Comorbidities and medication intake among people with dementia living in long-term care facilities

w w w . e l s e v i e r . p t / r p s p

Original

article

Comorbidities

and

medication

intake

among

people

with

dementia

living

in

long-term

care

facilities

Alda

Marques

,

Vânia

Rocha

,

Margarida

Pinto

,

Liliana

Sousa

,

Daniela

Figueiredo

a_{SchoolofHealthSciences,UniversityofAveiro(ESSUA),Aveiro,Portugal}

b_{Cintesis.UA(CenterforHealthTechnologyandServicesResearch),UniversityofAveiro,Aveiro,Portugal} c_{DepartmentofHealthSciences(SACS),UniversityofAveiro,Aveiro,Portugal}

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Articlehistory:

Received8March2014 Accepted30July2014 Availableonline2April2015

Keywords:

Peoplewithdementia Comorbidities Medication

Long-termcarefacilities

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Informationon comorbiditiesandmedication ofpeoplewith dementia(PWD)in long-term-facilities(LTF)isscarce.Thisstudyanalysedtypeandnumberofcomorbiditiesand medicationofPWD inLTF.A descriptive-studywasconductedin 40LTF,characterising 329PWD. Socio-demographics,dementia type,comorbidities and medication were col-lectedwith International-Classification-of-Functionality-checklist.Cognitiveimpairment wasassessedwithMini-Mental-State-Examination.Oneormorecomorbidities(2.1±1.6) werefoundin271participants.Hypertension,osteoarticular-problems,heart-diseaseand type-II-diabeteswerethefrequentlycomorbidities.327participantsconsumedoneormore medicines(7.3±3.2), mainly forcardiovascular system,anxiolytics and antipsychotics. Comorbiditiesandmedicationamountwassignificantlydifferentamongcognitive impair-mentlevels.Vascularcomorbiditieswerepresentinalldementiatypes.

©2014TheAuthors.PublishedbyElsevierEspaña,S.L.U.onbehalfofEscolaNacionalde SaúdePública.ThisisanopenaccessarticleundertheCCBY-NC-SAlicense (http://creativecommons.org/licenses/by-nc-sa/4.0/).

Comorbilidades

e

medicac¸ão

em

pessoas

com

demência

em

lares

de

idosos

Palavras-chave:

Pessoascomdemência Comorbilidades Medicac¸ão Laresdeidosos

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Oconhecimentoacercadascomorbilidadesedamedicac¸ãoempessoascomdemência (PCD)quevivememlaresdeidososélimitado.Assim,esteestudoanalisouotipoenúmero decomorbilidadesemedicac¸ãodePCDquevivememlaresdeidososportugueses.Um estudodescritivofoiconduzidoem40emlaresdeidosos.Foramincluídas329pessoascom diagnósticodedemência,dasquaisforamrecolhidasinformac¸õessociodemográficas,das

∗ _{Correspondingauthor.}

E-mailaddress:amarques@ua.pt(A.Marques).

http://dx.doi.org/10.1016/j.rpsp.2014.07.005

0870-9025/©2014TheAuthors.PublishedbyElsevierEspaña,S.L.U.onbehalfofEscolaNacionaldeSaúdePública.Thisisanopenaccess articleundertheCCBY-NC-SAlicense(http://creativecommons.org/licenses/by-nc-sa/4.0/).

comorbilidadesemedicac¸ãocomachecklistdaClassificac¸ãoInternacionalde Funcional-idade.OdéficecognitivofoiavaliadoatravésdoMini-MentalStateExamination.Umaou maiscomorbilidades(2,1±1,6)foiencontradaem 271participantes.Hipertensão, prob-lemasosteoarticulares,doenc¸acardíacaediabetestipoIIforamascomorbilidadesmais frequentes.327participantesconsumiamumoumaismedicamentos(7,3±3,2), principa-mentemedicac¸ãoparaosistemacardiovascular,ansiolíticoseanti-psicóticos.Aquantidade decomorbilidadesemedicac¸ãofoisignificativamentediferenteentreosníveisdedéfice cognitivo.Comorbilidadesvascularesestavampresentesemtodosostiposdedemência.

