*2.2.2 Analysis of time to mortality against prescriptions for psychotropic medications*

The purpose of this analysis is to advance findings from the preceding analysis in two ways. The first is to replace the binary target variable with a nominal variable

*Proportionate mortality by anxiolytic frequency in men and women.*

**Figure 5.**

*Proportionate mortality by hypnotic frequency in men and women.*

of time to death. The categories are 1–7, 8–30 and 31–90 days after the final assessment. We chose these categories to index mortality shortly, soon, and sometime after the final assessment but before the next scheduled assessment. The reference category is no recorded death. This analysis allows to use examine relationships between mortality and psychotropic prescriptions using a finer temporal scale.

The second advance is to include the CHESS scale [10] as a fixed effect. The CHESS is arguably the strongest current predictor of mortality for people within continuing care contexts. For example, mortality in the present database is <10% for residents with the lowest score but >85% for residents with the highest score. Consequently, inclusion of the CHESS helps us to test between two interpretations of PRN/mortality relationships. On the one hand, if nearness of death is the primary reason for PRN prescription (i.e., prescribed mainly for palliative reasons), its relationship to mortality should nullify after inclusion of the CHESS as a fixed effect. On the other hand, if PRN prescription increases the risk of subsequent mortality, a relationship should endure despite inclusion of the CHESS as a fixed effect.

**11**

**Table 3.**

*Psychotropic Medication Use and Mortality in Long-Term Care Residents*

higher with PRN anxiolytics and PRN analgesic prescriptions.

separate table in order to improve ease of readability.

The target variable in this analysis has a multinomial distribution with a generalized logit link. The random and fixed effects are the same as in the preceding analysis except for the addition of the CHESS as a fixed effect. The fixed effect coefficients for this analysis comprise a multi-layered table, wherein each layer represents a different time to death category. However, we present each layer as a

**Tables 3**–**5** respectively show findings from 1–7, 8–30, 31–90 days from the final assessment. The findings for demographic, functional capability and mortality risk measures show the following trends. Over all three mortality intervals, mortality is lower in women than men, higher at older ages, higher with greater activity limitation and higher with higher CHESS scores. For the interval 8–30 days after the final assessment, mortality is lower with higher cognitive impairment (i.e., higher scores

Compared to a reference category of no medication, the findings for prescribed medications show the following. **Table 3** shows mortality 1–7 days from the final assessment to be significantly lower with daily antidepressant prescription but significantly higher with PRN prescription of antipsychotics, analgesics and antidepressants. **Table 4** shows mortality 8–30 days after the final assessment is significantly lower with daily antidepressant and daily analgesic prescriptions but significantly

**Model term Odds ratio Sig. 95% confidence interval**

Intercept 0.017 0.000 0.013 0.022 Female 0.533 0.000 0.432 0.659

Age at assessment 1.032 0.000 1.017 1.048 Activities of daily living 1.625 0.000 1.484 1.780 Cognitive performance 0.986 1.000 0.922 1.053 CHESS scale 2.489 0.000 2.294 2.700 Daily antipsychotic 0.859 0.222 0.670 1.102 PRN antipsychotic 2.139 0.009 1.273 3.594

Daily antidepressant 0.606 0.000 0.487 0.755 PRN antidepressant 1.696 0.045 1.010 2.847

Daily analgesic 1.104 0.395 0.863 1.410 PRN analgesic 2.655 0.000 1.916 3.681

Daily anxiolytic 0.997 0.903 0.716 1.388 PRN anxiolytic 1.006 0.942 0.617 1.640

Daily hypnotic 1.104 0.586 0.711 1.716 PRN hypnotic 1.592 0.318 0.666 3.806

*Fixed effect odds ratios for predictors of mortality within 7 days after the final assessment.*

**Lower Upper**

*DOI: http://dx.doi.org/10.5772/intechopen.85971*

on the scale).

