh and 14 tongue" (Bum s and Phillipson, 1986). Although antiparkinsonian dm gs can be adm inistered to counteract and reduce neuroleptic adverse side effects, if antiparkinsonian dm gs are increased in dosage to control the abnorm al movements, they may likely cause the movements (especially those of the face, m outh and tongue) to worsen and become tardive dyskinesia (Bum s and Phillipson, 1986). Therefore, older individuals are very vulnerable during neuroleptic dm g treatm ent, because the greater their age at the sta rt of the treatm ent, the sooner tardive dyskinesia develops. A ntiparkinsonian dm gs alone can cause the elderly to become confused, restless, hallucinatory, memory impaired, and provoked to shouting outbursts. Neuroleptic drugs alone can cause side effects such as "loss of tem perature control, sudden falls of blood pressure (leading to faints and falls), skin reactions, jaundice, dm g interactions, weight gain and difficulties in sexual functioning" (Bum s and Phillipson, 1986). Together, neuroleptics and antiparkinsonian dm gs not only produce their individual side effects but these effects are magnified (Bum s and Phillipson, 1986). Although sedatives and tranquilizers have been issued to patients as forms of therapy for depression, antidepressant 15 medications (such as am itriptyline, im ipram ine, and trazodone) are more widely used for treating depression because they are able to lead to a remission. However, antidepressants also entail risks because the older individuafs body has delayed drug elimination, higher blood levels, and greater sensitivity. As a result, adverse drug reactions occur often and are frequently pronounced. A ntidepressants’ effects are not observable until two to three weeks after the first treatm ent (Bum s and Pbillipson, 1986). A ntidepressants are capable of producing such adverse reactions as postural hypotension, confusion, dry mouth, heart disturbances, sedation, and psychosis (Simonson, 1984). Many Americans suffer from sleep disturbances. Older adults experience such sleeping problems as less deep sleep (i.e., stage IV sleep), less rapid eye movement (REM) sleep (which is related to dream ing periods), greater sleep apnea (i.e., brief periods when the sleeping adult ceases to breathe), and greater incidence of awakenings (Woodruf-Pak, 1988). As a result, a large proportion of these elderly troubled sleepers take hypnotics to sleep better. In 1983, fifty percent of people over the age of 60 bad insom nia-related problems as compared to only half as m any (26%) people ages 20-29. Twenty-two million Americans over age 65 in 16 1983 reported having trouble sleeping. Of the approximately 45 percent of the elderly who live at home and claim to have trouble sleeping, over h alf (28%) were prescribed hypnotics regularly (Burns and Pbillipson, 1986). Flurazepam (Dalmane), one of the m ost frequently used hypnotics, and diazepam (Valium) are two drugs which are prescribed for sleeping disturbances. Their side effects involve daytime sleepiness, nausea and unsteadiness/ dizziness which are all ■ attributed to the elderiys increased drug sensitivity, greater delay in I drug elimination, and quicker accumulation and higher steady states ; of drug plasm a concentration levels (Bum s and Pbillipson, 1986). I I Psychotropic Drug Utilization within the Nursing Home Environment I In order to get a clearer picture of psychotropic medications and a profile of their consumers in long-term care facilities, this section describes some of the studies which have been conducted regarding psychotropic drug consumption pattem s which have been observed in the nursing home setting. In 1975, Ingman, Lawson, Pierpaoli, and Blake conducted a study concerning the prescription and adm inistration of drugs among 17 131 residents in a Conneticut long-term care institution. Their prelim inary investigation showed th a t among 100 residents in the study, six out of every ten residents received a m inor or major tranqilizer, while three out of every ten residents received a sedative/ hypnotic. The study’s results indicated th a t physicians had a tendency to prescribe psychotropic drugs (or "neuroactive" as Ingm an et al. caU this drug category) to residents who have relatively good m ental status and a high level of independence w ithin the institution (Ingman, Lawson, Pierpaoli, and Blake, 1975). These findings suggest th a t the heavy consumers of psychotropic drugs are not the m entally im paired and least active residents but those residents who are least im paired in either m ental status or activities. In 1980, Ray, Federspiel, and Schaffner surveyed 173 Tennessee nursing homes w ith 5,902 Medicaid patients 65 years and older. Seventy four percent of these patients were prescribed central nervous system (CNS) drugs. Among CNS drugs, antipsychotic drugs (i.e., tranquilizers) accounted for 43% of the patients. Thioridazine, chlorpromazine, and haloperidol were the three most frequently prescribed antipsychotic drugs. Interestingly, results indicated th a t as patients’ age increased, the num ber of antipsychotic drugs decreased (Ray, Federspiel, and Schaffner, 1980). This implies th a t 18 those patients in the younger age groups are prescribed more tranquilizers th an the older age patients. Since adults in younger age groups have less debilitating illnesses th an those in older age groups, they are assum ed to be more active and less impaired. Therefore, Ray et al.’ s findings parallel Ingm an et al.’ s findings because both findings suggest th a t the patients who are least im paired are a t greater risk of being prescribed a psychotropic drug th an those who are more impaired. In 1988, Beers, Avom, Soumerai, Everitt, Sherm an, and Salem studied 850 nursing home residents in M assachusetts and found th a t alm ost two thirds of residents (65%) received a psychotropic medication. Among the psychotropic drug users, 26% of them received an antipsychotic (i.e., tranquilizer). Haloperidol and thioridazine hydrochloride were the two m ost commonly prescribed antipsychotic drugs. Twenty eight percent of psychotropic drug users received a sedative/ hypnotic. Diphenhydram ine hydrochloride was the m ost commonly prescribed sedative/ hypnotic. Fourteen percent of psychotropic drug users received an antidepressant w ith the largest group of antidepressant users found taking am itriptyline (Beers, Avom, Soumerai, Everitt, Sherm an, and Salem, 1988). Sim ilar to the studies conducted by Ingm an et al. (1975) and Ray 19 et al. (1980), Beers et al.’s findings suggest th a t tranquilizer is the most frequently used psychotropic drug class and sedative/ hypnotic is the second m ost frequently used psychotropic drug class in nursing homes. Beers et al.’s findings also suggest th a t antidepressant is the third most commonly used psychotropic drugs in nursing homes. In 1984, Buck sampled 33,351 nursing home residents in Illinois and found th a t 60% (20,037) of the residents received a psychotropic medication. Again, results indicated th at haloperidol and thioridazine hydrochloride were the two most frequently prescribed antipsychotics. In addition to studies on high psychotropic drug utilization by nursing home residents, the appropriateness of psychotropic drug prescription has also been examined. Ingm an et al.’s study results in 1975 indicated th a t psychotropic drugs are prescribed more often for symptoms such as restlessness, pain, agitation, or rigidity th an for specific medical diagnoses. In 1988, Beers et al. found th a t among the 270 antipsychotic drug users sampled, only 36 (13%) had a documented diagnosis of schizophrenia or other psychosis. Similarly, among the 119 antidepressant users, only 47 (39%) had a documented diagnosis of depression (Beers et al., 1988). 20 Also in 1988, B um s and Kamerow studied 526 American nursing home residents using the data from the 1984 National N ursing Home Study P retest (originally collected by the National H ealth Center for H ealth Statistics). B um s and Kamerow found th a t 30% of the 212 psychotropic medications prescribed to residents did not have a corresponding diagnosis documented in the residents’ medical charts. This problem is even more serious considering the fact th a t these presum ably misprescribed medications without a corresponding diagnosis were not ju st sleeping pills but antipsychotics, which accounted for half (15%) of psychotropic drugs without a documented diagnosis (Bum s and Kamerow, 1988). Many areas of concern have arisen as a result of these studies regarding the psychotropic medication consumption p attem s of the elderly w ithin nursing homes. Results indicate th a t m any nursing home residents were heavily prescribed psychotropic medications. The three m ost frequently prescribed psychotropic dm g classes in nursing homes seem to be tranquilizer, sedative/ hypnotic, and antidepressant. Results from the above studies suggest th a t haloperidol and thioridazine are the two most frequently used tranquilizers, diphenhydram ine hydrochloride is the most frequently used sedative/ hypnotic, and am itriptyline is the most frequently 2 1 used antidepressant. Disturbingly, the studies indicated th a t the m ost active residents in term s of m ental ability and functional ability are those residents who are m ost likely to be prescribed psychotropic drugs. In addition, three of the studies (i.e., Ingm an et al., 1975; B um s and Kamerow, 1988; and Beers et al., 1988) indicated th a t physicians prescribed psychotropic medications to m any of the nursing home residents without proper (e.g. presence of or correct) docum entation of diagnosis. There is not only a large risk involved in dm g interactions and adverse drug reactions as a result of heavy psychotropic dm g usage, b ut nursing home residents who have no documentation of diagnoses were unnecessarily placed in danger of developing tardive dyskinesia (from neuroleptics), urinary retention (from antipsychotics such as chlorpromazine), hypotension, dizziness, confusion, forgetfulness, and possibly severe brain im pairm ent (haloperidol). These effects may not only im pair older individuals’ function, but they also place them at greater risks for falls and hip fractures, the first of m any steps in the cascade of disasters leading toward further decline in physical, psychologic, or functional health. 22 Residential Care Facilities ' Since the topic of this thesis is the residents of residential care facilities (RCF), this section provides a background on the development and growth of RCFs. I Residential care facilities (i.e. board and care homes) are defined by Eckert, Lyon, and Namazi as protective environments for older adults who are advancing in age, lack family support, and have low I ; income. The residents of RCFs, who are unable to live independently I but do not need institutional care, are provided with "a room, meals, I j help w ith activities of daily living, and protective supervision" ' (Eckert, Lyon, and Namazi, 1990). These homes vary in size from I one resident to over 100 residents, although typically there are 30 residents or less (Dobkin, 1989). During the past two decades the residential care facility industry i I has grown rapidly in both the num ber of facilities and the num ber of residents. This growth continues, and currently, more th an a million 1 disabled, m entally ill, and older Americans are living in RCFs at a cost of about $7 billion a year. It is estim ated th a t an additional 3.2 I million Americans are at risk of placem ent in RCFs. This spurt of ) i growth in the RCF industry is a result of: 1) the aging of our I population; 2) the deinstitutionalization of the m entally ill due to j 23 advancem ents in the fields of psychiatry and state efforts to cut costs; 3) the federal government establishing two key legislation m andates; i 4) the enactm ent of the S.S.L program; and 5) the shortage of nursing home beds and long-term care services/ facilities (U.S. Subcommittee I on H ealth and Long Term Care and U.S. Select Committee on Aging, I ! 