Medicine and Health Sciences Commons^™

Use Of Medications Of Questionable Benefit In Advanced Dementia, Jennifer Tjia, Becky Briesacher, Daniel Peterson, Qin Liu, Susan Andrade, Susan Mitchell

Jennifer Tjia

IMPORTANCE: Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized. OBJECTIVES: To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data …

Rationales That Providers And Family Members Cited For The Use Of Antipsychotic Medications In Nursing Home Residents With Dementia, Alice Bonner, Terry Field, Celeste Lemay, Kathleen Mazor, Daniel Andersen, Christina Compher, Jennifer Tjia, Jerry Gurwitz

Jennifer Tjia

OBJECTIVES: To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs). DESIGN: Qualitative, descriptive study. SETTING: Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions. PARTICIPANTS: Individuals diagnosed with dementia who received an antipsychotic medication. MEASUREMENTS: Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded …

Statin Discontinuation In Nursing Home Residents With Advanced Dementia, Jennifer Tjia, Sarah Cutrona, Daniel Peterson, George Reed, Susan Andrade, Susan Mitchell

Jennifer Tjia

OBJECTIVES: To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days.

DESIGN: Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files.

SETTING: All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida).

PARTICIPANTS: NH residents with dementia.

MEASUREMENTS: Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. …

Use Of Mechanical Ventilation By Patients With And Without Dementia, 2001 Through 2011, Tara Lagu, Marya Zilberberg, Jennifer Tjia, Penelope Pekow, Peter Lindenauer

Jennifer Tjia

Increasing demand for US critical care resources, including beds, intensivists, and invasive mechanical ventilation (IMV),has placed substantial strain on the critical care system. Since 2000, elderly patients treated in the intensive care unit have received higher intensity care (and have experienced lower mortality rates) than historical cohorts. Yet certain populations of elderly patients exposed to intensive care experience substantial long-term adverse effects, including functional decline and excess mortality. Patients with dementia receiving IMV, for example, are at high risk for delirium, which confers a 3.2-fold increased risk of 6-month mortality. The increasing use of aggressive therapies suggests that demand for …

Knowledge Of And Perceived Need For Evidence-Based Education About Antipsychotic Medications Among Nursing Home Leadership And Staff, Celeste Lemay, Kathleen Mazor, Terry Field, Jennifer Donovan, Abir Kanaan, Becky Briesacher, Sarah Foy, Leslie Harrold, Jerry Gurwitz, Jennifer Tjia

Jennifer Tjia

BACKGROUND/OBJECTIVES: Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members' knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Survey of leadership and direct care staff of nursing homes in Connecticut was conducted …

Dissemination Of Evidence-Based Atypical Antipsychotic Information To Nursing Homes, Celeste A. Lemay, Jennifer Tjia, Kathleen M. Mazor, Terry S. Field, Abir O. Kanaan, Jennifer L. Donovan, Jerry H. Gurwitz

Jennifer Tjia

Background: Accumulating evidence demonstrates minimal benefit and increased risk of off-label use of atypical antipsychotic medications for dementia-related behaviors. Optimal strategy for disseminating evidence-based guides to nursing home (NH) stakeholders is unclear. Our objective is to describe the impact of differing dissemination efforts in Connecticut NHs.

Methods: Forty-three Connecticut NHs were randomized to one of 3 arms receiving incrementally intensive dissemination strategies of the Agency for Healthcare Research and Quality Comparative Effectiveness Review Summary Guide on the off-label use of atypical antipsychotic drugs, which was included in a toolkit informed by a needs assessment of NHs. All NHs received the …

Understanding Antipsychotic Drug Use In The Nursing Home Setting, Celeste A. Lemay, Alice F. Bonner, Christina Compher, Terry S. Field, Jonathan Freedlander, Susan Joslin, Kathleen M. Mazor, Jennifer Tjia, Jerry H. Gurwitz

Jennifer Tjia

Introduction: The increasing prevalence of antipsychotic medication use in residents of nursing homes (NH) in the absence of psychiatric diagnoses is concerning. To address these concerns, it is essential to explore how these medications are being prescribed and managed in the NH setting. Our objectives were to understand the decision-making process that influences prescribing and factors that trigger administration of antipsychotic medications to residents with dementia in NHs and to explore why residents remain on antipsychotic medications over an extended period of time.

Methods: Interviews with prescribers, caregivers, and family members, on-site observations in study facilities, and review of NH …

Statin Discontinuation Among Nursing Home Residents With Advanced Dementia, Jennifer Tjia, Sarah L. Cutrona, Daniel J. Peterson, Becky A. Briesacher

Jennifer Tjia

Background: Statin use in elderly individuals with life-limiting illness such as advanced dementia is controversial.

Objective: To describe factors associated with statin discontinuation and estimate impact of discontinuation on 28-day hospitalizations in nursing home (NH) residents with advanced dementia.

Methods: Retrospective cohort study of NH residents ≥ 65 years with recent progression to advanced dementia from 5 large U.S. states drawn from the 2007-2008 Minimum Data Set 2.0. We identified residents using statins. Clinical characteristics and 28-day hospitalization risk were compared for residents discontinuing and continuing statins. Multivariable Cox proportional hazard models identified factors associated with time to statin discontinuation …

Potentially Inappropriate Use Of Antipsychotics In Community-Dwelling Adults With Dementia More Common In Those With Low Income, Jennifer Tjia

Jennifer Tjia

Comment on: The essential and potentially inappropriate use of antipsychotics across income groups: an analysis of linked administrative data. [Can J Psychiatry. 2012]

Patient Completion Of Laboratory Tests To Monitor Medication Therapy: A Mixed-Methods Study, Shira Fischer, Terry Field, Shawn Gagne, Kathleen Mazor, Peggy Preusse, George Reed, Daniel Peterson, Jerry Gurwitz, Jennifer Tjia

Jennifer Tjia

BACKGROUND: Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear. OBJECTIVE: To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests. DESIGN: Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews. PARTICIPANTS: Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or …

A Mixed-Methods Study To Characterize Pharmaceutical Marketing In The Nursing Home Setting: Off-Label Use Of Atypical Antipsychotics, Camilla Benedicto, Jennifer L. Donovan, Terry S. Field, Jerry H. Gurwitz, Sarah Foy, Leslie R. Harrold, Abir O. Kanaan, Celeste A. Lemay, Kathleen M. Mazor, Jennifer Tjia, Sruthi Valluri, Becky A. Briesacher

Jennifer Tjia

Background: Despite FDA warnings that atypical antipsychotic medications are associated with an increased risk of death when used to treat behavioral disorders in older adults with dementia, they are prescribed to nearly one-third of older U.S. nursing home (NH) residents. Reasons for their high use in NHs are poorly understood, but may include pharmaceutical marketing efforts in the NH setting.

Methods: This study is nested within an ongoing cluster randomized trial to improve the use of atypical antipsychotics in NHs. We analyzed semistructured interviews (n = 36) and surveys (n = 139) of administrators, directors of nursing and medical directors …