Male

No antipsychotic

No antidepressant

No analgesic

No anxiolytic

No hypnotic

*Psychotropic Medication Use and Mortality in Long-Term Care Residents DOI: http://dx.doi.org/10.5772/intechopen.85971*

*Aging - Life Span and Life Expectancy*

*Proportionate mortality by anxiolytic frequency in men and women.*

*Proportionate mortality by hypnotic frequency in men and women.*

of time to death. The categories are 1–7, 8–30 and 31–90 days after the final assessment. We chose these categories to index mortality shortly, soon, and sometime after the final assessment but before the next scheduled assessment. The reference category is no recorded death. This analysis allows to use examine relationships between mortality and psychotropic prescriptions using a finer temporal scale. The second advance is to include the CHESS scale [10] as a fixed effect. The CHESS is arguably the strongest current predictor of mortality for people within continuing care contexts. For example, mortality in the present database is <10% for residents with the lowest score but >85% for residents with the highest score. Consequently, inclusion of the CHESS helps us to test between two interpretations of PRN/mortality relationships. On the one hand, if nearness of death is the primary reason for PRN prescription (i.e., prescribed mainly for palliative reasons), its relationship to mortality should nullify after inclusion of the CHESS as a fixed effect. On the other hand, if PRN prescription increases the risk of subsequent mortality, a relationship should endure despite inclusion of the CHESS as

**Figure 4.**

**Figure 5.**

**10**

a fixed effect.

The target variable in this analysis has a multinomial distribution with a generalized logit link. The random and fixed effects are the same as in the preceding analysis except for the addition of the CHESS as a fixed effect. The fixed effect coefficients for this analysis comprise a multi-layered table, wherein each layer represents a different time to death category. However, we present each layer as a separate table in order to improve ease of readability.

**Tables 3**–**5** respectively show findings from 1–7, 8–30, 31–90 days from the final assessment. The findings for demographic, functional capability and mortality risk measures show the following trends. Over all three mortality intervals, mortality is lower in women than men, higher at older ages, higher with greater activity limitation and higher with higher CHESS scores. For the interval 8–30 days after the final assessment, mortality is lower with higher cognitive impairment (i.e., higher scores on the scale).

Compared to a reference category of no medication, the findings for prescribed medications show the following. **Table 3** shows mortality 1–7 days from the final assessment to be significantly lower with daily antidepressant prescription but significantly higher with PRN prescription of antipsychotics, analgesics and antidepressants.

**Table 4** shows mortality 8–30 days after the final assessment is significantly lower with daily antidepressant and daily analgesic prescriptions but significantly higher with PRN anxiolytics and PRN analgesic prescriptions.


**Table 3.**

*Fixed effect odds ratios for predictors of mortality within 7 days after the final assessment.*


#### *Aging - Life Span and Life Expectancy*

#### **Table 4.**

*Fixed effect odds ratios for predictors of mortality 8–30 days after the final assessment.*

During the 31–90 day interval after the final assessment, **Table 5** shows significantly lower mortality with daily antidepressant prescription but significantly higher mortality with PRN analgesic, anxiolytic, and hypnotic prescriptions.

At one or more levels of the target variable, the findings from this analysis replicate those from the preceding analysis that relate male gender, older age and greater activity limitation to significantly augmented mortality. They also replicate findings of augmented mortality with PRN prescription for all types of psychotropic medication. They further extend relationships of attenuated mortality to include daily prescription of both analgesic and antidepressant medication. The only failure of replication is the absence of significantly attenuated mortality with daily prescription of antipsychotic medication, despite a coefficient close to significance for the 8–30 day interval. Other significant findings include attenuated mortality with cognitive impairment (i.e., higher scores on the scale) at the 8–30 day interval and augmented mortality at each level of the target variable with higher estimates of mortality risk on the CHESS.

The inclusion of the CHESS provides a rationale to interpret findings of attenuated or augmented mortality associated with psychotropic prescriptions. The presence of such findings after control for the CHESS supports an interpretation that

**13**

to death seems less plausible.

are 0, 1, 2 and 3+ ordinal categories.

