**2. New analyses on relationships between psychotropic medication and mortality**

We try here to expand the scope and level of precision beyond those present in previous analyses, each of which examined associations of mortality with a single psychotropic medication. First, we analyze the effects on mortality of all the psychotropic prescriptions within a series of multivariate analyses that includes the psychotropic medications. Second, we introduce a verified measure of mortality risk into the array of control variables. Third, we examine intervals for mortality of 90 days from the final RAI 2.0 assessment (i.e., the scheduled date of the next

assessment) and shorter periods within that interval. Fourth, we examine predictors of daily and PRN prescriptions of psychotropic medications. Fifth, we examine the effects on mortality for residents receiving only daily, only PRN, or both daily and PRN prescriptions of psychotropic medication.

### **2.1 Methods**

Section 1.2 described the three datasets linked and encrypted by CIHI. Here we report analyses that restrict data entry to (1) scheduled intake, quarterly and yearly assessments, (2) in LTCH settings, (3) for residents aged 65+ years, (4) with an intake assessment during the financial year 2010/2011, and (5) subsequent assessments that do not exceed first yearly assessment (i.e., <13 months after the intake assessment). Consequently, the data enable computation of a census level 1-year incidence rate for mortality among LTCH residents aged 65 years and older.

The analyses that follow begin at a descriptive level and proceed to an inferential level. The latter analyses were performed using the SPSS 25 GLMM program. The target variables in different analyses include mortality within 90 days of the final assessment, time to mortality within that interval, and frequencies of daily and PRN prescriptions for psychotropic medication categories. The random variable in all analyses identifies the LTCH at intake assessment. Evidence of statistical significance for the random variable would confirm that levels on the target variable differ across the LTCH spectrum.

The fixed effects in different analyses include the following RAI 2.0 measures: demographics (gender, age at assessment); scales (Activities of Daily Living Hierarchy, Cognitive Performance Scale, Depression Rating Scale, Aggressive Behavior Scale, Pain Scale and the Changes in Health, End-Stage Disease, and Symptoms and Signs Scale); diagnoses (insomnia and dementia), and medications (antipsychotic, antidepressant, analgesic, anxiolytic, and hypnotic). Convincing evidence from earlier and more recent publications [28] attest to good data quality and psychometric properties associated with RAI 2.0 measures.

#### **2.2 Results**

Here we describe the sample with respect to demographics, psychotropic medication use, and mortality. The sample of 20,414 residents of 631 LTCH includes approximately 38% admissions from inpatient acute care, 28% from a private home, 13% from residential board and care, and 10% from home care. The remaining 11% of admissions are from residences with 24-hour nursing care, inpatient continuing care, inpatient rehabilitation, or inpatient psychiatry. The sample comprises 33.6% men and 66.4% women. The age distribution for men has a mean of 83.03 years and standard deviation of 7.37 years, with respective estimates for women of 85.29 and 7.19 years.

**Table 1** shows percentage frequencies for residents prescribed psychotropic medication during the week before the final assessment. Daily prescription is highest for analgesics followed by antidepressants followed by antipsychotics. More than half the residents use analgesics daily, nearly half use antidepressants daily, and approximately 30% receive daily antipsychotics. The frequency of PRN usage is low. The highest frequencies are 7.5% for analgesics and 3.3% for anxiolytics.

Frequencies of daily prescriptions for different types of psychotropic medication are as follows: 33.4% of residents receive one medication; 31.5% receive two medications; 17.6% use three or four (i.e., 3+) medications; and 17.4% of residents have no daily psychotropic medication. Frequencies for PRN prescriptions of psychotropic medication are as follows: 10.9% of residents use one medication; 1.6% use two or three (i.e., 2+) medications; and 87.5 of residents have no

**7**

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

psychotropic medication on a PRN basis. Frequencies for combinations of daily and PRN prescriptions are as follows: 74.6% of residents have only daily prescriptions for psychotropic medications; 4.5% have only PRN prescriptions; 8.0% have both daily and PRN prescriptions; and 12.9% have no prescription. These findings indicate that about half the residents receive two or more psychotropic medications daily, 12.5% receive one or more on a PRN basis, and 8.0% have both daily and

