INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 7: 53-58 (1992)

CONSUMPTION OF PSYCHOTROPIC DRUGS IN ELDERLY PERSONS REGISTERED AT THE

HOME NURSING CENTRE IN BERGEN, NORWAY HARALD A. NYGAARD

Fyllingsdulen Sykehjem, N-SO33 Bergen-Fyllingsdalen, Norway

SUMMARY

The regular use of psychotropic drugs in all patients aged 70 yr and over who were registered at the home nursing centre was studied. 27.4% of the patients used psychotropic drugs, 11.9% used antipsychotics, 14.6% anxiolytics and hypnoticsisedatives and 6% antidepressants. The use of antipsychotics was increased in mentally impaired patients and in wandering, restless aggressive persons, but declined with increasing age. Anxiolytics and hypnotics/ sedatives and antidepressants were more frequently used by apathetic/passive/anxious patients. The dosage of antipsy- chotics declined with age. The doses are usually in line with general suggestions. Drugs in which the efficacy is judged by the patients themselves seem to be taken in higher doses than drugs in which the efficacy is determined by the physician.

KEY woms-Mental impairment, psychotropic drug consumption, antipsychotics, anxiolytics, hypnotics, antidepres- sants, home nursing, elderly.

Drug consumption in elderly people is regarded as being disproportionately high. Multimorbidity plays an important part in this respect and mental disturbances are a major cause for prescription in the elderly. Prevalence studies on psychotropic drug consumption in the elderly living at home vary from 25%) to 37% (Tellnes et al., 1986a; Achong et al., 1978). Some studies show a lower drug use in persons above 59 yr (Greenblatt et al., 1975) and others after 80 yr (Tellnes et al., 1986a). Dispar- ities may occur due to methodological differences. Some reports are based on random samples and others on patients referred to medical assessment units.

Furthermore, it has been shown that treatment is often based on symptoms rather than on defined diagnosis (Bergman et al., 1979; Tellnes et al., 1986b). This seems more pronounced for primary care physicians than for psychiatrists (Beardsley et al., 1988). The present survey was performed to examine the extent of regular use of psychotropic drugs in patients receiving home nursing and to evaluate behaviour and physical disabilities of patients being treated.

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MATERIALS AND METHODS

The study is a part of a survey performed in Febru- ary 1985, in which all patients 50 yr and over who were registered at the local home nursing centre and all persons living in long-term institutions were registered (Nygaard et al., 1987). The population of the city numbers approximately 207 000 inhabi- tants, 10.7% being 70 yr and over. Patients aged 70+ receiving home nursing were included in this study.

The participants were registered by age, sex and marital status. Their consumption of psychotropic drugs was registered by the home nurse in charge. Each patient was further estimated in regard to mental capacity, activities of daily living (ADL) and behaviour.

Mental capacity was estimated by means of the Clinical Dementia Rating (CDR) scale (Hughes et al., 1982). The scale, which was developed as a stag- ing instrument for Alzheimer’s disease, has also been used for estimating mental capacity in the elderly in general (Nygaard et al., 1990). In one study including 32 patients admitted for a respite

Received 7 Januarv 1991 0 1992 by John Wiley & Sons, Ltd. Accepted24 May 1991

54 H. A . NYGAARD

stay in a nursing home, CDR was estimated prior to the admission by the home nurse in charge. In the institution the patient went through a routine workup. Mental competence was diagnosed according to DSM-I11 (American Psychiatric Asso- ciation, 1980) and staged according to CDR. The agreement of the ratings between the physician and the home nurse was good (kappa=0.71) (unpub- lished data).

ADL functions and behaviour were registered by means of a general workload scale (Adolfsson eta]., 1981; Nygaard et nl., 1990).

Psychotropic drugs were classified according to the Anatomical Therapeutic Chemical Classifica- tion Code (ATC classification) and doses according to defined daily doses (DDD) (WHO Collaboration Centre for Drug Statistics Methodology/Nordic Council on Medicines, 1990). The groups of psy- chotropic drugs were antipsychotics (N 05A), anxiolytics (N 05B), hypnoticslsedatives (N 05C) and antidepressants (N 06A). Anxiolytics and hyp- noticslsedatives consist mainly of benzodiazepines which share much the same properties (Committee on the Review of Medicines, 1980). For our pur- pose they were grouped together. The unit DDD is defined as the appropriate average dose, normally the weight of active substance, per day, used for the main indication of the preparation. All psycho- tropic drugs used on a regular basis were registered.

