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Patterns and Determinants of Dementia Pharmacotherapy in a Population-Based Cohort of Home Care Clients

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Abstract

Background

Little is known about the needs of older home care clients with dementia or their key quality of care issues, including their use of pharmacotherapy for Alzheimer’s disease.

Objectives

The objectives of this study were to (1) describe the sociodemographic, psychosocial, and health characteristics of clients with dementia (relative to two control subgroups) from a population-based home care cohort; and, (2) determine the distribution and associated characteristics of cholinesterase inhibitor (ChEI) and/or memantine use among dementia clients overall and according to medication class, comorbid illness, and year of assessment.

Methods

This cross-sectional study included all home care clients aged 50 years or older assessed with the Resident Assessment Instrument-Home Care (RAI-HC) in Ontario, Canada from January 2003 to December 2010. Multivariable logistic regression models were used to identify factors associated with receiving a dementia medication (a ChEI and/or memantine).

Results

There were 104,802 (21.5 %) clients with a diagnosis of dementia, 92,529 (18.9 %) cognitively impaired clients without a dementia diagnosis, and 290,929 (59.6 %) cognitively intact clients. Relative to the comparison groups, dementia clients were more likely to have reported conflicts with others, a distressed caregiver, greater levels of cognitive and functional impairment, and to exhibit wandering, aggressive behaviors, anxiety, hallucinations or delusions, and swallowing problems. Approximately half of dementia clients were taking a dementia medication, most commonly donepezil. Characteristics most strongly associated with use of ChEI monotherapy included age greater than 64 (especially 75–84), absence of economic barriers, availability of a primary caregiver, year of assessment, moderate to severe cognitive impairment, relative independence in function, health stability, no depressive symptoms or hallucinations/delusions, no recent hospitalization, use of at least 9 medications, the absence of chronic health and neurological conditions, and the use of an antipsychotic or antidepressant. For combination therapy, strong positive associations were observed for younger age, year of assessment, increasing cognitive impairment, presence of a primary caregiver, male sex, absence of economic barriers, use of at least 9 medications, and various indicators of positive health status (e.g., stability in health, absence of chronic health and neurological conditions, and no recent hospitalization). The percentage of clients receiving ChEIs increased with cognitive impairment scores but declined slightly at the highest level of impairment, whereas the percentage receiving memantine increased with cognitive impairment level. The number and percentage of dementia clients receiving any pharmacotherapy increased during the study interval.

Conclusions

We observed a relatively high prevalence of dementia-specific pharmacotherapy among Ontario long-stay home care clients as well as significant variation in utilization patterns by select sociodemographic, functional, and clinical characteristics, and over time. While physicians generally followed recommended guidelines regarding appropriate dementia pharmacotherapy, continued efforts to monitor practice patterns are required among vulnerable older adults across care settings.

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Acknowledgments

This study is part of the National Population Health Study of Neurological Conditions. We wish to acknowledge the membership of Neurological Health Charities Canada and the Public Health Agency of Canada for their contribution to the success of this initiative.

Funding for the study was provided by the Public Health Agency of Canada. The opinions expressed in this publication are those of the authors/researchers, and do not necessarily reflect the official views of the Public Health Agency of Canada. The study sponsor played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or in the decision to submit the paper for publication.

Dr. Hogan holds the Brenda Strafford Foundation Chair in Geriatric Medicine. Dr. Jetté holds an Alberta Innovates Health Solutions Population Investigator Award and a Canada Research Chair in Neurological Health Services Research. Dr. Bronskill is supported by a New Investigator Award in Aging from the Canadian Institutes of Health Research. Dr. Hirdes holds the Ontario Home Care Research and Knowledge Exchange Chair funded by the Ontario Ministry of Health and Long Term Care.

All co-authors declare that they have no conflicts of interest.

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Authors and Affiliations

  1. School of Pharmacy, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada

    Colleen J. Maxwell & Mary Vu

  2. School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada

    Colleen J. Maxwell, Mary Vu, Micaela Jantzi, George Heckman & John P. Hirdes

  3. Department of Community Health Sciences and Institute of Public Health, University of Calgary, Calgary, AB, Canada

    Colleen J. Maxwell, David B. Hogan, Scott B. Patten & Nathalie Jetté

  4. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    Colleen J. Maxwell & Susan E. Bronskill

  5. Division of Geriatric Medicine, Department of Medicine, University of Calgary, Calgary, AB, Canada

    David B. Hogan

  6. Centre de recherche, Institut universitaire de gériatrie de Montréal, Département de médecine, Université de Montréal, Montreal, QC, Canada

    Marie-Jeanne Kergoat

  7. Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada

    Nathalie Jetté

  8. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    Susan E. Bronskill

  9. Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada

    George Heckman

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  1. Colleen J. Maxwell
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Correspondence to Colleen J. Maxwell.

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Maxwell, C.J., Vu, M., Hogan, D.B. et al. Patterns and Determinants of Dementia Pharmacotherapy in a Population-Based Cohort of Home Care Clients. Drugs Aging 30, 569–585 (2013). https://doi.org/10.1007/s40266-013-0083-y

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