**Prescription of psychotropic medication**

**Medication type None (%) PRN (%) Daily (%)** Antipsychotic 69.2 1.4 29.4 Antidepressant 50.9 1.4 47.7 Analgesic 34.6 7.5 57.9 Anxiolytic 84.9 3.3 11.8 Hypnotic 93.7 0.7 5.6

Probabilistic mortalities within 90 days of the final assessment are 18.1% overall, 21.1% for males and 16.3% for females. The percentages of residents dying within different time periods after the final assessment are as follows: 2.2% mortality within 7 days after the final assessment, 6.1% within 8–30 days, and 9.8% within 31–90 days. The proportion of residents with no mortality within 90 days is 82%.

*2.2.1 Analysis of mortality's association with prescriptions of psychotropic medications*

The target variable in this analysis is mortality within 90 days of the final assessment, with 90 days being the time before the next scheduled assessment. The reference category for this variable is absence of mortality. The distribution of the target variable is binomial and related to a linear model by a complementary log-log link. SPSS 25 recommends such a linkage in survival analysis, where some observa-

The fixed effects include demographic variables (i.e., men/women, age at the final assessment); measures of functional capability (i.e., Cognitive Performance Scale, Activities of Daily Living Hierarchy); and prescribed frequency of usage for each type of psychotropic medication (i.e., none, PRN, daily). The analysis accords with conventional GLMM practices that include centering of continuous measures on their grand mean and comparison of levels on a nominal variable with a reference category. For the present nominal measures, the respective reference categories

are male gender and zero frequency of usage for a psychotropic medication.

Findings for the random variable in this and all subsequent analyses indicate significant differences (at *p* < 0.001) in levels of the target variable of mortality across facilities. The findings for fixed effects in **Table 2** indicate lower mortality in women than men and higher mortality at older ages. Mortality also increases with

covariation in prescribing practices across types of medication.

The purpose is to evaluate whether findings from separate analyses of relationships between mortality and types of psychotropic medication replicate in multivariate analysis that includes all such medications and potential confounders. The most significant findings from the earlier research indicate highest mortality with PRN prescription for each type of psychotropic medication. Replication in multivariate analysis would suggest that such relationships exist independently of any

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

*Percentage frequencies for usage of psychotropic medications.*

PRN prescriptions.

**Table 1.**

tions have no termination event.


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

#### **Table 1.**

*Aging - Life Span and Life Expectancy*

across the LTCH spectrum.

**2.2 Results**

**2.1 Methods**

and PRN prescriptions of psychotropic medication.

assessment) and shorter periods within that interval. Fourth, we examine predictors of daily and PRN prescriptions of psychotropic medications. Fifth, we examine the effects on mortality for residents receiving only daily, only PRN, or both daily

Section 1.2 described the three datasets linked and encrypted by CIHI. Here we report analyses that restrict data entry to (1) scheduled intake, quarterly and yearly assessments, (2) in LTCH settings, (3) for residents aged 65+ years, (4) with an intake assessment during the financial year 2010/2011, and (5) subsequent assessments that do not exceed first yearly assessment (i.e., <13 months after the intake assessment). Consequently, the data enable computation of a census level 1-year incidence rate for mortality among LTCH residents aged 65 years and older.

The analyses that follow begin at a descriptive level and proceed to an inferential level. The latter analyses were performed using the SPSS 25 GLMM program. The target variables in different analyses include mortality within 90 days of the final assessment, time to mortality within that interval, and frequencies of daily and PRN prescriptions for psychotropic medication categories. The random variable in all analyses identifies the LTCH at intake assessment. Evidence of statistical significance for the random variable would confirm that levels on the target variable differ

The fixed effects in different analyses include the following RAI 2.0 measures:

Here we describe the sample with respect to demographics, psychotropic medication use, and mortality. The sample of 20,414 residents of 631 LTCH includes approximately 38% admissions from inpatient acute care, 28% from a private home, 13% from residential board and care, and 10% from home care. The remaining 11% of admissions are from residences with 24-hour nursing care, inpatient continuing care, inpatient rehabilitation, or inpatient psychiatry. The sample comprises 33.6% men and 66.4% women. The age distribution for men has a mean of 83.03 years and standard deviation of 7.37 years, with respective estimates for women of 85.29 and 7.19 years. **Table 1** shows percentage frequencies for residents prescribed psychotropic medication during the week before the final assessment. Daily prescription is highest for analgesics followed by antidepressants followed by antipsychotics. More than half the residents use analgesics daily, nearly half use antidepressants daily, and approximately 30% receive daily antipsychotics. The frequency of PRN usage is low.