©2014TheAuthors.PublicadoporElsevierEspaña,S.L.U.emnomedaEscolaNacional deSaúdePública.EsteéumartigoOpenAccesssobalicençadeCCBY-NC-SA (http://creativecommons.org/licenses/by-nc-sa/4.0/).

Introduction

Dementiaisaglobalhealthchallenge.1_{Intheyear2010itwas}

estimatedthat35.6millionpeople hadAlzheimer’sdisease andotherdementiasworldwide.2_{Thisnumberwillincrease}

withanageingworldpopulationandwillreach66millionby theyear2030and115millionby2050.1

Comorbidities are highly prevalent among people with dementia3_{andhavebeenreportedasriskfactorsforcognitive}

impairment and dementia progression. Astudy associated comorbiditiestohalfoftheAlzheimer’sdiseasecases world-wideandithasbeensuggestedthatthereductionof10–25% inthesefactorscouldprevent3millioncasesofAlzheimer’s diseaseworldwide.4_{Consequently,comorbiditiescontributes}

todementiaonset4 _{andmayalsoleadtofasterprogression}

ofthedisease,representinganadditionalfactorfordisability andincreasedcosts.5_{However,thelevelsofcomorbiditiesin}

peoplewithdementiaremainacontroversialissue,withsome studiesreportingthatthispopulationpresentfewerthan non-dementedpeople6,7_{andotherssuggestingmorecomorbidities}

thangenerallythought.8,9_{Thiscontroversycausesdifficulties}

whenappropriatemeasurestopreventandtreat comorbidi-tiesindementiahavetobedefined.10_{Additionally,highlevels}

ofcomorbiditieshavebeenlinkedwithhighamountof pre-scribedmedicationinpeoplewithdementiawhencompared withotherindividuals.11_{Theuseofpsychotropicmedication}

(antipsychotics, antidepressants and anxiolytics) in people withdementiahasbeenstudied.11_{However,thismedication,}

consumedspeciallybypeoplelivinginlong-termcare facil-ities, showed tobe inappropriate and has been associated withnumerousadverseevents,whichledtohospitalisation andhighermortality.11_{Nevertheless,theoverallmedication}

descriptioninpeoplewithdementialivinginlong-termcare facilities10,12_{isstillunknown,asthispopulationduetotheir}

cognitiveimpairmenttendtobeexcludedfromthestudies.In atimeinwhichreducingcostsandoptimisinghealthcareis crucial,2_{characterisingcomorbiditiesandmedicationintake}

ofpeoplewithdementiabecomescrucial,asthisinformation hasthepotentialtoinformdecisiononappropriatestrategies topreventandtreatcomorbidities,adjustmedicationand sup-portplanningofhealthandsocialresources.13_{Therefore,this}

studyaimedtoanalysethetypeandnumberofcomorbidities andmedicationofpeoplewithdementialivinginlong-term carefacilities.

Methods

Studydesign

Anexploratorydescriptivestudywasconductedinthe cen-tralregionofPortugal.ThestudywassubmittedtotheEthics Committee ofthe Research Unit ofHealth Sciences at the Health School of Nursing in Coimbra (UICISA: E), Portugal (Ref.5-11/2010)andapprovalwasobtained.Legal represent-atives were invited to attend a meeting whereverbal and written information about the study was provided.A brief explanation aboutthe studywas alsogiventopeoplewith dementia. Written informed consents were collected from thelegalrepresentativesofthepeoplewithdementialiving in the long-term care facilities prior to any data collec-tion.

Participants

Fifty-sevenlong-termcarefacilitieswerecontactedand infor-mationaboutthestudywasprovidedtotheservicemanagers in an arranged meeting. Forty care facilities with a total of1780residents acceptedtoparticipate.Participantswere included in the study if theypresented a medical diagno-sisofirreversibledementiaaccordingtotheDiagnosticand StatisticalManualofMentalDisordersIV(DSM-IV)criteria.14

Peoplewithdementiawereexcludedif:(i)refusedtoanswer totheMini-MentalStateExamination(MMSE);(ii)weresevere ortotalsightlessand/orseverehearingimpaired;(iii)hadnot beenatthecarefacilityforatleast3months(consideredthe minimumindividualtimeneededtoadjusttotheinstitution dynamics);(iv)didnothavealegalrepresentativetosignthe writteninformedconsent;(v)ordiedduringthedata collec-tion.

