Publications (2)8.07 Total impact
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ABSTRACT: The availability of long-acting (LA) opioid medications represents an advance in the treatment of persistent pain, raising the question of what factors predict receipt of this newer treatment approach. This study sought to determine which factors predict use of LA opioid medications and which factors predict use of transdermal versus oral options in an older population. A retrospective analysis was conducted of Medicaid claims from May 1999 to April 2002 for older (aged >60 years) Kansas Medicaid beneficiaries receiving opioid medications equivalent to >or=600 mg of morphine per month. Demographic data, diagnoses, and medication use were derived from Medicaid claims data provided by the Kansas Department of Social and Rehabilitative Services to Dr. Shireman for a larger project. Bivariate analyses and multivariable models were used to determine which clinical and demographic factors predicted LA opioid use in general and which factors were associated with transdermal fentanyl (TDF) use in particular. The study population was mostly women, and more than one third were aged >85 years. Of the 766 claims, those patients taking LA opioids (n = 352) received oral sustained-release morphine, oral controlled-release oxycodone, or the TDF patch, with or without concomitant short-acting (SA) opioids. All others received SA opioids only (n = 414). In multivariate analysis, LA opioid use was more common among nursing home residents (adjusted odds ratio [AOR] = 1.45; 95% CI, 1.04-2.02) and persons under hospice care (AOR = 2.10; 95% CI, 1.19-3.73), with malignancy also bordering on a statistically significant association (AOR = 1.63; 95% CI, 1.00-2.66). Age, sex, race/ethnicity, and urban/nonurban residence were not associated with LA opioid use. Among those taking LA opioids, TDF use was more likely with older age (AOR = 2.89; 95% CI, 1.44-5.81 for aged >or=85 years vs aged 60-75 years), nursing home residence (AOR = 2.51; 95% CI, 1.46-4.49), dementia (AOR = 2.77; 95% CI, 1.03-7.48), malignancy (AOR = 3.03; 95% CI, 1.25-7.34), and nonwhite race (AOR = 2.72; 95% CI, 1.18-6.28), and less likely with chronic obstructive pulmonary disease (AOR = 0.47; 95% CI, 0.26-0.88), in adjusted analysis. Demographic and clinical predictors of TDF use differed from predictors of any LA opioid use among these older Medicaid beneficiaries. Qualitative research methods are needed to better understand what factors influence selection of opioid medications for older patients in nursing homes and community settings.
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ABSTRACT: Identification and treatment of depression in nursing facilities are of paramount importance to reduce psychological suffering and improve quality of life. Admission to a nursing facility is a life-altering event that predisposes to depression, and the lack of staff familiarity with a new resident's "baseline" may make identification of depressive symptoms more difficult. Admission also represents an opportunity to determine whether to continue antidepressants in those already receiving them. Although treatment benefits are less clear for non-mental health outcomes, studies are actively under way to determine whether treatment of depression will also be shown to positively impact other outcomes such as function, cognition, and recovery from catastrophic events such as stroke and hip fracture. In the meantime, routine screening and a high index of suspicion will help identify depressed older adults in long-term care settings who can benefit from the wide array of currently available treatment options.
Kansas City University of Medicine and Biosciences
Kansas City, Missouri, United States
- Department of Internal Medicine