*Psychotropic Medication Use and Mortality in Long-Term Care Residents*

**Model term Odds ratio Sig. 95% confidence interval**

Intercept 0.140 0.000 0.124 0.158 Female 0.650 0.000 0.587 0.720

Age at assessment 1.039 0.000 1.031 1.046 Activities of daily living 1.326 0.000 1.277 1.377 Cognitive performance 0.986 0.901 0.953 1.020 CHESS scale 1.542 0.000 1.474 1.614 Daily antipsychotic 0.989 0.807 0.882 1.108 PRN antipsychotic 1.436 0.092 1.003 2.056

Daily antidepressant 0.822 0.000 0.743 0.909 PRN antidepressant 1.226 0.269 0.854 1.758

Daily analgesic 0.894 0.052 0.803 0.995 PRN analgesic 1.406 0.000 1.172 1.687

Daily anxiolytic 1.011 0.689 0.866 1.181 PRN anxiolytic 1.392 0.006 1.093 1.772

Daily hypnotic 1.080 0.376 0.875 1.333 PRN hypnotic 1.990 0.006 1.243 3.186

**Lower Upper**

the medicinal prescriptions have direct or indirect effects on mortality beyond the levels of risk measured by the tool. An alternative interpretation that the findings on mortality are secondary to altered prescribing practices with perceived closeness

LTCH residents may receive more than a single type of psychotropic medication on a daily or PRN basis. The purpose of these analyses is to identify variables that contribute to the number of such prescriptions. The target variable in both analyses is the number of psychotropic categories prescribed on a daily or PRN basis. We modeled the target as an ordinal measure with a cumulative logit link in mixed multinomial logistic regression models. Levels on the daily prescription distribution are 0, 1, 2, 3 and 4+ ordinal categories. Levels on the PRN prescription distribution

The fixed effects include the same demographic, functional capability and mortality risk measures as in the preceding analyses. Other measures are scales (i.e., Depression, Aggressive Behavior, and Pain scales), diagnoses (i.e., Anxiety Disorder, and Dementia) and conditions (i.e., Insomnia) that might influence psychotropic medication use. We

*2.2.3 Analysis of predictors of multiple daily and PRN psychotropic prescriptions*

*Fixed effect odds ratios for predictors of mortality 31–90 days after the final assessment.*

added a final fixed effect of the total number of prescribed medications.

*DOI: http://dx.doi.org/10.5772/intechopen.85971*

Male

No antipsychotic

No antidepressant

No analgesic

No anxiolytic

No hypnotic

**Table 5.**


### *Psychotropic Medication Use and Mortality in Long-Term Care Residents DOI: http://dx.doi.org/10.5772/intechopen.85971*

#### **Table 5.**

*Aging - Life Span and Life Expectancy*

Male

No antipsychotic

No antidepressant

No analgesic

No anxiolytic

No hypnotic

**Table 4.**

During the 31–90 day interval after the final assessment, **Table 5** shows significantly lower mortality with daily antidepressant prescription but significantly higher mortality with PRN analgesic, anxiolytic, and hypnotic

*Fixed effect odds ratios for predictors of mortality 8–30 days after the final assessment.*

**Model term Odds ratio Sig. 95% confidence interval**

Intercept 0.089 0.000 0.077 0.103 Female 0.596 0.000 0.525 0.677

Age at assessment 1.022 0.000 1.013 1.031 Activities of daily living 1.495 0.000 1.423 1.572 Cognitive performance 0.947 0.047 0.909 0.986 CHESS scale 1.883 0.000 1.786 1.986 Daily antipsychotic 0.881 0.084 0.761 1.020 PRN antipsychotic 1.335 0.280 0.872 2.043

Daily antidepressant 0.675 0.000 0.594 0.768 PRN antidepressant 1.152 0.497 0.758 1.753

Daily analgesic 0.824 0.007 0.719 0.943 PRN analgesic 1.574 0.000 1.274 1.946

Daily anxiolytic 0.885 0.337 0.721 1.086 PRN anxiolytic 1.482 0.006 1.113 1.974

Daily hypnotic 1.049 0.624 0.802 1.370 PRN hypnotic 1.585 0.148 0.872 2.880

**Lower Upper**

At one or more levels of the target variable, the findings from this analysis replicate those from the preceding analysis that relate male gender, older age and greater activity limitation to significantly augmented mortality. They also replicate findings of augmented mortality with PRN prescription for all types of psychotropic medication. They further extend relationships of attenuated mortality to include daily prescription of both analgesic and antidepressant medication. The only failure of replication is the absence of significantly attenuated mortality with daily prescription of antipsychotic medication, despite a coefficient close to significance for the 8–30 day interval. Other significant findings include attenuated mortality with cognitive impairment (i.e., higher scores on the scale) at the 8–30 day interval and augmented mortality at each level of the target variable with higher estimates of

The inclusion of the CHESS provides a rationale to interpret findings of attenuated or augmented mortality associated with psychotropic prescriptions. The presence of such findings after control for the CHESS supports an interpretation that

**12**

prescriptions.

mortality risk on the CHESS.