From the total individuals living in the long-term care facilities, 353(19.8%)had amedicaldiagnosis ofdementia. However, 24 subjects were excluded as they: (i) refused to answer totheMMSE (n=4) ortheir familydidnotsign the writteninformedconsent(n=2);(ii)weresevereortotal sight-less(n=4)and/orseverehearingimpaired(n=2);(iii)havenot beenatthecarefacilityforatleast3months(n=6);(v)ordied duringthedatacollection(n=10).Thus,atotalof329people withdementiawereincluded.

Measures

AstructuredquestionnairebasedontheInternational Classifi-cationofFunctionality,DisabilityandHealth(ICF)checklist15

wasusedtocollect dataaboutsocio-demographics,typeof dementia,typeandnumberofcomorbiditiesandmedication ofpeoplewithdementia.Thisisachecklistofmajorcategories oftheInternational ClassificationofFunctioning,Disability andHealth(ICF)oftheWorldHealthOrganization.Itisa prac-ticaltooltorecordhealthinformationofeachindividualand acrossdifferentpopulations.Thisinformationwasobtained fromclinicalfilesandstaff(healthprofessionals,service man-agers,directcareproviders).

TheMMSE adapted tothe Portuguese population16 _was

appliedtothepeoplewithdementiatoassesstheircognitive status.Theseverity ofthe cognitiveimpairment was char-acterised using the MMSE cut-offs, published in European studies,i.e.,21–27mild,11–20moderateand0–10severe.

Dataanalyses

DataanalysiswasperformedusingthePASWStatistics ver-sion 18.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statisticswereappliedtocharacterisethesample.Non para-metric tests were performed as variables did not follow a normal distribution and the sample size was lower than 30 subjects in some variables sub-groups.17 _{Therefore, the}

Mann–WhitneyandKruskal–Wallisnon-parametrictestswere appliedto explore the differences between the number of comorbiditiesandthesamplecharacteristics(age,education, maritalstatus,periodlivinginthelong-termcarefacility,type ofdementiaandseverityofcognitiveimpairment);andthe amountofmedicationusedandthesamplecharacteristics. Thecorrelationbetweenthenumberofcomorbiditiesandthe amountofmedication usedwasanalysedwiththePearson coefficient(r),asthesamplesizewashigherthan30subjects.17

A-valueless than0.05wasconsideredstatistically signifi-cant.

Results

Samplecharacteristics

Table 1 describes the sample characteristics. People with dementiameanagewas83.6±7.1yearsold.Mostwereolder than85 yearsold(n=158;48%),female (n=262;79.6%),had onetofour yearsofeducation(n=168;51.1%)orno educa-tion (n=97;29.5%), were widowed(n=200;60.8%)and were livinginthefacilityforlessthan1year(n=105;31.9%)orfrom 2to4years(n=119; 36.2%).Mostparticipantsdidnothave theirtypeofdementiadefined(n=148;45%)however,fromthe participantswhopresentedaspecificdiagnosis,Alzheimer’s diseasewasthemostprevalent(n=138;41.9%).Accordingto theMMSE,anaveragescoreof8.7±7.9wasfoundand61.7% (n=203)hadseverecognitiveimpairment(Table1).

Comorbidities

Oneormorecomorbidities(2.1±1.6)werefoundin271(82.4%) participants(Table2).Themostfrequentcomorbiditieswere

Table1–Samplecharacteristics(n=329).