The statistical analyses were performed with the BMDP program package (Dixon, 1988). Non-para- metric tests were applied: chi-square test with Yates correction were appropriate and the Kruskal-Wal- lis test. Five per cent was accepted as level of signifi- cance.

All results are based on observations from the home nurses, who usually communicate well with their clients and are thus able to carry out such judgements,

One thousand nine hundred and twenty-five per- sons 70 yr and over received home nursing. The forms were incomplete in 13 cases, leaving 1912 patients, 468 men and 1444 women, available for the study. Information on dosage was missing for antipsychotics in 18 cases, for anxiolytics and hyp- notics in 34 cases and for antidepressants in 15 cases.

The median age for men was 81 yr (range 70-98) and for women 82 yr (range 70-101). 12.6% of the population were moderately or severely mentally impaired. 5.9% were incontinent for urine and 2,3% for faeces. 14.6% were dependent on help when eating, 45.2% with hygiene and 25.9% when dress-

ing. 35.7% were considered to be apatheticlpassivel anxious and 8.30/0 wanderinglaggressivelrestless. 1.3% were chairbound or bedridden.

RESULTS

Five hundred and twenty-three patients (27.4%) used psychotropic drugs regularly, significantly more women (N=417, 28.9%) than men ( N = 106, 22.6%) (p=O.Ol). Usage significantly declined with increasing age (Table 1).

Table 1. Percentage of home-nursed patients using psychotropic drugs according to age

Age % drug Odds 95% confidence groups user ratio interval

70-74 37.4 1 .o 15-79 32.2 0.8 0.6-1.1 80-84 27.9 0.6 0.54.9 85 + 19.0 0.4 0.34.5 All 21.4

Antipsycho tics

Two hundred and twenty-nine patients (1 1.9%) used an antipsychotic drug, 54 men (11.5%) and 175 women (12Y0); the difference between genders was not significant (p=0.8). In 48 patients (21%) antipsychotic drug consumption was combined with the use of an anxiolytic or a hypnotic drug and in 19 cases (8Yo) with an antidepressant. The odds for using an antipsychotic drug decreased with rising age and increased in mentally impaired elderly and in patients who were wanderinghest- lesslaggressive. Futhermore, usage was signifi- cantly associated with urinary and faecal incontinence and dependency when eating, with hygiene and dressing (Table 2).

In a stepwise logistic regression analysis apathy/ anxiousness, wanderinglrestlessnesslaggressive- ness, mental impairment (CDR 2-3) and age remained in the final model. Diminished ability to perform ADL functions was coassociated with dis- turbed behaviour and mental impairment. These

DRUGS IN THE ELDERLY AT HOME 55

Table 2. Factors significantly associated with the use of antisychotic drugs in home-nursed elderly

Factor User Non- Odds 95%

( N = 229) ( N = 1683) interval user ratio confidence

Agegroups(x2=30.8,p<0.001) 70-74 75-79 80-84 85 + CDR groups (x’ = 11 8.6, p <0.001) 0 4 . 5 1 2-3

Bladder function ( x ’ = 17.9,p<0.001) Continent Not continent Bowel function (x’ = 25.5,p<0.001) Continent Not continent Eating (x’ = 23.1, p < 0.001) Independent Need help Behaviour ( x 2 = 193.6,p<0.001) No disturbances Apathetic/anxious Wanderingirestiesslaggressive Hygiene (x’ = 40.2, p < 0.001) Independent Partially he1 ped Dependent Dressing ( x ’ = 46.2,p<0.001) Independent Partially helped Deoenden t

218 387 503 575

1 .o 0.6 0.5 0.3

55 63 64 47

0.4-1.0 0.3-0.8 0.24.5

109 44 76

1303 216 164

1 .o 2.4 5.5

1.7-3.6 4.1-7.6

159 70

1373 310

1 .O 1.9 1 &2.7

195 34

1585 98

1 .o 2.8 1 .94 .3

171 58

1462 22 1

1 .o 2.2 1.6-3.1

46 117 66

1015 565 103

1 .O 4.6 14.1

3.3-6.4 9.9-20.3

86 48 95

96 1 329 393

1 .o 1.6 2.7

1.1-2.4 2.0-3.7

131 53 45

1285 264 134

1 .o 2.0 3.3

1.4-2.8 2.34.8

were removed from the model when the latter was introduced.