*Fixed effect odds ratios for predictors of mortality 31–90 days after the final assessment.*

the medicinal prescriptions have direct or indirect effects on mortality beyond the levels of risk measured by the tool. An alternative interpretation that the findings on mortality are secondary to altered prescribing practices with perceived closeness to death seems less plausible.

## *2.2.3 Analysis of predictors of multiple daily and PRN psychotropic prescriptions*

LTCH residents may receive more than a single type of psychotropic medication on a daily or PRN basis. The purpose of these analyses is to identify variables that contribute to the number of such prescriptions. The target variable in both analyses is the number of psychotropic categories prescribed on a daily or PRN basis. We modeled the target as an ordinal measure with a cumulative logit link in mixed multinomial logistic regression models. Levels on the daily prescription distribution are 0, 1, 2, 3 and 4+ ordinal categories. Levels on the PRN prescription distribution are 0, 1, 2 and 3+ ordinal categories.

The fixed effects include the same demographic, functional capability and mortality risk measures as in the preceding analyses. Other measures are scales (i.e., Depression, Aggressive Behavior, and Pain scales), diagnoses (i.e., Anxiety Disorder, and Dementia) and conditions (i.e., Insomnia) that might influence psychotropic medication use. We added a final fixed effect of the total number of prescribed medications.


#### *Aging - Life Span and Life Expectancy*

#### **Table 6.**

*Fixed effect odds ratios for predictors of number of daily medications for the final assessment.*

The findings in **Table 6** show fixed findings for daily prescriptions of psychotropic medication. The table includes thresholds (i.e., intercepts) at different levels of the target variable and coefficients for the predictors. Predictors of significantly higher frequencies of daily prescription include categorical measures of female gender, anxiety disorder, insomnia, and dementia; higher scores on scales measuring activity limitation, cognitive impairment, depression, aggressive behavior, and pain; and the total number of medications. These findings suggest that residents prescribed more types of psychotropic medication have higher levels on multiple conditions that might benefit from psychotropic intervention. Findings that seem at odds with the preceding are relationships of younger age and lower mortality risk (i.e., on the CHESS) to higher frequencies of daily psychotropic prescriptions.

**Table 7** shows fixed effect findings for PRN prescriptions of psychotropic medication. Significant predictors of higher levels of PRN prescribing are limited to the Aggressive Behavior, Pain, and CHESS scales, and the presence of insomnia. Age and diagnosed dementia have negative relationships with the number of PRN prescriptions.

The most revealing differences in outcome of the two preceding analyses relate to diagnosed dementia and the CHESS scale. Diagnosed dementia relates positively to the number of daily but negatively to the number of PRN prescriptions. Conversely, higher mortality risk relates negatively to the number of daily but positively to the number of PRN prescriptions.

**15**

*Psychotropic Medication Use and Mortality in Long-Term Care Residents*

**Model term Odds ratio Sig. 95% confidence interval**

Threshold for Number = 0 7.737 0.000 6.970 8.587 Threshold for Number = 1 73.344 0.000 63.257 85.040 Threshold for Number = 2 399.408 0.000 303.212 526.123 Female 1.033 0.496 0.941 1.134

Age at assessment 0.993 0.029 0.988 0.999 Activities of daily living 1.019 0.252 0.987 1.052 Cognitive performance 0.977 0.194 0.942 1.012 Depression scale 1.008 0.437 0.988 1.028 Aggressive behavior scale 1.085 0.000 1.064 1.107 Pain scale 1.334 0.000 1.268 1.404 CHESS scale 1.214 0.000 1.165 1.266 Anxiety disorder 0.991 0.917 0.838 1.173

Insomnia 1.618 0.000 1.444 1.812

Dementia 0.789 0.000 0.710 0.877

Total medications 0.996 0.423 0.986 1.006

**Lower Upper**

*2.2.4 Analysis of mortality against multiple daily and PRN psychotropic prescriptions*

*Fixed effect odds ratios for predictors of number of PRN medications for the final assessment.*

daily prescriptions only. The reference category is zero prescriptions.

show significant differences across all four categories.