Variables n % Age(years) 50–64 3 0.9 65–74 32 9.7 75–84 136 41.3 +85 158 48.0 Gender Male 67 20.4 Female 262 79.6 Yearsofeducation Illiterate 97 29.5 1–4 168 51.1 5–9 17 5.1 +10 20 6.1 Missing 27 8.2 Maritalstatus Single 53 16.1

Married/Livingwithapartner 61 18.5

Divorced/Separated 15 4.6

Widowed 200 60.8

Timelivinginthelong-termcarefacility(years)

<1 105 31.9 2–4 119 36.2 5–7 54 16.4 8–10 27 8.2 >11 24 7.3 Typesofdementia Unspecifieddementia 148 45.0 AlzheimerDisease 138 41.9 VascularDementia 29 8.8 Othertypes 14 4.3

Severityofthecognitiveimpairment(MMSEscore)

Mildcognitiveimpairment(21–27) 28 8.5

Moderatecognitiveimpairment(11–20) 95 28.9

Severecognitiveimpairment(0–10) 203 61.7

Notapplicable 3 0.9

hypertension(n=136;41.3%),osteoarticularproblems(n=73; 22.2%), heart disease (n=67;20.4%),type IIdiabetes (n=65; 19.8%)andhypercholesterolemia(n=42;12.8%)(Table2).

Mostparticipantswithunspecifieddementia(n=67)and Alzheimer’s disease (n=71) had 1–2 comorbidities, whilst subjectswithvasculardementia(n=12)had3–4 comorbidi-ties (Table3).Vascular riskfactors were themostfrequent among participants however, theywere more prevalent in peoplewithvasculardementia(hypertension–68.9%,heart disease –44.8%, typeII diabetes – 37.9% and hypercholes-terolemia–24.1%)thaninpeoplewithunspecifieddementia (hypertension – 40.5%, heart disease – 22.9%, type II dia-betes–17.2%andhypercholesterolemia–12.2%)orAlzheimer disease participants (hypertension– 35.8%,heart disease – 13.4%,type IIdiabetes –17.2% and hypercholesterolemia – 10.4%).

Thenumberofcomorbiditieswasnotsignificantly differ-entaccordingtoageorgenderhowever,itwassignificantly differentamongthetypesofdementia(<0.001)andseverity (=0.005)ofcognitive impairment (Table 3),in which indi-vidualswithseverecognitiveimpairmentpresentedahigher

Table2–Descriptionofpeoplewithdementia comorbidities(n=329). n % Typesofcomorbidities Hypertension 136 41.3 Osteoarticularproblems 73 22.2 Heartdisease 67 20.4 TypeIIdiabetes 65 19.8 Hypercholesterolemia 42 12.8 Gastro-intestinalproblems 33 10.0 Depression 32 9.7 Parkinsondisease 27 8.2 Renalproblems 26 7.9

Vascularandcirculatoryproblems 25 7.6

Visualproblems 24 7.3 Respiratoryproblems 21 6.4 Anaemia 17 5.2 Osteoporosis 15 4.6 Hearingproblems 13 4.0 Neoplasms 13 4.0 Genitourinaryproblems 10 3.0

Thyroidhormoneproblems 8 2.4

Missing 4 1.2 Numberofcomorbidities 0 58 17.6 1–2 151 45.9 3–4 93 28.3 +5 27 8.2

amountofcomorbiditiesthanthosewithmildtomoderate cognitiveimpairment.However,14.0%(n=46)ofthesample withseverecognitiveimpairmentalsopresentedno comor-bidities(Table3).

Medicationintake

One or more medicines (7.3±3.2) were consumed by 327 (99.4%)participants(Table4).Medicationforthe cardiovas-cularsystem(n=238;72.3%),anxiolytics(n=178;54.1%)and antipsychotics(n=176;53.5%)werethemostcommonlyused (Table4).

Therewerenostatisticallysignificantdifferencesbetween theamountofmedicationusedandage,genderandtypeof dementia (Table 3). The amount ofmedication was signif-icantly different amongthe levels ofcognitive impairment (<0.001)(Table3)i.e.,ahigheramount ofmedication was observedinpeoplewithseverecognitiveimpairment.

Numberofcomorbiditiesvs.amountofmedication

Therewasasignificantpositivecorrelationof0.39(<0.001) betweenthenumberofcomorbiditiesandtheamountof med-icationusedbypeoplewithdementialivinginlong-termcare facilities.

