Clinical Complexity and Use of Antipsychotics and Restraints in Long-Term Care Residents with Parkinson’s Disease

Article type: Research Article

Authors: Heckman, George A.^{a; b; *} | Crizzle, Alexander M.^{a; c} | Chen, Jonathen^a | Pringsheim, Tamara^d | Jette, Nathalie^d | Kergoat, Marie-Jeanne^e | Eckel, Leslie^a | Hirdes, John P.^a

Affiliations: [a] School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada | [b] Schlegel Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada | [c] School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada | [d] Department of Clinical Neurosciences and Hotchkiss Brain Institute and Department of Community Health Sciences and Institute for Public Health, University of Calgary, Calgary, AB, Canada | [e] Département of Médicine, Université de Montréal, Montréal, QC, Canada

Correspondence: [*] Correspondence to: George A. Heckman, MD, MSc, FRCPC, Schlegel Research Chair for Geriatric Medicine, Associate Professor, Schlegel Research Institute for Aging, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada. Tel.: +1 519 888 4567 31028; Fax: +1 519 746 2510; E-mail: ggheckman@uwaterloo.ca.

Abstract: Background: Patients with Parkinson’s disease (PD) and/or Parkinsonism are affected by a complex burden of comorbidity. Many ultimately require institutional care, where they may be subject to the application of physical restraints or the prescription of antipsychotic medications, making them more vulnerable to adverse outcomes. Objectives: The objectives of this paper are to: 1) describe the clinical complexity of older institutionalized persons with PD; and 2) examine patterns and predictors of restraint use and prescription of antipsychotics in this population. Methods: Population-based cross-sectional cohort study. Residents with PD and/or Parkinsonism living in long-term care (LTC) facilities in 6 Canadian provinces and 1 Northern Territory and Complex Continuing Care (CCC) facilities in Manitoba and Ontario, Canada. The RAI MDS 2.0 instrument was used to assess all LTC residents and CCC residents. Clinical characteristics and the prevalence of major comorbidities were examined. Multivariate modeling was used to identify the characteristics of PD residents most associated with the prescription of antipsychotics and the use of restraints in LTC and CCC facilities. Results: Residents with PD in LTC and CCC exhibit a high prevalence of dementia, major psychiatric disorders, stroke, heart failure, chronic obstructive pulmonary disease and diabetes mellitus. More than 90% of LTC and CCC residents with PD had cognitive impairment; with more than half having moderate to severe impairment. Residents with PD were more likely to receive antipsychotics than those without PD. Antipsychotic use was associated with psychosis and aggressive behaviours, but also with unsteady gait and higher comorbidity and medication count. Similarly, although more common in CCC than LTC facilities, both psychosis and aggressive behaviours were associated with restraint use, as was greater cognitive and functional impairment, and urinary incontinence. Younger age, male gender, and lower physician access were all associated with greater antipsychotic and restraint use. Conclusions: LTC and CCC residents with PD are very complex medically. Use of antipsychotics and restraints is common, and their use is often associated with factors other than psychosis or aggression.

Keywords: Parkinson’s disease, Resident Assessment Instrument, minimum data set, nursing home, restraints, antipsychotics

DOI: 10.3233/JPD-160931

Journal: Journal of Parkinson's Disease, vol. 7, no. 1, pp. 103-115, 2017