1989). i I First, over the last ten years, there has been a 20% increase in the elderly population. W hereas there were approximately 25 million older individuals in 1979, there are currently more th an 30 million 1 ! Americans over the age of 65 (U.S. Subcommittee on H ealth and Long Term Care and U.S. Select Committee on Aging, 1989). The Census B ureau projects th a t by the year 2030, 21% of the population will be I age 65 and older, a virtual doubling since 1980. W ithin this i I population, the greatest growth is among the very old who are age 85 I and over (Dobkin, 1989). This age group is the most likely to need I the care th a t is provided in RCFEs and nursing homes because of j their declining functional abilities and need for assistance with activities of daily living. Second, the dram atic reduction of institutionalized m entally ill individuals was influenced by the advancem ents in the fields of psychiatry. M any m entally ill individuals, who were previously 24 institutionalized for their safety, were able to live in the community upon the development of psychotropic medications (such as antidepressants and neuroleptics) which became available (U.S. Subcommittee on H ealth and Long-Term Care and U.S. Select Committee on Aging, 1989). In addition, the states have tried to cut costs largely as a result of the dram atic rise in expenses for the care of the m entally ill at state m ental hospitals. The average cost per year of providing a m entally ill individual w ith care has increased from $5,626 in 1965 to $41,131 in 1987. As a result, the num ber of m entally ill individuals residing in state m ental hospitals has declined within the last two decades. W hereas there were 479,709 Americams institutionalized in a state m ental hospital in 1969, there were a quarter as m any (114,686) residing in state m ental hospitals in 1987 (U.S. Subcommittee on H ealth and Long-Term Care and U.S. Select Committee on Aging, 1989). Third, two federal legislative m andates have served as catalysts in the movement towards deinstitutionalization of the m entally ill. In 1963, the federal government established 1) categorical aid to the disabled and 2) community m ental health center legislation. The first memdate (which is now SSI) allocated categorical aid to the disabled 25 and enabled former m entally ill patients to be eligible for financial support from the federal government. Therefore, the newly deinstitutionalized m entally ill had access to federal grants-in-aid. The second m andate provided incentive for the development of community health centers for outpatient services to tre a t the deinstitutionalized m entally ill (Subcommittee on H ealth and Long- Term Care and Select Committee on Aging, 1989). Fourth, in Jan u ary 1972, the Supplem ental Security Income (S.S.I.) program was developed and enabled the elderly, starting in Jan u ary 1974, to receive grants directly from S.S.I. to pay for their stay in RCFs (U.S. Subcommittee on H ealth and Long-Term Care and U.S. Select Committee on Aging, 1989). The availability of these grants and the lack of strict regulations have prompted m any people to open their own "Mom and Pop" board and care homes (Dobkin, 1989). Fifth, the decline in the num ber of available nursing home beds (due to a lim ited num ber of nursing homes available), the shortage of long-term care services/ facilities, and the growing AIDS epidemic have made a large im pact on the growth of the board and care industry by relaying a need for personalized care in a comfortable "like home" environm ent (U.S. Subcommittee on H ealth and 26 Long-Term Care and U S. Select Committee on Aging, 1989). Issue; Psychotropic Medication Utilization within Residential Care Facilities Although m any studies have discussed psychotropic medication problems and their effects on the nursing home population, few have mentioned the prevalence of sim ilar problems for the residents of RCFEs. This population of older adults residing in RCFEs is distinguished from the nursing home population by two facts: 1) the compliance w ith medication regimens of RCFE residents is usually ensured by the staff in the facilities, and 2) RCFE residents are rarely visited by a physician or pharm acist while the residents’ prescriptions, m any for renewals, are often ordered and collected by a surrogate such as a staff member (Weedle, Poston, and Parish, 1990). This thesis addresses the question, "Given the psychotropic medication consumption p attem s which have been discovered in nursing homes, w hat psychotropic medication consumption pattem s are seen in residential care facilities for the elderly?" One assum es th a t the residents who reside in nursing homes are very old (854-), frail, impaired, and likely to need personal care because of their declining functional abilities. Does this description 27 also fit the residents of RCFEs? Do residents of different size RCFEs differ in their consumption of psychotropic medications? Do RCFE residents frequently use tranquilizers, sedatives/ hypnotics, and antidepressants? Which types of psychotropic medications are more often prescribed in RCFEs? Do the majority of the residents have some form of dem entia? Is there an accompanying prim ary diagnosis for each prescribed psychotropic medication? It is hoped th a t this thesis will be able to answer these questions and shed some light on a new and growing population of older adults. I I 1 L _ _ _ _ _ _ 2 8 CHAPTER 3 - METHODOLOGY AND SAMPLE Methodology The objective of this thesis is to provide a description of RCFE residents in greater Los Angeles and sections of Orange County and their psychotropic medication consumption patterns. The data used for this descriptive analysis are baseline data derived from a Hartford Foimdation-funded project titled "The Impact of Clinical Pharm acist Services on D rug Use in Residential Care Facilities for the Elderly". This three year project was conducted by Bradley R. Williams, Pharm .D., and Loren G. Lipson, M.D., the University of Southern California’s Schools of Pharm acy and Medicine, and the Andrus Gerontology Center. The project was implem ented in three phases. Phase 1, which lasted six m onths from November 1989 to April 1990, involved facility recruitm ent, testing of data collection instrum ents, and design and testing of educational programs for staff and residents of the facilities. Phase 2, which lasted two years from May 1990 to May 1992, involved the intervention of a chnical pharm acist, data collection before and after intervention, and initial program evaluation. Phase 3, which is currently taking place and lasts six 29 m onths from June 1992 to November 1992, involves data analysis and program evaluation (Williams, Nichol, McCombs, Lowe, and Yoon, 1992). A complete list of all licensed RCFEs within Los Angeles and Orange Counties was obtained w ith the aid of professional organizations [such as the California Association of Homes for the Aged (CAHA) and the California Association of Residential Care Homes (CARCH)] and government organizations (such as the California D epartm ent of Aging and the California D epartm ent of I Social Services Community Care Licensing Branch). A letter I i I requesting participation in the project for the duration of the study, I I regardless of which group assignm ent (i.e., experim ental or control) it I i received, was sent out to the adm inistrator of each RCFE. Of the more th an 200 RCFEs which were sent letters, approximately five declined to participate, and the U.S.C. schools were able to recruit 54 licensed RCFEs located m ainly in Los Angeles County and a few from Orange County. It is assum ed th a t the tw enty five small facilities, seventeen medium facilities, and twelve large facilities which agreed to participate in the project represent the m ajority of the RCFEs in Los Angeles and Orange Counties. These facilities were prim arily owned 30 by householders who either provided or hired someone to provide protective oversight care to unrelated adults in exchange for paym ent for their room, board, meals, and other functional assistance. Very few of the facilities were owned by foundations or corporations (Williams et al., 1992). The areas in which the RCFEs are located are: Alhambra, Altadena, Anaheim, Baldwin Park, Claremont, Culver City, Diamond Bar, Downey, Gardena, Garden Grove, G ranada Hills, Lawndale, La Cresenta, Long Beach, Los Angeles, N orth Hollywood, Northridge, Pasadena, Pomona, Rancho Palos Verdes, Reseda, Santa Ana, Santa Monica, Stanton, Sylmar, Torrance, Valencia, Van Nuys, Venice, Wilmington, and Woodland Hills. The baseline data, which is being used for the descriptive analysis, are the data at the end of phase 1 and the beginning of phase 2. The baseline d ata were collected from all the residential care facilities which participated and included the following inform ation about RCFE procedures and residents: drug distribution system, potential drug problems, and drug use controls and monitoring systems already in place (Williams et al., 1992). 