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Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment.
J Manag Care Pharm. 2012 Oct; 18(8):598-606.JM

Abstract

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is prevalent in nursing home residents. National and international guidelines exist for management of COPD; however, little is known about "real-world" management of COPD in this population. Nursing home patients with significant cognitive impairment may have difficulty utilizing handheld device (HHD) formulations of respiratory medications and may be clinically appropriate candidates for nebulized therapy.

OBJECTIVES

To determine (a) the prevalence, clinical characteristics, and treatment of patients with a diagnosis of "emphysema/COPD" per Minimum Data Set (MDS) version 2.0 records in U.S. nursing homes and (b) the relationship of nebulized versus HHD formulations of medication to prevalence of shortness of breath in a cohort of cognitively impaired nursing home residents.

METHODS

In a descriptive, retrospective analysis of a large data repository of skilled nursing home residents with COPD, prescription claims and MDS data from October 1, 2009, through September 30, 2010, were extracted, linked, and de-identified. Measures included medications, diagnoses, and selected outcome parameters from the MDS. Cognitive impairment was defined as a score of 3-6 on the Cognitive Performance Scale derived from MDS records. A proxy of ≤ 14-day courses of respiratory antibiotics, oral corticosteroids, or both was used to identify COPD exacerbations. Shortness of breath (SOB) in the last 7 days was captured from Section J1.l. of the MDS.

RESULTS

The total number of unique patients with at least 1 MDS record during the study period was 126,121. Of those, 27,106 (21.5%) had COPD. The prevalence rates of diagnoses concurrent with COPD were as follows: asthma = 8.6%, Alzheimer's disease or other dementia = 37.2%, congestive heart failure = 37.5%, anxiety disorder = 23%, depression = 50.1%, pneumonia = 21.2%, and respiratory infection = 9%. 58% of patients with COPD were white females aged 75 years or older. According to the MDS, 62% of COPD patients had a short-term memory problem, while 43.3% of patients had moderately or severely impaired cognitive skills for daily decision making. 83% of COPD patients with pharmacy claims (17,395/27,106) received at least 1 medication used to treat COPD; 9,711 (17.1%) received no respiratory medications. Use of beta-agonists (53.9%), anticholinergic medications (41.2%), long-acting beta-agonist/corticosteroid (LABA/ICS) combinations (28%) in HHD, and nebulized beta-agonist/anticholinergic combinations (26.6%) was prevalent. Inhaled LABA/ICS and long-acting anticholinergic therapy was received by 28% and 22% residents, respectively. 22% (n = 5,085) of patients exhibited at least 2 exacerbations of COPD, and 33% were noted to have SOB. Monotherapy with short-acting beta-agonists (SABA) was evident in 48.7% of cognitively impaired COPD patients. SOB within the previous 7 days was noted in 39.1% of cognitively impaired COPD patients treated with nebulized SABA monotherapy. 38% of these patients exhibited 2 or more COPD exacerbations, and 57.9% were hospitalized at least once during the 12-month period. LABA monotherapy or combined LABA/SABA use represented ≤ 1% of beta-agonist use for unique COPD patients with cognitive impairment.

CONCLUSIONS

In this retrospective analysis of administrative data, 21.5% of nursing home residents had a diagnosis of COPD, and 17% of these residents received no respiratory medications. These residents had significant cognitive and functional impairment and concurrent diagnoses. 22% of residents experienced at least 2 exacerbations of COPD during the 12 months of study. As many as 60% were not receiving inhaled LABA/ICS or inhaled tiotropium, and 33% exhibited SOB. There is significant use of nebulized SABA monotherapy, which may be contributing to SOB and exacerbations or hospitalizations in nursing home residents with COPD.

Authors+Show Affiliations

Omnicare, Inc., Livonia, MI 48150, USA. barbara.zarowtiz@omnicare.comNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23127147