Discussion

Similarlytoothers,thisstudyfoundahighnumberof comor-bidities in people with dementia living in long-term care facilities,specificallyhypertension,18_{heartdisease,}10_typeII

diabetes19_{andhypercholesterolemia.}18_{Thesecomorbidities,}

whichrepresentvascularriskfactors,havebeenreferredas highlyprevalentinnumerouspopulationswithdementia8,20

and have been associatedwith anincreasedrisk of devel-opingdementia.21_Evidence4,22_{suggeststhatpreventingand}

Table3–Differencesinthenumberofcomorbiditiesandmedicationaccordingtoage,gender,typeofdementia andseverityofcognitiveimpairment(n=329).

Numberofcomorbidities Numberofmedications

n M[IQR]  n M[IQR]  Age 50–64 3 2[1;2] 3 2[2;2] 65–74 32 2[2;3] 29 3[2;3] 75–84 136 2[2;3] 115 3[3;3] +85 158 2[2;3] 0.223a _{137 3[2;3] 0.221}a Gender Male 67 2[2;3] 67 3[2;3] Female 262 2[2;3] 0.605b _{262 3[2;3] 0.213}b Typeofdementia Unspecified 148 2[2;3] 148 3[2;3] Alzheimerdisease 138 2[1;2] 138 3[2;3] Vasculardementia 29 3[2;3] 29 3[2;3] Othertypes 14 3[2;3] <0.001a _{14 3[3;3] 0.487}a Severity(MMSE) Mild 31 2[2;3] 31 3[2;3] Moderate 95 2[2;3] 95 3[3;3] Severe 203 2[2;3] 0.005a _{203 3[3;4] <0.001}a

M:median;IQR:interquartilerange[p25;p75];:-value.

Inboldstatisticallysignificantp-values.

a _{Kruskal–Wallis.}

Table4–Descriptionofpeoplewithdementia medication(n=329).

n %

Typeofmedication

Cardiovascularsystem 238 72.3

Anxiolyticsedativesandhypnotics 178 54.1

Antipsychotic 176 53.5

Treatmentofcognitivechanges 151 45.9

Antidepressants 144 43.8

Gastrointestinalsystem 122 37.1

Anticoagulants 118 35.9

Analgesicsandantipyretics 90 27.4

Cholesterolinhibitors 82 24.9

Anti-diabeticsandinsulin 66 20.1

Antiparkinsonianagents 64 19.5

Antianemics 63 19.1

Muscle-skeletalsystem 55 16.7

Antiepilepticandanticonvulsant 52 15.8

Genital-urinarysystem 35 10.6 Respiratorysystem 30 9.1 Eyesystem 22 6.7 Numberofmedications 0 2 0.6 1–5 91 27.7 6–10 188 57.1 11–15 45 13.7 +16 3 0.9

treatingvascularrisksfactorscouldpreventordelaythe incre-ment ofcognitive impairmentin people withoutdementia andreducetheburdenassociatedwithvascularriskfactors onthose with dementia.Therefore, as nocure isavailable fordementia,primarypreventionofcomorbidities,seemsto havegreatpotentialtoreducethenumberofdementiacases emergingeachyear4_{however,thisneedsfurtherinvestigation.}

Although the number of comorbidities was not signifi-cantly different considering age and gender,8 _{people with}

moreseverecognitive impairmenthad ahighernumber of comorbidities.Moreover,theabsenceofcomorbiditiesin sev-eralindividualswithseverecognitiveimpairment,foundin this study, suggests a possible lack of diagnosis.23,24 _This

meansthatif thecomorbiditiesdiagnosis isnotperformed inmildtomoderatestages,itmightbedifficulttobemade intheseverestagesofthedisease,sincethispopulationdoes notcomplainorreceivefrequentclinicalrevision.23

Furthermore, the amount of comorbidities was signifi-cantly different according to type of dementia. Therefore, vascular dementia was associated with a higher number ofcomorbiditiesthan unspecifieddementia or Alzheimer’s disease.8,25_{Thistypeofdementiahadshownahigher}

preva-lence of vascular risk factors,such as hypertension, heart disease,typeIIdiabetesandhypercholesterolemia.Although Alzheimer’s disease and vascular dementia shared several riskfactors,hypotheseshavebeenraisedsuggestingthatthe increaseburdenassociatedwithvascularriskfactorsorwith thenumberofvasculardiseasesleadtoanincreasedriskof vasculardementia,26_{explainingthefindingsofthisstudy.}