31 Sample The sample included only those RCFEs which agreed to participate in the project. Although the RCFEs were not selected for participation through random sampling, the assignm ent of each facility as a study or control group was made by stratified random ization to the strata of facility size: small, medium, and large. Facilities were grouped based on their licensed capacity as small (<10 beds), m edium (10-50 beds), and large (>50 beds), w ith an oversampling of the small facilities to ensure a representative sample of homes w ithin the stated geographical area. The majority of small facilities housed six residents although the range varied from four to seven residents per small facility. The m ajority of medium facilities housed approximately 36 residents although the range varied from 10 to 49 residents per medium facility. The m ajority of large facilities housed over a hundred residents although the range varied from 50 to 300 residents. A total of 840 residents were studied. Data Collectioii Description D ata for the RCFEs in the two experim ental groups were collected and recorded by a clinical pharm acist, while data for RCFEs 32 in the control group were collected and recorded by non-health care providers who were students in the fields of pharm acy or gerontology. By having non-healthcare personnel collect the data for the control group, the pharm acist was not confronted w ith the ethical dilemma of not intervening when he or she observed drug dangers and risks although he or she had been taught to prevent any harm to the patient (Williams et al., 1992). D ata were collected using the residents’ files and by examining the residents’ medications which were usually stored in a central office in each RCFE. There was no direct contact with residents during data collection. D ata were not collected on every resident from the participating RCFEs. In order to be included in the project and data collection, residents had to m eet the criteria of being 65 years-old or over and not being able to adm inister and store their own medications (i.e., not self-medicated). Any RCFE resident who did not m eet these two requirem ents was excluded from the data collection. Usually, if the residents’ medicine is not stored in a central office of the facility, it is assum ed th a t those residents self-medicate. Also, the age of the resident is indicated in the residents’ files. Overall, approximately 10% of residents from the RCFEs were excluded because they did not m eet one or both of the 33 requirem ents. Therefore, the 90% of residents who did m eet the requirem ents represent the m ajority of the residents in the facilities. D ata which were collected regarding the residents included the following: sex, age, race, paym ent sources (e.g.. Medicare), height, weight, diet, allergy, activity of daily living level, term ination date, and term ination reason (i.e., death or transfer). O ther data collected from the residents included the following: drug nam es, dose, frequency of adm inistrations per day, prescription or nonprescription status, routine or take as needed adm inistration, sta rt date, stop date, residents’ prim ary and secondary diagnoses, physicians’ nam es and addresses, and pharm acies’ nam es and addresses. The d ata collected on the medications represent the medications documented in the residents’ medical files by prescribing physicians. Although there is no way to verify if the residents consumed all the medications which they were prescribed or if any of the residents refused drug adm inistration, it is assum ed in the presentation of the results and findings th a t the residents do consume th eir prescribed medications. The inform ation was coded and entered into a customized program w ritten in dBaseIII+ (Aston-Tate, 1986). 34 Operationalization of Variables The demographic variables which have been selected for the data analysis are sex, age, and race. O ther variables selected for the data analysis are the residents’ prim ary medical diagnosis, facility size, and activity of daily living level. The medication variables which have been selected for the data analysis belong to the drug category of psychotropic medications from the American Society of Hospital Pharm acist Drug Inform ation (ASHP-DI) Handbook (McEvoy, 1989). The medication variables are (the drug classes of) antidepressant, tranquilizer, barbiturate, benzodiazepine, anxiolytic/ sedative/ hypnotic, and antim anic agent. ASHP-DI includes a six digit drug classification code (McEvoy, 1989). Two digits were added to the end of each ASHP-DI code to allow identification of a specific drug. Because a medical diagnosis of a m ental condition or a nervous system disorder causes psychotropic medications to be prescribed to the patient, this thesis is particularly examining these two medical diagnosis categories which are classified in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) medical diagnoses codebook frequently used by physicians (U.S. D epartm ent of H ealth and H um an Services, Public 35 H ealth Service, and H ealth Care Financing A dm inistration, 1989). ICD-9-CM uses a three to five digit diagnosis classification code. Facility size is ranked in order of attributes: small, medium, and large. The assignm ent of one of these attributes to each participating facility is based on its resident capacity. Small facilities have less th a n ten residents/ beds. M edium facilities have 10 to 50 residents/ beds. Large facilities have over 50 residents/ beds. The functional status of RCFE residents is indicated by a four category m easure based on the residents’ ability to perform six activities of daily living (ADL). These six activities of daily living include: bathing, dressing, toileting, transfer from bed or chair, continence, and feeding. The residents are categorized as no lim itation (i.e., able to perform all six ADLs), slight lim itation (i.e., able to perform four to five ADLs), moderate lim itation (i.e., able to perform two to three ADLs), or severe lim itation (i.e., able to perform zero or one ADL). These categorizations are assigned to the residents w ith the assum ption th a t they are able perform the activities w ithout trouble or aiding from staff. ( The psychotropic drug consumption pattem s of RCFE residents I are indicated as: 1) the num ber of psychotropic drugs ordered per | I class, 2) the most frequently used psychotropic drug classes, 3) the 36 most frequently used drug type w ithin a psychotropic drug class, and 4) the num ber of psychotropic drugs corresponding to a m ental condition or nervous system disorder diagnosis. It is the intention of this thesis to find out which psychotropic drug classes are used the most by RCFE residents and w hether they are used appropriately for a diagnosis. Also examined is the question of who the heavy consumers of psychotropic drugs are. Are these consumers prim arily males or females? W hites or nonwhites? Young elderly or old elderly? Those with a prim ary diagnosis of a m ental condition or nervous system disorder or those w ithout a diagnosis in either of these two categories? Those who are not lim ited in their activities or those who are severely limited? Those residents residing in small facihties or those residing in large facilities? Statistical Procedures In order to achieve the purpose of this thesis, both univariate analysis and bivariate analysis were done for the selected study variables. Frequencies and cross-tabulations were performed using SAS, Statistical Analysis Software (SAS Institute, 1985). A frequency distribution was performed on each of the selected study variables to provide a description of the RCFE residents. The mode, a m easure of 37 central tendency, was determ ined using the data th a t was retrieved. Cross-tabulations, a form of bivariate/ m ultivariate analysis, was also done to compare subgroup values. Limitations of Study There are a variety of study lim itations which may affect the reliability of the data. It is possible th a t data collectors and coders are the basis for unreliable m easurem ent. This m easurem ent unreliability could be due to the different judgem ents (in classif^ng or coding data) and viewpoints (in interpreting data) by the m any different coders and data collectors. For example, one data collector m ay view an older adult w ith a w alker "slightly limited" while another may view the same adult as "moderately limited". The effect of these lim itations is th a t the results may not accurately represent the RCFE residents. O ther lim itations involve missing data, data th a t was not found in the residents’ medical records due to poor organization or lack of docum entation by the facilities’ staff. Since the data collectors did not have direct contact w ith residents for inform ation retrieval, data collectors who were faced w ith medical records lacking such crucial characteristics as race and sex had to rely on the staff for supplying 38 such information. The results may reflect a large proportion of m issing inform ation because the staff may not have been able to supply the missing information. O ther lim itations of the data analysis involve not being able to find out w hether other medications were taken w ith psychotropic drugs, w hether psychotropic drugs had an accompanying diagnosis th a t is not a m ental condition or nervous system disorder, and the average/ m ean num ber of drugs taken by the population. These lim itations are m ainly the result of this thesis examining only the category of psychotropic medications and the diagnoses categories of < m ental condition and nervous system disorder. Therefore, any data j belonging to other medication or medical diagnoses categories were ! I not looked at. 39 CHAPTER 4 - RESULTS AND FINDINGS Characteristics of the Baseline Sample Population; RCFE Residents Age 65 and Above As shown in Table 1, an overwhelming percentage (78.0%) of the RCFE residents sam pled at baseline are female. W hite residents constitute over 90 percent of the sample. Among the 8.5% th a t is composed of nonwhite groups, black residents constitute 5% of the sample (See Table 1). The m ajority of the RCFE residents sampled are in their eighties and above. As shown in Table 1, the largest percentage of residents (31.6%) are found in the 85 to 89 years-old age group. The second largest percentage (26.5%) of residents are found in the 80 to 84 years-old age group, while the third largest percentage (17.8%) of residents are found in the 90 to 94 years-old age group. The m ean age of the residents is approximately 83 years-old w ith a standard deviation of 6.7 years. The ages of the elderly residents range from 65 years-old to 105 years-old. Table 2 looks at the characteristics of RCFE residents in term s of the size of the facilities in which these residents live. Sim ilar percentages of m ales (15.3%) and females (15.3%) live in small 40 facilities. The percentage of males (34.4%) slightly exceeds th a t of females (26.5%) in medium size facilities. Large facilities house over h alf of the m ales and females sampled, with the percentage of female residents (58.2%) surpassing the percentage of male residents (50.3%) in large facilities (See Table 2). Looking a t Table 2, about h alf of the Asians/ Pacific Islanders (50.0%), Hispanics (50.0%), and Blacks (60.0%) sam pled live in medium size RCFEs. There are even num bers of Hispanics in both small (50.0%) and m edium (50.0%) RCFEs. The m ajority of the residents who are of mixed Black and Hispanic descent (50.0%) live in small facilities, while the m ajority of the W hite residents (43.8%) live in large facilities (See Table 2). As illustrated in Table 2, medium size RCFEs house large percentages of residents in the younger elderly age groups: 65-69 years-old (42.9%), 70-74 years-old (43.2%), and 75-79 years-old (45.1%). Large facilities house the majority of residents in the sam ple’s older elderly age groups: 80-84 years-old (52.2%), 85-89 years-old (58.3%), and 90-94 years-old (65.7%). W ithin the oldest elderly age group, the percentage of residents living in medium size facilities nearly is two tim es th a t of residents living in large facilities (33.3%). 