Citation

Zarowitz, Barbara J., and Terrence O'Shea. "Chronic Obstructive Pulmonary Disease: Prevalence, Characteristics, and Pharmacologic Treatment in Nursing Home Residents With Cognitive Impairment." Journal of Managed Care Pharmacy : JMCP, vol. 18, no. 8, 2012, pp. 598-606.
Zarowitz BJ, O'Shea T. Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. J Manag Care Pharm. 2012;18(8):598-606.
Zarowitz, B. J., & O'Shea, T. (2012). Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. Journal of Managed Care Pharmacy : JMCP, 18(8), 598-606.
Zarowitz BJ, O'Shea T. Chronic Obstructive Pulmonary Disease: Prevalence, Characteristics, and Pharmacologic Treatment in Nursing Home Residents With Cognitive Impairment. J Manag Care Pharm. 2012;18(8):598-606. PubMed PMID: 23127147.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Chronic obstructive pulmonary disease: prevalence, characteristics, and pharmacologic treatment in nursing home residents with cognitive impairment. AU - Zarowitz,Barbara J, AU - O'Shea,Terrence, PY - 2012/11/7/entrez PY - 2012/11/7/pubmed PY - 2013/3/7/medline SP - 598 EP - 606 JF - Journal of managed care pharmacy : JMCP JO - J Manag Care Pharm VL - 18 IS - 8 N2 - BACKGROUND: Chronic obstructive pulmonary disease (COPD) is prevalent in nursing home residents. National and international guidelines exist for management of COPD; however, little is known about "real-world" management of COPD in this population. Nursing home patients with significant cognitive impairment may have difficulty utilizing handheld device (HHD) formulations of respiratory medications and may be clinically appropriate candidates for nebulized therapy. OBJECTIVES: To determine (a) the prevalence, clinical characteristics, and treatment of patients with a diagnosis of "emphysema/COPD" per Minimum Data Set (MDS) version 2.0 records in U.S. nursing homes and (b) the relationship of nebulized versus HHD formulations of medication to prevalence of shortness of breath in a cohort of cognitively impaired nursing home residents. METHODS: In a descriptive, retrospective analysis of a large data repository of skilled nursing home residents with COPD, prescription claims and MDS data from October 1, 2009, through September 30, 2010, were extracted, linked, and de-identified. Measures included medications, diagnoses, and selected outcome parameters from the MDS. Cognitive impairment was defined as a score of 3-6 on the Cognitive Performance Scale derived from MDS records. A proxy of ≤ 14-day courses of respiratory antibiotics, oral corticosteroids, or both was used to identify COPD exacerbations. Shortness of breath (SOB) in the last 7 days was captured from Section J1.l. of the MDS. RESULTS: The total number of unique patients with at least 1 MDS record during the study period was 126,121. Of those, 27,106 (21.5%) had COPD. The prevalence rates of diagnoses concurrent with COPD were as follows: asthma = 8.6%, Alzheimer's disease or other dementia = 37.2%, congestive heart failure = 37.5%, anxiety disorder = 23%, depression = 50.1%, pneumonia = 21.2%, and respiratory infection = 9%. 58% of patients with COPD were white females aged 75 years or older. According to the MDS, 62% of COPD patients had a short-term memory problem, while 43.3% of patients had moderately or severely impaired cognitive skills for daily decision making. 83% of COPD patients with pharmacy claims (17,395/27,106) received at least 1 medication used to treat COPD; 9,711 (17.1%) received no respiratory medications. Use of beta-agonists (53.9%), anticholinergic medications (41.2%), long-acting beta-agonist/corticosteroid (LABA/ICS) combinations (28%) in HHD, and nebulized beta-agonist/anticholinergic combinations (26.6%) was prevalent. Inhaled LABA/ICS and long-acting anticholinergic therapy was received by 28% and 22% residents, respectively. 22% (n = 5,085) of patients exhibited at least 2 exacerbations of COPD, and 33% were noted to have SOB. Monotherapy with short-acting beta-agonists (SABA) was evident in 48.7% of cognitively impaired COPD patients. SOB within the previous 7 days was noted in 39.1% of cognitively impaired COPD patients treated with nebulized SABA monotherapy. 38% of these patients exhibited 2 or more COPD exacerbations, and 57.9% were hospitalized at least once during the 12-month period. LABA monotherapy or combined LABA/SABA use represented ≤ 1% of beta-agonist use for unique COPD patients with cognitive impairment. CONCLUSIONS: In this retrospective analysis of administrative data, 21.5% of nursing home residents had a diagnosis of COPD, and 17% of these residents received no respiratory medications. These residents had significant cognitive and functional impairment and concurrent diagnoses. 22% of residents experienced at least 2 exacerbations of COPD during the 12 months of study. As many as 60% were not receiving inhaled LABA/ICS or inhaled tiotropium, and 33% exhibited SOB. There is significant use of nebulized SABA monotherapy, which may be contributing to SOB and exacerbations or hospitalizations in nursing home residents with COPD. SN - 1944-706X UR - https://www.unboundmedicine.com/medline/citation/23127147/Chronic_obstructive_pulmonary_disease:_prevalence_characteristics_and_pharmacologic_treatment_in_nursing_home_residents_with_cognitive_impairment_ L2 - http://www.diseaseinfosearch.org/result/7979 DB - PRIME DP - Unbound Medicine ER -