The average number of medication prescribed to peo-ple with dementia living in long-term care facilities was 7.3±3.2, higher than the average found in other research studies which ranged between 5.1 and 6.53,27,28 _however,

similar to the study of Andersen et al.,10 _{that reported a}

meanof6.9±3.9medicines.Themedicationusedindementia hasbeenassociatedwithseveralsideeffects,e.g., deteriora-tion ofcognitiveandpsychomotor function,sedation,falls, fractures,29 _{increased risk of delirium,}11 _{increased risk of}

stroke anddying.30_{Therefore, theadequacyofthe}

medica-tion inpeople with dementia should beexplored for each person before decisions are taken 30 _{since it appropriate}

use hasalready been questioned,10–12 _{mainly inlong-term}

carefacilities.31_{Furthermore,non-pharmacological}

interven-tions seem a promisingapproach to reduce these typeof medication32_{andmeritsfurtherresearch.}

Previous studies reported that people with more severe cognitive impairment consume a higher amount of medication,10,33 _{which is inagreement with the results}

ofthis study.Questionsonthe potentialoveruseand cost-effectivenessofmedicationinpeoplewithdementiashould beassessedinallstagesofdementiaandmainlyonsevere dementia, inwhichdecisionstodiscontinuesome medica-tion should beexplored,e.g., antipsychoticsinterruption if symptomshavebeenabsentorminimalforthreemonths.12

The significant positive correlation found between the numberofcomorbiditiesandtheamountofmedication pre-scribed in people with dementia was previously reported by Linjakumpu et al.,34 _{and highlights the importance of}

preventing and treatingcomorbiditiesto reducethe useof medication in this population. A lower number of comor-bidities and consequently amount of medication would potentiallyresultinthereductionofcognitiveandfunctional decline,lowerriskofinstitutionalisation,hospitalisation3_and

mortalityandtherefore,meritsfurtherresearch.

Clinicalimplications

• High levels of comorbidities (i.e., hypertension, osteoar-ticular problems, heart disease, type II diabetes and hypercholesterolemia)werefoundinpeoplewith demen-tialivinginlong-termcarefacilities.Thesupervisionand earliertreatmentofthesecomorbiditiesmightreduce mor-bidityandimprovequalityoflifeofpeoplewithdementia. • Alargeamountofmedicationwasconsumedbypeoplewith

dementiainallstagesofthedisease,mainlymedicationfor thecardiovascularsystem,anxiolyticsandantipsychotics. • Vasculardementiawas associatedwithahigher number

ofcomorbiditiesthanunspecifieddementiaorAlzheimer’s disease.Treatingvascularriskfactorsmightbeimportant toreducetheriskofvasculardementia.

Conclusion

Thehighnumberofcomorbiditiesfound,mainlyvascularrisk factorsfordementiaonsetandprogression,raisesawareness forthepotentialpreventionofdementiacasesthroughearly diagnosisandtreatmentofvascularriskfactorsand comor-bidities.

Alargeamountofmedicationinpeoplewithdementiawas alsofound,whencomparedwithpreviousstudies.Thisstudy alertsforthepossibilityofinappropriateuseofmedication in peoplewith dementialivingin long-termcarefacilities.

Additionally,asthenumberofcomorbiditieswaslinkedwith theamountofmedication,thepreventionandtreatmentof comorbiditiescouldresultinaloweramountofmedication intake.

Thedesignofthisstudywassuitabletoperforma descrip-tive analysis on comorbidities and medication intake of Portuguesepeoplewithdementialivinginlog-termcare facil-ities. However, comparisons across studies using different methodologies impair the generalisation of results. Future research should be conducted with more robust designs, includingacontrolgroupofpeoplewithdementialivinginthe communityshouldbeconductedtostrengthenthesefindings andexploredifferencesthoroughly.

Sinceacurefordementiaisnotavailableyet,finding effec-tive approaches to reduce the burden associated with the disease,improvepeople’squalityoflifeandreducethe dis-easeassociatedcostsareessentialforasustainablesocietyin anagingworld.

Conflicts

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