41 Over h alf of males (50.9%) and females (60.9%) sam pled have no lim itation in their activities of daily living (See Table 3). The num ber of females with slight lim itation (40.4%) is approximately ten percent less than th a t of women with no lim itation (50.9%). The num ber of males w ith slight lim itation (31.2%) is nearly h alf of th a t of m en with no lim itation (60.9%) (See Table 3). Besides the one resident who is of Native American descent, the mode for the residents’ activity of daily living (ADL) level in the race distribution is no lim itation (See Table 3). All the races, except for Native American, have the greatest percentage of residents in the ADL category of no lim itation: Asian/ Pacific Islander (62.5%), Black (65.5%), Hispanic (75.0%), mixed Black and Hispanic (50.0%), and W hite (48.4%). While the percentage of residents having slight lim itation is approximately one-half of th a t of residents having no lim itation for the races of Black and mixed Black and Hispanic, the percentage of the white residents having slight lim itation (42.2%) closely follows the percentage of the white residents having no lim itation (48.4%) (See Table 3). W hen examining age groups in Table 3, the mode for activity of daily hving level is also no Hmitation. The m ajority of residents in the five age groups sampled (with the exception of the 90-94 years-old 42 and the 95+ years-old age groups) have no lim itation: 65-69 years-old (79.2%), 70-74 years-old (63.6%), 75-79 years-old (62.9%), 80-84 years-old (58.5%), 85-89 years-old (59.3%). Specifically, the age groups of 80-84 years-old and the 85-89 years-old have sim ilar percentages in the no lim itation category (58.5% and 59.3%, respectively) and the slight lim itation category (34.1% and 34.2%, respectively). The percentage of residents who have no lim itation in the 70-74 years-old age group (63.6%) and the 75-79 years-old age group (62.9%) is twice as great as the percentage of residents found w ith slight lim itation in those age groups (30.3% and 29.6%, respectively). For two age groups, the highest percentage of residents are in the slight lim itation category: the 90-94 years-old age group (50.0%) and the 95 years-old and above age group (66.7%) (See Table 3). RCFE Residents with a Primary Diagnosis of a Mental Condition or Nervous System Disorder Of the 59 prim ary diagnoses which are classified under the m ental condition category in the ICD-9-CM medical diagnoses codebook, the seven m ental conditions of interest for this analysis are listed in Table 4. Fifty-six RCFE residents have a prim ary diagnosis 43 Table 1 D em ographic C haracteristics o f RCFE R esid en ts in Sam ple Population C h aracteristics N um ber of R esidents P ercen tag e of R esidents Sex (N=832) Male 183 22.0 Female 649 78.0 Race (N=604) Native American/ Alaskan 1 0.2 Asian/ Pacific Islander 8 1.3 Black 30 5.0 Hispanic 8 1.3 Mixed Black and Hispanic 4 . 0.7 White 553 91.5 Age (N=607) 65-69 years-old 28 4.6 70-74 years-old 44 7.3 75-79 years-old 71 11.7 80-84 years-old 161 26.5 85-89 years-old 192 31.6 90-94 years-old 108 17.8 95 + years-old 3 0.5 Mean = 83.3 years-old SD = 6.7 years-old Range = 65-105 years-old Note. The acronym RCFE stands for residential care facilities for the elderly. Table 2 D em ographic C haracteristics o f RCFE R esid en ts by F acility Size 44 C h aracteristics % (No.) in Sm all of RCFE R esidents F acility Size of M edium Large Total % (No.) of R esidents Sex (N=832) Male 15.3(28) 34.4 (63) 50.3 (92) 100.0(183) Female 15.3(99) 26.5(172) 58.2(378) 100.0(649) Race (N=604) Native American/ 0.0(0) 100.0(1) 0.0(0) 100.0(1) Alaskan Asian/ Pacific 25.0(2) 50.0(4) 25.0(2) 100.0(8) Islander Black 36.7(11) 60.0(18) 3.3(1) 100.0(30) Hispanic 50.0(4) 50.0(4) 0.0(0) 100.0(8) Mixed Black and 50.0(2) 25.0(1) 25.0(1) 100.0(4) Hispanic White 19.2(106) 37.1(205) 43.8(242) 100.1(553) Age Qi=607) 65-69 years-old 25.0(7) 42.9(12) 32.1(9) 100.0(28) 70-74 years-old 18.2(8) 43.2(19) 39.6(17) 100.0(44) 75-79 years-old 15.5(11) 45.1(32) 39.4(28) 100.0(71) 80-84 years-old 21.7(35) 26.1(42) 52.2(84) 100.0(161) 85-89 years-old 14.1(27) 27.6(53) 58.3(112) 100.0(192) 90-94 years-old 14.8(16) 19.4(21) 65.7(71) 99.9(108) 95 + years-old 0.0(0) 66.7(2) 33.3(1) 100.0(3) Note. The acronym RCFE stands for residential care facilities for the elderly. The percentage total may not be 100.0% due to rounding off of numbers. 45 Table 3 D em ographic C haracteristics o f RCFE R esid en ts by A ctivity o f D aily L iving Level C h aracteristics % (No.) of RCFE R esidents w ith A ctivity of D aily L iving Level Total % (No.) of R esidents No Lim it. Slight Lim it. M oderate Lim it. Severe Lim it. Sex (N=633) Male 60.9(84) 31.2(43) 5.1(7) 2.9(4) 100.1(138) Female 50.9(252) 40.4(200) 5.9(29) 2.8(14) 100.0(495) Race (N=560) Nat. American/ 0.0(0) 100.0(1) 0.0(0) 0.0(0) 100.0(1) Alaskan Asian/ Pacific 62.5(5) 25.0(2) 12.5(1) 0.0(0) 100.0(8) Islander Black 65.5(19) 31.0(9) 3.5(1) 0.0(0) 100.0(29) Hispanic 75.0(6) 25.0(2) 0.0(0) 0.0(0) 100.0(8) Mixed Black 50.0(2) 25.0(1) 25.0(1) 0.0(0) 100.0(4) and Hispanic White 48.4(247) 42.2(215) 5.9(30) 3.5(18) 100.0(510) Age (N=488) 65-69 years-old 79.2(19) 20.8(5) 0.0(0) 0.0(0) 100.0(24) 70-74 years-old 63.6(21) 30.3(10) 6.1(2) 0.0(0) 100.0(33) 75-79 years-old 62.9(34) 29.6(16) 3.7(2) 3.7(2) 99.9(54) 80-84 years-old 58.5(72) 34.1(42) 4.9(6) 2.4(3) 99.9(123) 85-89 years-old 59.3(92) 34.2(53) 3.9(6) 2.6(4) 100.0(155) 90-94 years-old 42.7(41) 50.0(48) 4.2(4) 3.1(3) 100.0(96) 95 + years-old 0.0(0) 66.7(2) 0.0(0) 33.3(1) 100.0(3) Note. The acronym RCFE stands for residential care facilities for the elderly. The percentage total may not be 100.0% due to rounding off of numbers. 46 of a m ental condition. Almost h alf (46.4%) of these residents w ith I with a m ental condition are diagnosed as having senile dem entia, 1 I while over a quarter (28.6%) of them are diagnosed as having a ! schizophrenic disorder. Almost eighteen percent (17.9%) of the RCFE I residents w ith a m ental condition are diagnosed w ith depression (See Table 4). Of the 44 prim ary diagnoses which are classified under the ^ category of nervous system disorders, only five nervous system 1 ! disorders are observed in this population (See Table 5). Twenty-six i RCFE residents have a prim ary diagnosis of a nervous system disorder. Among these residents, half (50.0%) have a prim ary diagnosis of Alzheimer’s disease. As shown in Table 5, almost a quarter (23.1%) of the residents who have a nervous system disorder are diagnosed w ith Pick’ s Disease, while a little over nineteen percent (19.2%) of them are diagnosed w ith epilepsy. Shown in Table 6 is the percentage distribution of RCFE residents who have a prim ary diagnosis which is dem entia related. Among the 46 residents w ith a dem entia related prim ary diagnosis, over half (56.5%) are diagnosed with senile dem entia, while over a quarter (28.3%) of them are diagnosed with Alzheimer’s disease. 47 Table 4 Percentage of Primary D iagnoses of a Mental Condition of a Given Type Type RCFE R esidents w ith a M ental C ondition DX % No. Anxiety States 1.8 1 Bipolar Affective Disorder 1.8 1 Depression 17.9 10 Personality Disorder 1.8 1 Psychoses 1.8 1 Schizophrenic Disorder 28.6 16 Senile Dementia 46.4 26 Total 100.1 56 Note. The acronyms RCFE and DX stand for residential care facilities for the elderly and primary diagnosis, respectively. Of the 59 primary diagnoses that are classified under mental conditions in the ICD-9-CM medical diagnoses codebook, the seven primary diagnoses listed above are the mental conditions which involve one or more resident(s). The percentage total may not be 100.0% due to rounding off of numbers. Table 5 Percentage of Primary Diagnoses o f a Nervous System Disorder of a Given Type 48 Type RCFE R esidents w ith a N ervous System D isorder DX % No. Alzheimer’s disease 50.0 13 Cerebral Degeneration 3.8 1 Epilepsy 19.2 5 Palsy 3.8 1 Pick’s Disease 23.1 6 T otal 99.9 26 Note. The acronyms RCFE and DX stand for residential care facilities for the elderly and primary diagnosis, respectively. Of the 44 primary diagnoses that are classified under nervous system disorders in the ICD-9-CM medical diagnoses codebook, the five primary diagnoses listed above are the nervous system disorders which involve one or more residents. The percentage total may not be 100.0% due to rounding off of numbers. 49 Table 6 Percentage of Primary Diagnoses of a Dem entia Related Diagnosis D em entia R elated DX RCFE R esidents w ith a D em entia R elated DX % No. Alzheimer’s disease 28.3 13 Cerebral Degeneration 2.2 1 Pick’s Disease 13.0 6 Senile Dementia 56.5 26 Total 100.0 46 Note. The acronyms RCFE and DX stand for residential care facilities for the elderly and primary diagnosis, respectively. 50 Differences Among RCFE Residents in Different Size Facilities Presented in Table 7 are percentage distributions of activity of daily living level of RCFE residents by facility size. The mode for activity of daily living is no lim itation. Over half of the residents from each of the facility sizes have no limitation: 50.0% for residents of sm all facilities, 52.4% for residents of medium facilities, and 54,8% for residents of large facilities. Over a third of the residents from each of the facility sizes are found in the slight lim itation category: 37.9% for small, 34.5% for medium, and 41.3% for large. Shown in Table 8, over sixty percent (61.5%) of RCFE residents who are diagnosed w ith senile dem entia live in m edium size facilities, while alm ost thirty five (34.6%) of these residents live in sm all facilities. Over half (56.3%) of residents diagnosed w ith a schizophrenic disorder live in m edium size facilities and over a third (37.5%) of these residents live in large facilities. Equal percentages of RCFE residents diagnosed with depression reside in medium (40.0%) and large (40.0%) facilities (See Table 8). Shown in Table 9, alm ost seventy percent (69.2%) of RCFE residents w ith a prim ary diagnosis of Alzheimer’s disease live in m edium size facilities. Equal percentages of residents diagnosed w ith Alzheimer’ s disease live in small (15.4%) and large (15.4%) facilities. 51 H alf (50.0%) of the RCFE residents diagnosed with Pick’s Disease live in small facilities, while slightly less (40.0%) live in medium size facilities. Sim ilar percentages of residents diagnosed with epilepsy live in sm all (40.0%) and large (40.0%) facilities (See Table 9). Among the 46 RCFE residents with a dem entia related prim ary diagnosis, m edium size facilities house the greatest percentage of residents who have either Alzheimer’s disease (69.2%) or senile dem entia (61.5%) (See Table 10). Also among the dem entia related population, small facilities house the greatest percentage of residents with Pick’s Disease (See Table 10). Drug Consumption Among RCFE Residents Using Psychotropic Medications Presented in Table 11 are percentage distributions of psychotropic drug orders per class among RCFE residents using psychotropic medications. A total of 567 psychotropic medications are ordered/ prescribed to the sample population. A quarter (25.0%) of these psychotropic drug orders are antidepressants. Approximately a third each of these psychotropic drug orders are tranquilizers I (31.2%) or benzodiazepines (33.9%) (See Table 11). j Presented in Table 12 are distributions by sex in consumption of ! 52 I Table 7 I P ercen tage o f RCFE R esid en ts w ith A ctivity o f D aily L iving L evel by F acility Size A ctivity o f D aily L iving % (No.) o f RCFE R esid en ts in F acility Size of Sm all M edium Large No Limitation 50.0(62) 52.4(108) 54.8(166) Slight Limitation 37.9(47) 34.5(71) 41.3(125) Moderate Limitation 8.1(10) 8.3(17) 3.0(9) Severe Limitation 4.0(5) 4.9(10) 1.0(3) Total 100.0(124) 100.1(206) 100.1(303) Note. The acronym RCFE stands for residential care facilities for the elderly. The The percentage total may not be 100.0% due to rounding off of numbers. 