An tidepressan ts

One hundred and fourteen patients (6%), 19 men (4.1%) and 95 women (6.6%), used antidepressant drugs (p=0.06). In 35 cases (31%) the drug was combined with an anxiolytic or a hypnotic drug and in 21 cases (18%) with an antipsychotic drug. In six cases (5%) all three drugs were combined. Usage declined significantly with increasing age and increased in apathetictpassivetanxious persons (Table 4).

Anxiolytics and hypnoticshedatives

Two hundred and eighty patients (14.6%) used these drugs, 52 men (11.1Y0) and 228 women (1 8.8%); the difference between the genders was sta- tistically significant (p =0.02). In 79 patients (28.2%) other psychotropic drugs were used simul- taneously. The odds for apathetic/passive/anxious patients using these drugs were significantly increased (Table 3). There was no statistical asso- ciation between the consumption of an anxiolytic or hypnotic drug and age or ADL functions.

Drug dosage

The median DDD was 0.25 (mean 0.43, SD 0.56) for antipsychotics, 0.6 (mean 0.9, SD 0.7) for anxio-

56 H. A. NYGAARD

Table 3. Factors significantly associated with the use of anxiolytics and hypnotics/sedatives in home-nursed elderly

~

Variable User Non- Odds 95% user ratio confidence

( N = 280) ( N = 1632) interval

Gender (x’ = 5 . 8 , ~ = 0.02) Male 52 416 1 .o Female 228 1216 1.5 I. 1-2.1

Behaviour(X’ = 62.3,p<0.001) No disturbances Apathetic/anxious Wandering/restless/aggressive

99 962 1 .o 157 525 2.9 2.2-3.8 24 145 1.6 1.0-2.7

Table 4. Factors significantly associated with the use of antidepressants in home-nursed elderly

Variable User Non- Odds 95% confidence user ratio

( N = 114) ( N = 1798) interval

Agegroups (~2=40.5,p<0.001) 70-74 33 240 1 .o 75-79 37 413 0.7 0.61.1 80-84 32 535 0.4 0.3-0.7 85 + 12 610 0.1 0.14.3

Behaviour (x’ = 33. I , p < 0.001) No disturbances 35 1026 1 .o Apatheticlpassivelanxious 68 614 3.1 2.14.7 Wandering/restless/aggressive 11 158 2.0 0.94.3

lytics and hypnotics, and 0.5 (mean 0.59, SD 0.38) for antidepressants. Differences in dosage were stu- died by means of the Kruskal-Wallis test with mul- tiple comparisons. The dosage of antipsychotics declined with increasing age (H=12.9, df = 3, p =0.005); however, only the difference between patients aged 70-74 yr and those aged 80 and over was statistically significant (Table 5). For the other groups there was no statistical age difference in dosage, but for anxiolytics/hypnotics/sedatives there was a significant difference between the genders (men median 1 .O DDD, women median 0.5 DDD, H=9.2, df= 1, p=0.002). The distribution of patients according to DDD is shown in Table 6.

DISCUSSION

There are limitations in the present study. The patients in the study constitute the frail elderly of the city, as indicated by their status as receivers

Table 5. Defined daily doses according to age in home-nursed elderly

Age N Antipsychotics groups Mean (SD) Median

70-74 49 0.61 (0.67) 0.33 75-79 51 0.51 (0.73) 0.25 80-84 60 0.36 (0.37) 0.25

Total 21 1 0.43 (0.56) 0.25 85 + 45 0.23 (0.20) 0.20*

*70-74 versus 85 + , p < 0.05.

of home nursing. Furthermore, patients treated with psychotropic drugs were estimated with regard to signs which in themselves may be influenced by the treatment. Usually the home nurses are well informed about drug consumption among their cli- ents. However, anxiolytics and hypnoticsisedatives are often prescribed ‘as needed’, hence these results may be underestimated. Antidepressants and anti- psychotics are usually prescribed in fixed schedules.

