Medication use increased among nursing home residents during pandemic

Recent data revealed an increase in medication use among nursing home residents in Ontario, Canada, “with the potential for adverse effects” during the COVID-19 pandemic, according to researchers.

The findings were published in JAMA Network Open.

Colleen Maxwell, PhD, a professor at the University of Waterloo in Ontario and senior adjunct scientist at ICES, a health informatics nonprofit, and colleagues said the shortage of health care professionals and resident isolation may have led to “less timely and/or less appropriate clinical care and oversight, including the management of medications.”

“These initial trends are potentially troubling as these medications, particularly when used concurrently or at high dosages or for long durations, are associated with increased risks for poor health outcomes among older long-term care residents, including increased cognitive impairment and falls,” Maxwell told Healio Primary Care.

The researchers conducted a population-based cohort study with interrupted time-series analysis of medication use in 630 nursing homes in Ontario. They compiled prescription data from March 2017 to September 2020 using health administrative databases.

Maxwell and colleagues compared medication use among weekly cohorts. Data on the first weekly cohort were from the week of March 5, 2017, while data on the last weekly cohort were from the week of Sept. 20, 2020.

The annual cohort size of residents ranged from 75,850 to 76,549. Their mean age was 83.4 years, and most of the participants (68.9%) were women.

After the onset of the pandemic, Maxwell and colleagues found a statistically significant increase in the weekly proportion of residents who received antipsychotics (P < .001), benzodiazepines (P < .001), antidepressants (P < .001), trazodone hydrochloride (P < .001), anticonvulsants (P = .03) and opioids (P < .001). However, the absolute differences in observed vs. projected medication use were small by the end of September, ranging from 0.48% for anticonvulsants to 1.52% for antipsychotics, according to Maxwell and colleagues. The absolute difference of other medications was 1.43% for antidepressants, 1.06% for trazodone, 1.06% for opioids and 0.64% for benzodiazepines.

The researchers found no significant differences in the use of antibiotics, angiotensin receptor blockers or angiotensin-converting enzyme inhibitors during pre-pandemic vs. pandemic periods.

COVID-19 has likely had a profound effect on the mental and physical health of nursing home residents due to social isolation and “a subsequent increased prevalence of depression” coupled with decreased access to nonpharmacological interventions, Maxwell and colleagues noted.

“There may be many drivers of medication use in long-term care, including input and pressure from other long-term care staff and family caregivers,” Maxwell said. “For physicians involved in long-term care and physician prescribers who treat older adults in community care settings, there are likely to be increases in the number of residents and patients presenting with mental health concerns (depression, anxiety) because of the pandemic.”

Going forward, Maxwell said that prescribers should carefully examine the relative risks and benefits of each medication for each individual patient, “especially in the context of all other medication use, and if a medication is deemed to be appropriate, to select one with the lowest risk and always use it at the lowest possible dose and for the shortest duration possible.”

In a related commentary, Christina Reppas-Rindlisbacher, MD, and Paula A. Rochon, MD, MPH, of the University of Toronto, and Nathan M. Stall, MD, of Sinai Health in Toronto and the University Health Network, discussed the overarching problems of medication prescribing trends. Even short-term increases in prescribing of “potentially inappropriate medications with known harms is concerning,” they wrote.

“Psychotropic medications in particular were frequently overprescribed in Ontario prior to the pandemic, but overall rates were decreasing in large part due to quality improvement initiatives to reduce potentially inappropriate prescribing,” Reppas-Rindlisbacher and colleagues wrote. “The observed increases in psychotropic prescribing documented by Maxwell et al are concerning, as the COVID-19 pandemic appears to have undone some of these gains.”

Nonpharmacologic approaches should be emphasized, including multidisciplinary care, music, massage and touch therapy for the treatment of behavioral and psychological dementia symptoms, which affect about 70% of Canadian nursing home residents, according to Reppas-Rindlisbacher and colleagues.

References:

Campitelli MA, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.18441.

Reppas-Rindlisbacher C, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.19028.