53 0 0 « 1 g >! I > . I I ci *o •S i .2 fi a § ü I a I I I *o 1 CD S C 5 c i C 5 «H < x > io 00 e o «H ai ai ai ai ai C O ai ai m •S i a S 3 T 3 1 < s 2 a § c d î a CO g T 3 H k « I i s I 1 % f 2 I o o o s ~ o fl s 1 I 1 f e a I 0) & 2 54 03 I I I I e s * S 1 I Q I 09 I A I 1 1 0 > % CO CD lO o o e < M 0 3 CD CO O 1 I I I I c £ 3 1 i I 1 T 3 g I I I I O ) £ 55 i H g i» I 03 I i 'd I 1 C 6 I I î S ! C O « M O 0 0 C O i O C O lO l / l l / l l / l l / l m < ù % z 4 1 I f- 4 'd ê ë S I î 'd "3 £ 1 g ' d g « (A I I a % I • s * g I I 0 8 T — I < U r£> 1 & d 0 1 § A a ! 56 specific psychotropic drugs. Approximately three quarters of psychotropic drug orders are made for female psychotropic drug users in the following psychotropic classes: antidepressant (74.8%), tranquilizer (79.3%), barbiturate (84.6%), benzodiazepine (82.2%), and anxiolytic/ sedative/ hypnotic (88.9%). The percentage of antim anic agents drug orders for females (68.8%) doubles th a t of m ales (31.3%) using psychotropic drugs. Overall, female psychotropic drug consumers receive 79.5% of psychotropic drug orders while male I psychotropic drug consumers receive 20.5% of psychotropic drug I orders (See Table 12). I As shown in Table 13, approximately ninety percent or more of I I psychotropic drug orders belong to white psychotropic drug users in ' the following psychotropic drug classes: antidepressant (95.5%), tranquilizer (87.8%), barbiturate (100.0%), benzodiazepine (95.2%), anxiolytic/ sedative/ hypnotic (94.7%), and antim anic agent (100.0%). Although there are no drug orders of a barbiturate or antim anic j agent for nonwhite psychotropic drug users, over a ten th (12.2%) of j tranquilizer orders are made for nonwhite psychotropic drug users (See Table 13). Overall, 92.9% of psychotropic drug orders are for white psychotropic drug consumers and 7.1% of the orders are for nonwhite psychotropic drug consumers (See Table 13). 57 Illustrated in Table 14 are percentage distributions by age groups in consumption of specific psychotropic drugs. The psychotropic drug users in the age group of 80-84 years old receive the greatest num ber (30.6%) of psychotropic drugs orders. This population receives approximately a third each of psychotropic drug orders belonging to the classes: antidepressant (34.4%), barbiturate (41.7%), and benzodiazepine (30.3%). They also receive almost seventy percent of antim anic agent (66.7%) drug orders, 28.6% of anxiolytic/ sedative/ hypnotic drug orders, and 24.5% of tranquilizer drug orders (See Table 14). Also shown in Table 14, the 85-89 years-old psychotropic drug consumers receive almost a quarter (24.8%) of all psychotropic drug orders. Although there are no barbiturate or antim anic agent drug orders for consumers of this age group, they receive over tw enty percent of drugs in the following drug classes: antidepressant (27.2%), tranquilizer (21.6%), benzodiazepine (23.5%), and anxiolytic/ sedative/ hypnotic (28.6%). The psychotropic drug consumers who are 65-69 years old have the lowest percentage (5.3%) of psychotropic drug orders (See Table 14). Among this population, the greatest consumers are found to receive tranquilizers (10.8%). 58 Illustrated in Table 15 are percentage distributions of psychotropic drug orders per class for RCFE psychotropic drug users w ith different activity of daily living (ADL) levels. The m ajority (56.6%) of psychotropic drug orders are made to psychotropic drug consumers who have no hm itation in their ADLs. Psychotropic drug users w ith no lim itation receive the following percentages of drug orders: 61.9% of antidepressant orders, 56.9% of tranquilizer orders, 66.7% of barbiturate orders, 48.9% of benzodiazepine orders, 65.0% of anxiolytic/ sedative/ hypnotic orders, and 100.0% of antim anic agent orders (See Table 15). Over a third (35.7%) of psychotropic drug orders are made to psychotropic drug consumers who have slight lim itation with their ADLs (See Table 15). These psychotropic drug consumers receive: 30.9% of antidepressant orders, 36.2% of tranquilizer orders, 33.3% of barbiturate orders, 40.3% of benzodiazepine orders, and 35.0% of anxiolytic/ sedative/ hypnotic orders. As shown in Table 16, over half (54.0%) of psychotropic drug orders are made to RCFE psychotropic drug users residing in large facilities, while a little less th an a third (30.9%) of them are made to psychotropic drug users residing in medium size facilities. This population of psychotropic drug users living in large facilities receives 59 over half of all psychotropic drug orders in five of the six psychotropic drug classes: antidepressant (58.5%), barbiturate (53.9%), benzodiazepine (63.5%), anxiolytic/ sedative/ hypnotic (51.9%), and antim anic agent (87.5%). The largest percentage (41.8%) of tranquilizers orders are prescribed to RCFE psychotropic consumers residing in medium size facilities (See Table 16). Psychotropic Drug Orders Prescribed For a Primary Diagnosis of a Mental Condition or a Nervous System Disorder Presented in Table 17 are percentage distributions of psychotropic drug orders prescribed to RCFE psychotropic drug users j who have a prim ary diagnosis of a m ental condition. Almost a third j I I (31.3%) of the 16 antim anic agent orders are prescribed according to a i I m ental condition diagnosis. The drug classes of antidepressant and i I tranquilizer constitute sim ilar percentages (29.4% and 28.2%, j i respectively) of psychotropic drug orders which are prescribed for a ' m ental condition. As shown in Table 17, tw enty percent (20.1%) of the 139 ! i antidepressant orders and almost nineteen percent (18.8%) of the 16 ! antim anic agent orders have an accompanying diagnosis of | depression. Almost thirteen percent (12.5%) of antim anic agent ! Table 11 Percentage of Psychotropic Drug Orders Per Class Among RCFE Psychotropic Drug Users 60 P sychotropic D rug Class % (No.) o f P sychotropic D rug O rders A m ong P sychotropic D rug U sers Antidepressant 25.0(142) Tranquilizer 31.2(177) Barbiturate 2.3(13) Benzodiazepine 33.9(192) Anxiolytic, Sedative, or Hypnotic 4.8(27) Antimanic Agent 2.8(16) Total % (No.) of Psychotropic Orders 100.0(567) Note. The acronym RCFE stands for residential care facilities for the elderly. Of the sixteen drug classes classified under Central Nervous System drug category in the American society of Hospital Pharmacy Drug Information Handbook, the six drug classes listed above belong to the psychotropic drug category. 61 S S ri X J l X J l 1 XJl XJl XJl t 00 T 3 T 3 lO to g 5 e CO CO àC lO CO o to o to to c r T 3 O ) C Q T 3 «M o o o (M 62 «M O I 0 5 0 5 O O CO r - H 0 5 o p C O s lO (M i 0 5 S 0 5 O O 0 5 lO S lO lO 0 5 OO O O CO «H O O o «H o o 0 0 I sc I I I Q * o I I .2 1 g b f I so s I I 0 1 .2 PL, *o 1 t H tH lO CO tH 0 5 0 5 0 5 0 5 tH (M § id G lO 0 5 ¥ CO C M CO 00 ° o CO 0 5 tH 0 5 tH 0 0 tH CM 00 5 00 CO s 00 CO tH CO CO CO 00 CO tH 00 CM tH 00 0 5 0 5 S 3 CO o d s 00 00 00 tH s lO 0 5 SB CO 00 ° g 00 tH tH CM 00 00 00 II « b e % M c r o 63 I o o o a & - 2 3 I I a I I ( 1 ) 6 < s C A < D c S (1) I I I M « f i i I 3 I k (1) a I I C Q I I a I I % I a I C Ü I i 1 % I I ■ § 1 3 I I 3 f I o I ft l> - s £ I I rS ft I * s I Î Q p C i I I .2 Î I I I I 0 9 1 6 1 2 I 1 & * o s 1 c c I ; s h ^ i > : a p CO CO 00 § 0 5 o o o q o q 00 s CO c q 00 II « • H CO 00 00 00 3 ( M CO 00 CO CO 00 fl OO 00 CO CO 0 5 CO » o 00 CO 0 5 CO CO CO C O CO T 3 < X ) CQ cr 1 3 « Q 64 I I 1 3 I C m o g 0 a 1 o 3 <u i u <u P Q i e g g g 1 2 = s " O g « ! < x > ë 00 00 <u g to 2 g I <u to I i ft < D Î g <u e g a cfc to I g C Ü 1 3 % I S ' I % I 0) 1 I :S I t X D I I o I ft I I ft 65 C O I .a % a I 1 b i 2 I I I I I 1 2 ! CO CO o p & Q CO 3 CO CO CO CO 00 iC 0 0 lO iC CO CO iC CO 00 iC 00 § lO CO p p 00 CO CO iC C Q ( M CO CO A A CO 00 lO CO ( M s 0 5 CO ( M o cr T3 T3 I i . o o T — I (3 I I a i I < D rp «+ H (A < D < D c 3 1 I « S M F 3 H « t I I < D r4 I k rC I C A I CD • S a I T3 I • s i I C Ü i u CD pq I % % I I ■ § 1 T3 I ■ I I I 0 1 f I A [ ~ 00 CO CD rp g CA I I I ■ s CD rP Î I A 6 6 orders have an accompanying diagnosis of bipolar affective disorder, while approximately nine percent (9.2%) of the 174 tranquilizer orders have an accompanying m ental condition diagnosis of schizophrenic disorder. The percentage (14.4%) of tranquilizer orders w ith an accompanying diagnosis of senile dem entia doubles th a t of antidepressant orders (6.5%) (See Table 17). Presented in Table 18 are percentage distributions of psychotropic drug orders prescribed according to a prim ary diagnosis of a nervous system disorder. Approximately fifteen percent (15.4%) of the 13 barbiturates are prescribed according to persons w ith a nervous system disorder, specifically epilepsy. About nine percent (9.2%) of tranquilizer drug orders are prescribed for a nervous system disorder, m ainly Alzheimer’s disease which constitutes 8.6% of this percentage. Similar percentages of antidepressant (3.6%), benzodiazepine (3.7%), and anxiolytic/ sedative/ hypnotic (3.7%) orders have an accompanying m ental condition diagnosis (See Table 18). Shown in Table 19, the total percentages of psychotropic drug orders which have an accompanying prim ary diagnosis of either a m ental condition or nervous system are combined to produce the total percentage of psychotropic drug orders which are prescribed according 67 to a m ental condition or nervous system disorder diagnosis. A third (33.0%) of the total antidepressant drug orders have an accompanying diagnosis of a m ental condition or nervous system disorder; however, the rem aining 67.0% of antidepressant drug orders do not. Similarly, 37.4% of the total tranquilizer orders have an accompanying diagnosis; however, 63.2% of tranquilizer orders do not (See Table 19). Approximately thirty percent (31.3%) of total antim anic agent orders have an accompanying diagnosis while 68.7% of these orders do not. Approximately a tenth of total barbiturate orders (15.4%), benzodiazepine (15.2%) orders, and anxiolytic/ sedative/ hypnotic (11.1%) orders have an accompanying prim ary diagnosis of a m ental condition or nervous system disorder. Therefore, the rem aining 84.6% of barbiturate orders, 84.8% of benzodiazepine orders, and 88.9% anxiolytic/ sedative/ hypnotic orders do not have an accompanying m ental condition or nervous system disorder (See Table 19). «H » o CO s 00 o ô c o % • rt o i l cc ê I «H ë à O O O '(f is § ( M s 3 c o ( M * S' io C £ > b ü o % cc 68 I I < 2 t n O ) ë i î H k § I I I I % 0 0 I % I I I I I A I 'd 0 ) 1 I u ! * o s a I I I A I b J l î c n % S 3 « S -2% O .2 II li & C Ü •ss o b o * 1 # § i I ^ g ^ i i ; ïfii o o o t- c6 CD CO s o o lO CD 00 s CD CO I C O I I o o o o o o o o o o o o CD o o o o I I Q Î o o o o o o o iq o id S o o o o o & I o o o o o o o o o o o o s o o o o o 2 o o o o o o o o o o o o S o o s o o I 69 o o o CO CO id CD c q < 3 5 e CD CO * o I I l l e I II % b o I I I I s I M 1 2 J I I " O w § I I % G ) S i I a * o 99 99 O a i £ j ■ § A ■ s 1 i O I i * o â 1 I s 0 1 99 I C i ë d o ■ § o 99 i l l | 99 99 99 " g rt O u 8 I I 99 CO l i a ë II il •s g 3! i î « I g | §|ll l l l î ^ •i I lO c o t H c o Ë lO o o o s ( M $ s 1 o o o o c o c o s ic c o < N 0 5 lO w c o I I I : z ; s c o T—H c o c o s ( M ic s à O 3 c o c o c o c o * o i I 'd .8 I 5 la I! o 99 ■ |s l l I 99 A S : 1 si g i ; II i 00 c o i 00 00 s iH w 00 c o 00 8 < N c o ' c o c o 0 5 c o îi II il 3 Q g fi o et 1 1 ci o d 99 II Z ë a .2 il Ô 70 I I c S S i 1 g c S 9 9 'T S H I I I I 71 Psychotropic Drug Consumption by Type Presented in Table 20 are percentage distributions of psychotropic drug orders by class and w ithin class. Among the 142 antidepressants ordered, am itriptyline hydrochloride constitutes the greatest percentage (21.8%) while nortriptyline hydrochloride and trazodone hydrochloride constitute sim ilar percentages (15.5% and 15.5%, respectively). Twelve percent of antidepressant orders are for desipram ine hydrochloride. Following closely is im ipram ine hydrochloride/ im ipram ine pam oate which constitutes 9.2% of antidepressant orders (See Table 20). Among the 177 tranquilizers ordered, haloperidol constitutes the greatest percentage (42.4%). Almost a quarter (23.7%) of tranquilizer orders are thioridazine/ thioridazine hydrochloride. A ten th (10.2%) of tranquilizer orders are thiothixene/ thiothixene hydrochloride (See Table 20). Among the 13 barbiturates, phénobarbital constitutes 84.6% of barbiturate drug orders (See Table 20). Among the 192 benzodiazepines orders, triazolam and flurazepam hydrochloride each constitute 20.3%. Lorazepam constitutes 18.2% of benzodiazepine orders. Equal percentages of benzodiazepine orders are for tem azepam (13.0%) and alprazolam (13.0%) (See Table 20). 