DRUGS IN THE ELDERLY AT HOME 57

Table 6. Distribution of drug consumption according to doses in home-nursed elderly (percentage of patients)

Drug group Number Defined daily doses Below 0.5 0.51-1 .O Above 1 .O

Antipsychotics 21 1 80.1 11.4 8.5 Anxiolytics and hypnoticskedatives 246 46.3 38.6 15.0 Antidepressants 99 62.6 32.3 5.1

The reports on these drugs are considered to be in accordance with the true consumption.

In the present study 27.4% of the clientele regu- larly used psychotropic drugs, a rate which is in the lower range of other reports (Tellnes et al., 1986a; Achong et al., 1978; Osterlind et al., 1986). Skegg et al. (1977) and Landahl (1987) found an increasing consumption with rising age, while others (Greenblatt et al., 1975; Tellnes et al., 1986a), in accordance with the present study, demonstrated a reduced consumption in the higher age groups.

Aggressive, restless and wandering behaviour are symptoms which sometimes accompany dementia. Antipsychotics, which seem to have a definite but limited effect, are important drugs in the treatment of these symptoms (Helms, 1985; Schneider et al., 1990). It is difficult to draw conclusions with respect to therapeutic influence on behaviour from the present study. However, it is striking that 28% of the patients being treated were wandering, restless or aggressive and 5 1% were apathetic or anxious.

Community studies from various countries demonstrate consumption of anxiolytics and hyp- noticshedatives drugs between 17% and 48% of the elderly population (Landahl, 1987; Achong et al., 1978; Osterlind et al., 1986; Hendriksen et al., 1983). The disparities are difficult to explain, regional habits being probably one important rea- son. Sales (DDD/l000 inhabitantdday) in 1980 in Denmark, for instance, were about 100% higher than in Norway (Sjoblom et al., 1984), and within Norway there are differences of 100% between vari- ous regions (Sakshaug, 1988). Anxiety problems favour the use of these drugs. There is no firm evi- dence that long-term use of benzodiazepines offers the desired efficacy in regard to anxiety and insom- nia, and rebound phenomena may produce symp- toms similar to those which initiated the benzodizepine treatment (Committee on the Review of Medicines, 1980), thus making disconti- nuation difficult.

Depression is a common disorder in the elderly (Lindsay et al., 1989). Six per cent of the cohort

consuming antidepressants is more than others have indicated (Landahl, 1987 apd Osterlind et al., 1986 about 4% and Achong et al., 1978 1'%0). This may be due to an increased prevalence of depression among frail, home-nursed elderly (Mur- phy, 1982). Declining use in the oldest may indicate that depressive states have not been recognized in these age groups. However, it has been shown that while depressive symptoms may be somewhat more common in later life, the prevalence of discrete affective illnesses is probably lower (Swartz and Blazer, 1986). The predominance of women is in accordance with existing prevalence figures (Lind- say et al., 1989). There is no special item concerned with mood in this study. Anxiety problems are, however, frequently associated with a depressive state, and these features often persist in spite of treatment with an antidepressant (Blazer et al., 1989).

It has been recommended that 30-50% of the adult dosage of psychotropic drugs (equivalent to 0.3-0.5 DDD) should be prescribed to elderly per- sons (Koch-Weser, 1983); however, reports on actual doses are scarce. It has been shown that resi- dents in nursing homes and homes for the aged are given antipsychotic drugs in doses between 27% and 60% of the DDD (Nygaard et al., 1989, 1990; Rorvik and Laake, 1990), and that the doses decline with increasing age (Nygaard et al., 1989, 1990). In a review study Schneider et al. (1990) found that doses between 8% and 230% of the DDD had been used to treat disturbed behaviour in institutiona- lized, elderly demented patients. With respect to benzodiazepines among institutionalized elderly, Laake et al. (1983) found that approximately 60% of the patients were given doses over 50% of the DDD.

The present results indicate that dosages of psy- chotropic drugs are by and large in accordance with established recommendations. However, it seems as if drugs in which the effect is to a certain extent determined by the patients themselves are con- sumed in higher doses. The drug treatment of demented patients with disturbed behaviour is a

58 H. A. NYGAARD

difficult task and must be combined with other mea- sures. It is not possible from the present data to evaluate the efficacy of the drug treatment. It is, however, tempting to question the benefit of anti- psychotic treatment in several of the patients pre- sented in this study.

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