The purpose of this analysis is to ascertain relationships between mortality within 90 days of the final assessment and the distribution of prescriptions of psychotropic medications at the final assessment. The target variable has a binomial distribution with a complementary log-log link. The fixed effect variables include the same demographic, functional capability and mortality risk measures as previous analyses. Categories within the distribution of prescriptions include (1) no prescriptions, (2) daily and PRN prescriptions, (3) PRN prescriptions only and (4)

The findings in **Table 8** show significantly lower mortality for women than men and for residents with greater cognitive impairment (i.e., lower scores on the scale). Mortality is significantly higher at older ages and for residents scoring higher on activity limitation and the CHESS measure of mortality risk. Findings for the distribution of prescriptions show significantly attenuated mortality for residents with daily prescriptions only, significantly augmented mortality residents with PRN prescriptions only, and significantly augmented mortality for residents with both daily and PRN prescriptions. Paired comparisons with Bonferroni correction

We interpret these findings as follows. Antipsychotics, antidepressants and analgesics have the highest rates of daily prescription. Daily prescription of each of those psychotropics attenuates mortality in at least one of our analyses. Consequently, the present association between attenuated 90-day mortality in residents with only daily prescriptions is unsurprising. For similar reasons, findings of augmented mortality in

*DOI: http://dx.doi.org/10.5772/intechopen.85971*

Male

No anxiety disorder

No insomnia

No dementia

**Table 7.**


### *Psychotropic Medication Use and Mortality in Long-Term Care Residents DOI: http://dx.doi.org/10.5772/intechopen.85971*

#### **Table 7.**

*Aging - Life Span and Life Expectancy*

Male

No anxiety disorder

No insomnia

No dementia

**Table 6.**

The findings in **Table 6** show fixed findings for daily prescriptions of psychotropic medication. The table includes thresholds (i.e., intercepts) at different levels of the target variable and coefficients for the predictors. Predictors of significantly higher frequencies of daily prescription include categorical measures of female gender, anxiety disorder, insomnia, and dementia; higher scores on scales measuring activity limitation, cognitive impairment, depression, aggressive behavior, and pain; and the total number of medications. These findings suggest that residents prescribed more types of psychotropic medication have higher levels on multiple conditions that might benefit from psychotropic intervention. Findings that seem at odds with the preceding are relationships of younger age and lower mortality risk (i.e., on the CHESS) to higher frequencies

*Fixed effect odds ratios for predictors of number of daily medications for the final assessment.*

Insomnia 1.124 0.000 1.079 1.170

Dementia 1.393 0.000 1.348 1.439

Total medications 1.191 0.000 1.187 1.195

**Model term Odds ratio Sig. 95% confidence interval**

Threshold for Number = 0 0.225 0.000 0.214 0.237 Threshold for Number = 1 1.504 0.000 1.433 1.579 Threshold for Number = 2 9.442 0.000 8.970 9.939 Threshold for Number = 3 87.211 0.000 81.593 93.216 Female 1.047 0.002 1.017 1.079

Age at assessment 0.973 0.000 0.971 0.974 Activities of daily living 1.015 0.003 1.005 1.025 Cognitive performance 1.118 0.000 1.105 1.131 Depression scale 1.108 0.000 1.100 1.115 Aggressive behavior scale 1.067 0.000 1.060 1.074 Pain scale 1.208 0.000 1.187 1.230 CHESS scale 0.915 0.000 0.900 0.929 Anxiety disorder 2.744 0.000 2.599 2.896

**Lower Upper**

**Table 7** shows fixed effect findings for PRN prescriptions of psychotropic medication. Significant predictors of higher levels of PRN prescribing are limited to the Aggressive Behavior, Pain, and CHESS scales, and the presence of insomnia. Age and diagnosed dementia have negative relationships with the number of PRN prescriptions. The most revealing differences in outcome of the two preceding analyses relate

to diagnosed dementia and the CHESS scale. Diagnosed dementia relates positively to the number of daily but negatively to the number of PRN prescriptions. Conversely, higher mortality risk relates negatively to the number of daily but

**14**

of daily psychotropic prescriptions.

positively to the number of PRN prescriptions.

*Fixed effect odds ratios for predictors of number of PRN medications for the final assessment.*