72 Among the 27 anxiolytics/ sedatives/ hypnotics ordered, over forty percent (44.4%) of them are hydroxyzine hydrochloride/ hydroxyzine pamoate. Over twenty-two percent (22.2%) of anxiolytic/ sedative/ hypnotic orders are meprobamate. Slightly less is buspirone hydrochloride which constitutes 18.5% of these orders (See Table 20). 73 Table 20 P ercen tage o f P sychotropic D rug Orders by Class and w ith in Class P sychotropic Class % (No.) of D rug O rd ers w ith in C lass % (No.) o f D rug O rd ers P e r Class Antidepressant 25.0(142) Amitriptyline Hydrochloride 21.8(31) Amoxapine 3.5(5) Desipramine Hydrochloride 12.0(17) Doxepin Hydrochloride 7.7(11) Imipramine Hydrochloride/ 9.2(13) Imipramine Pamoate Maprotiline Hydro chloride 2.1(3) Nortiptyline Hydrochloride 15.5(22) Phenelzine Sulfate 0.7(1) Protriptyline Hydrochloride 2.1(3) Trazodone Hydrochloride 15.5(22) Fluoxetine 6.3(9) Bupropion 3.5(5) Tranquilizer 31.2(177) Chlorpromazine/ 5.6(10) Chlorprom. Hydrochloride Chlorprothixene/ 6.2(11) Chlorproth. Hydrochloride/ Chlorproth. Lactate Fluphenazine Decanoate/ 5.1(9) Fluphenazine Enanthate/ Fluphenazine Hydrochloride Haloperidol 42.4(75) Mesoridazine Besylate 0.6(1) Molindone Hydrochloride 0.6(1) Pimozide 0.6(1) Thioridazine/ 23.7(42) Thioridaz. Hydrochloride Thiothixene/ 10.2(18) Thiothixene Hydrochloride Trifluoperazine Hydrochloride 5.1(9) 74 Table 20 (continued) Percentage of Psychotropic Drug Orders by Class and w ithin Class P sychotropic Class % (No.) of D rug % (No.) of D rug O rders w ith in Class O rders P e r Class Barbiturate 2.3(13) Phénobarbital 84.6(11) Secobarbital Sodium 7.7(1) Talbutal 7.7(1) Benzodiazepine 33.9(192) Alprazolam 13.0(25) Chlordiazepoxide/ 2.1(4) Chlordiaz. Hydrochloride Clonazepam 3.1(6) Clorazepate Dipotassium 0.5(1) Diazepam 7.8(15) Flurazepam Hydrochloride 20.3(39) Lorazepam 18.2(35) Oxazepam 1.0(2) Prazepam 0.5(1) Temazepam 13.0(25) Triazolam 20.3(39) Anxiolytic, Sedative, or Hypnotic 4.8(27) Buspirone Hydrochloride 18.5(5) Chloral Hydrate 11.1(3) Hydroxyzine Hydrochloride/ 44.4(12) Hydro3QTzine Pamoate Meprobamate 22.2(6) Promethazine Hydro chloride 3.7(1) Antimanic Agent 2.8(16) Lithium Salt 100.0(16) Total Psychotropic Drug Orders --- 100.0(560) 75 CHAPTER 5 « DISCUSSION AND CONCLUSION This chapter discusses the impHcations of the findings and results which are presented in the last chapter. To date, very little has been w ritten about drug therapy among residents of residential care facilities for the elderly. It is the intention of this thesis to provide a description of this fairly understudied population. Discussion The m ajor findings presented in the previous chapter indicate m any things about the residents of RCFEs. First, the m ajority of RCFE residents are women, white, and age 85+. These findings parallel recent demographic statistics compiled by the U.S. Senate Special Committee on Aging, the American Association of Retired Persons, the Federal Council on Aging, and the U.S. A dm inistration on Aging in 1991. Because women age 65 and above tend to live longer th an men, they outnum ber m en by three to two, w ith elderly women num bering 18.3 million and men num bering 12.6 million in 1989. The elderly white population is also greater in num ber th an the nonwhite populations. The U.S. B ureau of Census reported th a t in 1989, there were 30,984,000 elderly Americans. Of this figure, elderly white 76 Americans constituted 89.8% (27,822,000) while elderly nonwhites constituted 10.2% (3,162,000) (U.S. Special Committee on Aging, the American Association of Retired Persons, the Federal Council on Aging, and the U.S. A dm inistration on Aging, 1991). In addition, it is expected th a t the 85+ population will triple in size between 1980 and 2030 as a result of greater disease prevention and health care. Already, the 85+ population has jum ped from 123,000 in 1900 to 2.2 million in 1980. It is expected th a t this population will increase from 10 percent of the elderly population in 1989 to 22 percent in 2050 (U.S. Senate Special Committee on Aging et al., 1991). The results indicate th a t sex does not appear to be associated w ith facility size. Sim ilar percentages of m ales and females are residents of different facility sizes (See Table 2). However, race appears to be related to facility size. Native Americans, Asians/ Pacific Islanders, Blacks, Hispanics, and mixed Blacks and Hispanics have a greater representation in small and medium size RCFEs than in large facilities. Conversely, whites have a greater representation in large RCFEs th an in small or medium RCFEs. Therefore, this suggests th a t nonwhites are more likely to live in medium or small facilities th an w hites who are more likely to live in large facilities 77 (See Table 2). However, these results m ust be viewed cautiously as the num ber of m inority group members in the sample is too small for definitive results. Age also appears to be related to facility size. Residents of younger age groups in the elderly population (i.e., 65-69 years old, 70-74 years old, and 75-79 years old) tend to be clustered in medium size facilities, while residents of older age groups (i.e., 80-84 years old, 85-89 years old, and 90-94 years old) tend to live in large residential care facilities (See Table 2). There appears to be a slight relation between sex and residents’ level of activity of daily living. Although m ales and females have sim ilar percentages in all four activity of daily living levels when comparing the sexes, more females th an m ales are slightly lim ited and m oderately lim ited in their activities of daily living (See Table 3). Race appears to be highly associated w ith activity of daily living level. Among the six race categories in the baseline sample, five of the races (i.e., Asian/ Pacific Islander, Black, Hispanic, mixed Black and Hispanic, and White) have a large percentage of residents who are not lim ited in th eir activities of daily living. However, nonwhites have a greater percentage of residents in the no lim itation category th an whites (See Table 3). 78 These results regarding the large percentage of RCFE residents w ith no lim itation are surprising considering the fact th a t among the total elderly population (27.9 million) residing outside institutions, in the community, 11.4% (almost 3.2 million) of them had one or more ADL limitation(s). Among this 3.2 million, 47 percent (1,450,000) had one lim itation, 34 percent (1,060,000) had two to three lim itations, and 21 percent (670,000) had four or more lim itations (U.S. Senate Special Committee on Aging et al., 1991). It is possible th a t the results reflect the unreliable m easurem ent of residents’ ADL. D ata collectors may have assessed ADL levels differently. For example, some d ata collectors m ay have considered the residents’ illnesses (e.g., medical diagnoses) which are documented in the residents’ files when they assigned each resident a level of ADL. This data collector bias could have heen prevented had each ADL been clearly defined and a scale ranging from independent to unable to perform been developed for each ADL. Age also appears to be highly associated w ith activity of daily level. Noteworthy is the fact th a t the younger age groups (e.g., 65-69 years-old) have a higher percentage of residents w ith no lim itation th an those in the older age groups (e.g. 90-94 years-old) (See Table 3). These results are to be expected since people tend to have a higher 79 prevalence of chronic illnesses or conditions which may lead to their functional im pairm ent and possible disability as they grow older (U.S. Senate Special Committee on Aging et al., 1991). Activity of daily living level also appears to be associated w ith facility size. Residents w ith no lim itation or slight lim itation are more likely to live in large facilities, while residents who have m oderate or severe lim itation are likely to be found in sm all and m edium facilities (See Table 7). This suggests th a t residents of small facilities require greater protective care, supervision, and assistance w ith their activities of daily living. This also implies th a t residents living in small facilities have lower health status th an residents living in large facilities. Among RCFE residents w ith a m ental condition, senile dem entia, schizophrenic disorder, and depression are the most frequently observed prim ary diagnoses (See Table 4). Among RCFE residents w ith a nervous system disorder, Alzheimer’s disease, Pick’s Disease, and epilepsy are the most frequently observed prim ary diagnoses (See Table 5). Among RCFE residents with a dem entia related diagnosis, Alzheimer’ s disease and senile dem entia are the most frequently observed (See Table 6). There appears to be a relationship between a prim ary diagnosis 80 of a m ental condition and facility size. Residents w ith depression and a schizophrenic disorder are found more often in large facilities. Conversely, residents w ith senile dem entia are more often found in small facilities. However, the m ajority of residents who are diagnosed w ith senile dem entia or a schizophrenic disorder live in medium facilities (See Table 8). There appears to be relationship between a prim ary diagnosis of a nervous system disorder and facility size. Residents with Pick’ s Disease constitute a greater percentage in sm all facilities th an those in medium and large facilities. A large percentage of residents who have Alzheimer’s disease are more often found in m edium facilities th an in small or large facilities. RCFE residents who have Alzheimer’s disease or epilepsy tend to live in small or large facilities (See Table 9). There appears to be an association between residents w ith a dem entia related diagnosis and facility size. Residents who have senile dem entia or Alzheimer’s disease tend to live in medium size RCFEs while those residents who have Pick’s disease tend to live in small RCFEs (See Table 10). It would be unwise to generalize an association or nonassociation between sex and psychotropic drug consumption since there are 81 sm aller num bers of males th an females in the population (See Table 12). It would be unwise to generalize an association or nonassociation between race and psychotropic drug class because of the very low num ber of residents who represent the nonwhite/ m inority races of Native American/ Alaskan, Asian/ Pacific Islander, Black, Hispanic, and mixed Black and Hispanic in Table 13. There appears to be an association between residents’ ages and psychotropic drug consumption. RCFE residents who are 80-84 years old receive the greatest num ber of antidepressant, tranquilizer, barbiturate, benzodiazepine, anxiolytic/ sedative/ hypnotic, and antim anic agent orders th an any other age groups. Residents who are 85-89 years old receive approxim ately a quarter of all antidepressant, benzodiazepine, and anxiolytic/ sedative/ hypnotic orders. Residents who are 65-69 years-old receive the lowest proportion of psychotropic drug orders (See Table 14). Activity of daily living and psychotropic drug consumption appear to be related. Over half of all psychotropic drugs ordered are consumed by RCFE psychotropic drug users who have no lim itation w ith their ADLs. Approximately a third of all psychotropic drugs ordered are consumed by RCFE psychotropic drug users who are 82 ! I slightly lim ited w ith their ADLs. Less th an a ten th of residents ' using psychotropic drugs are m oderately lim ited or severely lim ited (See Table 15). This implies th a t RCFE residents who are the least im paired in their ADLs are given the greatest num ber of psychotropic orders while the m ost im paired residents receive the least num ber of ; psychotropic orders. This finding supports the findings of Ingm an et al. (1975) and Ray et al. (1986) who suggested the same association ' I i although their populations were nursing home residents. ! Facility size and psychotropic drug consumption also appears to I be associated. Psychotropic drug users who live in large facilities j I receive a greater num ber of emtidepressant, barbiturate, I j benzodiazepine, anxiolytic/ sedative/ hypnotic, and antim anic agent j orders th an residents from small and medium faciHties. Residents who reside in m edium facilities receive a greater num ber of , tranquilizer orders th an those in small or large facilities 1 (See Table 16). i I Sim ilar to the findings of the nursing home studies, the results of ' this study indicate th a t an overwhelming percentage of RCFE residents who consume psychotropic drugs do not have a prim ary diagnosis of either a m ental condition or nervous system disorder. A possible reason for this prescribing pattern is th a t residents may 83 complain largely of illness symptoms and persuade physicians to prescribe w ithout documenting a diagnosis. Among psychotropic drug users, the three most frequently used drug classes are antidepressant, tranquilizer, and benzodiazepine. These three psychotropic drug classes are among m any drug classes which are "often prescribed to tre a t insom nia...[although they may not be] prim arily indicated for sleep disorders" (Yakabowich, 1992). Although benzodiazepines are appropriately prescribed for sleep problems, tranquilizers and antidepressants are not specifically indicated for sleep disturbances and m ay be prescribed as a result of symptoms. Benzodiazepines are effective in treating sleep disturbances, because they reduce sleep latency (i.e., the time it takes to fall asleep) and nocturnal awakenings and increase the total tim e in sleep. However, the danger w ith prescribing tranquilizers and antidepressants for sleep disturbances is th a t the residents experience a wide range of side effects (such as orthostatic hypotension) w ithout alleviating the disorders. The three most commonly used antidepressants by RCFE residents are am itriptyline hydrochloride, nortriptyline hydrochloride, and protriptyline hydrochloride. The three m ost commonly used tranquilizers in the population are haloperidol, thioridazine/ 84 thioridazine hydrochloride, and thiothixene/ thiothixene hydrochloride. The three m ost commonly used benzodiazepines are triazolam , flurazepam hydrochloride, temazepam , lorazepam, and alprazolam. Conclusion Several conclusions have emerged from this thesis. First, the m ajority of RCFE residents are female, white, and age 85 and above. Second, m any of these residents have no apparent lim itation with their ADLs. Third, the facility size of these residents appears to be associated w ith the resident’s level of ADL as well as a prim ary diagnosis of either a m ental condition or nervous system disorder. Fourth, the race of the residents appears to be associated with both facility size and residents’ ADL level. Fifth, the age of the residents also appears to be related to facility size, and residents’ ADL level. Sixth, the three most frequently used psychotropic classes are antidepressant, tranquilizer, and benzodiazepine. Seventh, the three most frequently observed prim ary diagnoses among RCFE residents w ith a m ental condition are senile dem entia, schizophrenic disorder, and depression. Among RCFE residents w ith a nervous system disorder, the three m ost frequently seen disorders are Alzheimer’s I 85 I I disease, Pick’s Disease, and epilepsy. Among the RCFE residents ! w ith a dem entia related diagnosis, Alzheimer’s disease and senile dem entia are the m ost frequently observed. Lastly, among the 82 residents who consume psychotropic medications, over h alf of those who are prescribed antidepressants, tranquilizers and benzodiazepines do not have an accompanying diagnosis of a m ental condition or nervous system disorder. These j findings suggest m any of the residential care facilities are needlessly i I placed in danger of developing adverse drug reactions as a result of I taking psychotropic drugs which do not relate to the residents’ ^ underlying illness and m ay in fact, cause illnesses to develop. ' M any of the psychotropic drugs are extremely dangerous for i older adults, because they are long-acting and rem ain in the bodies ; for m any hours, possibly days. Benzodiazepines such as flurazepam and diazepam — two of the three most frequently observed benzodiazepines found in the psychotropic drug user population— are ^ very hazardous to the older adult. These drugs accum ulate w ithin j the older bodies and act for long durations as a result of the ! dim inished capacity of the older adult’s mixed function oxidase I system to metabolize these drugs. However, benzodiazepines such as I lorazepam and tem azepam are generally preferred for elderly 86 patients, because they are not metabolized by the mixed function oxidase system (Sloan, 1981). M any antidepressants such as am itriptyline are very sedating and can cause the older person’ s sleep cycle to become disrupted. Desipramine is another antidepressant which is commonly used. It is preferred over other tricyclic antidepressants because of its lower anticholinergic side effects. Anticholinergic effects can be especially dangerous to patients w ith congestive h eart failure and angina pectoris (Sloan, 1981). Tranquilizers are hazardous to older adults because they are associated with extrapyram idal side effects in addition to causing sedation. Haloperidol and thiothixene— two of the three most frequently observed tranquilizers in the population— are associated with extrapyram idal side effects and therefore are considered very dangerous. The preferred tranquilizer is thioridazine— the rem aining of the three m ost frequently observed tranquilizers among psychotropic drug users (Sloan, 1981). The point to be emphasized is th a t psychotropic drugs are very dangerous not only because they result in side effects and adverse drug reactions, but this category of drugs can strongly sedate the older adult and place him/ h er at risk of falling and breaking his/ her 87 hip. Once bedridden, the older adult is at a large risk of gradually declining in health, developing decubitus ulcers, and dying. Although nursing homes have to adhere to strict regulations as a result of the Omnibus Budget Reconciliation Act (OBRA) of 1987, residential care facilities do not have such a regulatory am endm ent. OBRA’s recent am endm ent has recently upgraded the regulations regarding physician prescribing practices in nursing homes, especially the prescribing of psychotropics. The OBRA am endm ent requires physicians to document reasons for any prescribed psychotropic drug and has identified certain psychotropics such as barbiturates inappropriate for residents. It has also established dosage reductions and drug holidays for those residents who have a documented reason for using psychotropics. In addition, nursing home residents’ blood levels are checked periodically (Smith, 1990). Residential care facilities, however, do not have such established regulations. These facilities have been developed more for providing social services than for health services. Many of the elderly residents who live in residential care facilities do not receive the necessary care for the m aintenance of their health and quality of life, because m any of the staff are not trained adequately nor are they fam iliar with the medications which they adm inister to residents (U.S. Subcommittee 88 on H ealth and Long-Term Care and U.S. Select Committee on Aging, 1989). It is recommended th a t regulations be established sim ilar to those of OBRA for residential care facilities. In order to prevent future catastrophic drug illnesses from occurring, regulations need to be establish to deter physicians from overprescribing psychotropic drugs and endangering residents. 89 REFERENCES Ashton-Tate, Inc. (1986). Phase III plus, volume 1.1. Torrance, CA: Ashton-Tate. Beers, M., Avom, J., Soumehal, S. B., Everitt, D. E., Sherm an, D. S., & Salem, S. (1988). Psychoactive medication use in interm ediate- care faciUty residents. Journal of American Medical Association. 260. 3016-3020. Buck, J. A. (1988). Psychotropic drug practice in nursing homes. Journal of American Geriatric Societv, 36. 409-418. Bum s, B. J., & Kamerow, D. B. (1988). Psychotropic dm g prescriptions for nursing home residents. The Journal of Familv Practice, 26, 155-160. Bum s, B., & Phillipson, C. (1986). Drugs, ageing, and societv: Social and pharmacological perspectives. London, Britain: Croom Helm. Dobkin, L. (1989). The board and care svstem: A regulatorv jungle. W ashington, DC: American Association of Retired Persons. Dunkle, R. E., Petot, G. J., & Ford, A. B. (1986). (Eds.). Food, dm gs, and aging. New York: Springer. Eckert, J. K., Lyon, S. M., & Namazi, K. H. (1990). Congmence between residents and the environm ent in small board and care homes: An exploratory study. Adult Residential Care Joum al, ^ 227-240. (From A bstracts in Social Gerontologv, 1991, 34, A bstract No. 228) Ingman, S. R., Lawson, I. R., Pierpaoli, P. G., Blake, P. (1975). A survey of the prescribing and adm inistration of drugs in a long-term care instituion for the elderly. Joum al of the American Geriatric Societv. 23, 309-316. 90 REFERENCES (continued) McCormack, P., & O’ Malley, K. (1986). Biological and medical I aspects of treatm ent in the elderly. In R. E. Dimkle, G. J. Petot, i & A. B. Ford (Eds.). Food, drugs, and agfing (pp. 19-27). New i York: Springer. i McEvoy, G. K. (Ed.). (1989). AFHS drug inform ation 89. Bethesda, MD: American Society of Hospital Pharm acists. McKim, W. A., & M ishara, B. L. Drugs and aging. Toronto, Canada: Butterw orths. Moore, S. R., & Teal, T. W. (Eds.). (1985). G eriatric drug use: Clinical and social perspectives. Elmsford, New York: Pergam on Press. Ouslander, J. G. (1986). Polypharmacy and the elderly. In R. E. Dunkle, G. J. Petot, & A. B. Ford (Eds.). Food, drugs, and aging (pp. 29-40). New York: Springer. Ray, W. A., Federspiel, C. F., & Schaffner, W. (1989). A study of antipsychotic drug use in nursing homes. Epidemiologic evidence suggesting misuse. American Journal of Public H ealth. 70, 485-491. SAS Institute, Inc. (1985). SAS U ser’s Guide: Basics. Version 5 Edition. Cary, NC: SAS Institute. Simonson, W. (1984). Medications and the elderly: A guide to promoting proper use. Rockville, Maryland: Aspen Systems. Sloan, R. W. (1981). G eriatric drug therapy. The Journal of Family I Practice. 13. 599-609. i ' Smith, D.A. (1990). New rules for prescribing psychotropics in ! nursing homes. Geriatrics. 45. 44-56. 91 REFERENCES (continued) U. S. D epartm ent of H ealth and H um an Services. (1981). H ealth United States 1981 (DHHS Publication No. PHS 82-1232). Hyattsville, MD: U.S. Government Printing Office. U.S. D epartm ent of H ealth and H um an Services, Public H ealth Service, & H ealth Care Financing Administration. (1989). The international classification of diseases, ninth revision, clinical modification (3rd ed.) (DHHS Publication No. PHS 89-1260). W ashington, DC: U.S. Government Printing Office. U. S. Senate Special Committee on Aging, the American Association of Retired Persons, the Federal Council on Aging, & the U.S. Adm inistration on aging. (1991). Aging America: Trends and projections (DHHS Publication No. FCoA 91-28001). W ashington, DC: U.S. Government Printing Office. U. S. Subcommittee on H ealth and Long-Term Care, & U.S. Select Committee on Aging. (1989). Board and care homes in America: A national tragedv (Publication No. 107-111). W ashington, DC: U.S. Government Printing Office. Williams, B. R., Nichol, M., McCombs, N., Lowe, B., Yoon, P. (1992). Pharm acist interventions in residential care facilities (in press). Annual Review of Gerontology and G eriatrics. Williams, B. R., & Lipson, L. G. (1989). The im pact of clinical pharm acist services on drug use in residential care facilities for the elderly. A Proposal to the John A. H artford Foundation (Research Proposal). Los Angeles, CA: U.S.C. Schools of Gerontology, Medicine, and Pharmacy. Weedle, P. B., Poston, J. W., & Parish, P. A. (1988). Use of hypnotic medicines by elderly people in residential homes. Journal of the Roval College of General Practitioners, 38, 156-158. 92 REFERENCES (continued) Weedle, P. B., Poston, J. W., & Parish, P. A. (1990). Drug prescribing in residential homes for elderly people in the U nited Kingdom. DICP. The Annals of Pharm acotherapy, 24, 533-536. Woodruf-Pak, D. (1988). Psychology and aging. Englewood Cliffs, New Jersey: Prentice Hall. Yakabowich, M. R. (1992). Hypnotics in the elderly: Appropriate usage guidelines. Journal of G eriatric Drug Therapy, ^ 5-21. 93 APPENDIX A Mental Condition Diagnoses Listed in the International Classification of Diseases, 9th Revision. Clinical Modification (ICD-9-CM) ICD-9-CM Codes Medical Diagnoses 301.1 Affective personality disorder 301.10 Affective personality disorder 300.21 Agoraphobia w ith panic attacks 300.22 Agoraphobia w ithout mention of panic attacks 303.9 Alcoholism (Alcohol Dependence Syndrome) 300.12 Amnesia, psychogenic 307.1 Anorexia Nervosa 300.02 Anxiety disorder, generalized 300.0 Anxiety states 300.00 Anxiety states, unspecified 290.4 Arteriosclerotic dem entia 296.4 Bipolar affective disorder, manic 296.5 Bipolar affective disorder, mixed 301.12 Chronic depressive 301.11 Chronic hypomanie 300.11 Conversion disorder 301.13 Cyclothymic disorder 293.0 Delirium, acute 293.1 Delirium, subacute 290.1 Dementia, presenile 311 Depression, general, unspecified 300.4 Depression, neurotic 300.4 Depression, reactive 291 ETOH (Alcoholic) psychosis 300.7 Hypochondriasis 300.1 H ysteria 300.10 H ysteria, unspecified 296.3 Major depressive disorder, recurrent episode 296.2 Major depressive disorder, single episode 296.1 Manic disorder, recurrent episode 94 APPENDIX A (continued) Mental Condition Diagnoses Listed in the International Classification of Diseases, 9th Revision. Clinical Modification (ICD-9-CM) ICD-9-CM Codes Medical Diagnoses 296.0 Manic disorder, single episode 319 M ental retardation 300 Neurotic disorders 300.8 Neurotic disorders, other 300.9 Neurotic disorders, unspecified 300.3 Obsessive-compulsive disorders 310.9 Organic B rain Syndrome 300.29 O ther isolated or simple phobias 300.01 Panic disorder 301.0 Paranoid personality disorder 301 Personality disorders 300.20 Phobia, unspecified 300.2 Phobic, unspecified 300.2 Phobic disorders 296 Psychoses, affective 293 Psychotic conditions, transient organic 310.1 Memory loss, mild 309.0 Grief reaction, mild 301.2 Schizoid personality disorder 301.20 Schizoid personality disorder, unspecified 295 Schizophrenic disorders 295.5 Schizophrenic disorders, latent 295.3 Schizophrenic disorders, paranoid type 295.0 Schizophrenic disorders 290.0 Senile dem entia, uncomplicated 290.3 Senile dem entia w ith delirium 290.8 Senile psychotic conditions 290 Senile/ presenile organic psychotic conditions 300.23 Social phobia 300.81 Somatization disorder 95 APPENDIX B Nervous System Disorder Diagnoses Listed in the International Classification of Diseases, 9th Revision. Clinical Modification (ICD-9-CM) ICD-9-CM Codes Medical Diagnoses 331 Alzheimer’s disease 335.20 Amyotrophic lateral sclerosis 351.0 Bell’s palsy 335.22 Bulbar palsy, progressive 354.0 Carpal tunnel syndrome 334.3 Cerebellar ataxia, other 334.2 Cerebellar degeneration, prim ary 331.9 Cerebral degeneration, unspecified 333.4 Chorea, H untington’s 333.5 Choreas, other 331.2 Degeneration of brain, senile 333.0 Degenerative disease of the basal ganglia, other 341 Demyelinating disease of central nervous system, other 345 Epilepsy 345.1 Epilepsy, generalized convulsive 345.0 Epilepsy, generalized nonconvulsive 345.3 Epilepsy, grand mal status 345.2 Epilepsy, petit mal status 333 Extrapyram idal disease, other 342.9 Hem iparesis 342 Hemiplegia 342.0 Hemiplegia, flaccid 342.1 Hemiplegia, spactic 342.9 Hemiplegia, unspecified 331.3 Hydrocephalus, communicating 331.4 Hydrocephalua, obstructive 337.0 Idiopathic peripheral autonomic neuropathy 335.24 Lateral sclerosis, prim ary 346 M igraine 96 APPENDIX B (continued) Nervous System Disorder Diagnoses Listed in the International Classification of Diseases, 9th Revision. Clinical Modification (ICD-9-CM) ICD-9-CM Codes Medical Diagnoses 340 M ultiple sclerosis 335.21 M uscular atrophy, progressive 358.0 M yasthenia gravis 333.2 Myoclonus 350.1 Neuralgia, trigem inal 335.23 Palsy, pseudobulbar 344.1 Paraplegia 332.1 Parkinsonism , secondary 332 Parkinson’ s disease 331.1 Pick’s disease 344.0 Quadriplegia 333.82 Tardive Dyskinesia 333.3 Tics of organic origin 333.1 Tremor, senile, essential, other specified forms 97 APPENDIX C Psychotropic Drug Classification Adapted from the American Society of Hospital Pharmacists Drug Information (ASHP-DI) Handbook ASHP-DI Codes Psychotropic Drugs By Class ANTIDEPRESSANTS Isocarboxazid Phenelzine Sulfate Tranylcypromine Sulfate Amitriptyline Hydrochloride Amoxapine Desipramine Hydrochloride Doxepine Hydrochloride Im ipram ine Hydrochloride/ Im ipram ine Pam oate M aprotiline Hydrochloride N ortriptyline Hydrochloride Protriptyline Hydrochloride Trim ipram ine M aleate Trazodone Hydrochloride Clomipramine Fluoxetine Bupropion 28 16 04 00 28 16 04 01 28 16 04 02 28 16 04 03 28 16 04 04 28 16 04 05 28 16 04 06 28 16 04 07 28 16 04 08 28 16 04 09 28 16 04 10 28 16 04 11 28 16 04 12 28 16 04 13 28 16 04 14 28 16 04 15 28 16 04 16 I 98 I APPENDIX C (continued) Psychotropic Drug Classification Adapted from the American Society of Hospital Pharmacists Drug Information (ASHP-DI) Handbook ASHP-DI Codes Psychotropic Drugs By Class TRANQUILIZERS Acetophenazine M aleate Chlorpromazine/ Chlorpromazine Hydrochloride Fluphenazine Decanoate/ Fluphenazine E nanthate/ Fluphenazine Hydrochloride Mesoridazine Besylate Perphenazine Prochlorperazine/ Prochlorperazine Edisylate/ Prochlorperazine M aleate Promazine Hydrochloride Thioridazine/ Thioridazine Hydrochloride Trifluoperazine Hydrochloride Trifluopromazine Hydrochloride Chlorprothixene/ Chlorprothixene Hydrochloride Chlorprothixene Lactate Droperidol Haloperidol Loxapine Hydrochloride/ Loxapine Succinate Molindone Hydrochloride Pimozide Thiothixene/ Thiothixene Hydrochloride 28 16 08 00 28 16 08 01 28 16 08 02 28 16 08 03 28 16 08 04 28 16 08 05 28 16 08 06 28 16 08 07 28 16 08 08 28 16 08 09 28 16 08 10 28 16 08 11 28 16 08 12 28 16 08 13 28 16 08 14 28 16 08 15 28 16 08 16 28 16 08 17 99 APPENDIX C (continued) Psychotropic Drug Classification Adapted from the American Society of Hospital Pharmacists Drug Information (ASHP-DI) Handbook ASHP-DI Codes Psychotropic Drugs By Class BARBITURATES Amobarbital/ Amobarbital Sodium Aprobarbital B utarbital Sodium M ephobarbital M ethohexital Sodium Pentobarbital/ Pentobarbital Sodium Secobarbital Talbutal BARBITURATES M ephobarbital M etharbital Phénobarbital Sodium Primidone 28 24 04 00 28 24 04 01 28 24 04 02 28 24 04 03 28 24 04 04 28 24 04 05 28 24 04 06 28 24 04 07 28 24 04 08 28 12 04 00 28 12 04 01 28 12 04 02 28 12 04 03 28 12 04 04 1 0 0 APPENDIX C (continued) Psychotropic Drug Classification Adapted from the American Society of Hospital Pharmacists Drug Information (ASHP-DI) Handbook ASHP-DI Codes Psychotropic Drugs By Class 28 24 08 00 BENZODIAZEPINES 28 24 08 01 Alprazolam 28 24 08 02 Chlordiazepoxide/ Chlordiazepoxide Hydrochloride 28 24 08 03 Clorazepate Dipotassium 28 24 08 04 Diazepam 28 24 08 05 Flurazepam Hydrochloride 28 24 08 06 Halazepam 28 24 08 07 Lorazepam 28 24 08 08 Midazolam Hydrochloride 28 24 08 09 Oxazepam 28 24 08 10 Prazepam 28 24 08 11 Temazepam 28 24 08 12 Triazolam 28 24 08 13 Clonazepam 28 12 08 00 BENZODIAZEPINES 28 12 08 01 Clonazepam 28 12 08 02 Clorazepate 28 12 08 03 Diazepam 1 0 1 APPENDIX C (continued) Psychotropic Drug Classification Adapted from the American Society of Hospital Pharmacists ASHP-DI Codes Psvchotropic Drugs By Class 28 24 92 00 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, & HYPNOTICS 28 24 92 01 Buspirone Hydrochloride 28 24 92 02 Chloral H ydrate 28 24 92 03 Chlormazanone 28 24 92 04 Ethchloryynol 28 24 92 05 Ethinem ate 28 24 92 06 Glutethim ide 28 24 92 07 Hydroxyzine Hydrochloride/ Hydroxyzine Pamoate 28 24 92 08 M eprobamate 28 24 92 09 M ethotrim eprazine Hydrochloride 28 24 92 10 M ethyrylon 28 24 92 11 Paraldehyde 28 24 92 12 Prom ethazine Hydrochloride 28 24 92 13 Propiomazine Hydrochloride 28 24 92 14 Diphenhydram ine Hydrochloride 28 24 92 15 Doxylamine Succinate 28 28 00 00 ANTIMANIC AGENTS 28 28 00 01 Lithium Salts

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Psychotropic drug prescribing patterns in the nursing home

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Creator Vuong, Jeannette Diem-Trang (author)

Core Title Psychotropic medication consumption patterns observed in residential care facilities for the elderly

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