The highest frequencies are 7.5% for analgesics and 3.3% for anxiolytics.

Frequencies of daily prescriptions for different types of psychotropic medication are as follows: 33.4% of residents receive one medication; 31.5% receive two medications; 17.6% use three or four (i.e., 3+) medications; and 17.4% of residents have no daily psychotropic medication. Frequencies for PRN prescriptions of psychotropic medication are as follows: 10.9% of residents use one medication; 1.6% use two or three (i.e., 2+) medications; and 87.5 of residents have no

demographics (gender, age at assessment); scales (Activities of Daily Living Hierarchy, Cognitive Performance Scale, Depression Rating Scale, Aggressive Behavior Scale, Pain Scale and the Changes in Health, End-Stage Disease, and Symptoms and Signs Scale); diagnoses (insomnia and dementia), and medications (antipsychotic, antidepressant, analgesic, anxiolytic, and hypnotic). Convincing evidence from earlier and more recent publications [28] attest to good data quality

and psychometric properties associated with RAI 2.0 measures.

**6**

*Percentage frequencies for usage of psychotropic medications.*

psychotropic medication on a PRN basis. Frequencies for combinations of daily and PRN prescriptions are as follows: 74.6% of residents have only daily prescriptions for psychotropic medications; 4.5% have only PRN prescriptions; 8.0% have both daily and PRN prescriptions; and 12.9% have no prescription. These findings indicate that about half the residents receive two or more psychotropic medications daily, 12.5% receive one or more on a PRN basis, and 8.0% have both daily and PRN prescriptions.

Probabilistic mortalities within 90 days of the final assessment are 18.1% overall, 21.1% for males and 16.3% for females. The percentages of residents dying within different time periods after the final assessment are as follows: 2.2% mortality within 7 days after the final assessment, 6.1% within 8–30 days, and 9.8% within 31–90 days. The proportion of residents with no mortality within 90 days is 82%.

### *2.2.1 Analysis of mortality's association with prescriptions of psychotropic medications*

The purpose is to evaluate whether findings from separate analyses of relationships between mortality and types of psychotropic medication replicate in multivariate analysis that includes all such medications and potential confounders. The most significant findings from the earlier research indicate highest mortality with PRN prescription for each type of psychotropic medication. Replication in multivariate analysis would suggest that such relationships exist independently of any covariation in prescribing practices across types of medication.

The target variable in this analysis is mortality within 90 days of the final assessment, with 90 days being the time before the next scheduled assessment. The reference category for this variable is absence of mortality. The distribution of the target variable is binomial and related to a linear model by a complementary log-log link. SPSS 25 recommends such a linkage in survival analysis, where some observations have no termination event.

The fixed effects include demographic variables (i.e., men/women, age at the final assessment); measures of functional capability (i.e., Cognitive Performance Scale, Activities of Daily Living Hierarchy); and prescribed frequency of usage for each type of psychotropic medication (i.e., none, PRN, daily). The analysis accords with conventional GLMM practices that include centering of continuous measures on their grand mean and comparison of levels on a nominal variable with a reference category. For the present nominal measures, the respective reference categories are male gender and zero frequency of usage for a psychotropic medication.

Findings for the random variable in this and all subsequent analyses indicate significant differences (at *p* < 0.001) in levels of the target variable of mortality across facilities. The findings for fixed effects in **Table 2** indicate lower mortality in women than men and higher mortality at older ages. Mortality also increases with


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

#### **Table 2.**

*Fixed effect odds ratios including daily, PRN and No psychotropic predictors of mortality within 90 days of the final assessment.*

activity limitation, as indexed by higher scores on the activities of daily living scale. The findings for psychotropic medications show significantly lower mortality for daily antipsychotic and antidepressant prescription compared with no prescriptions. The findings for PRN prescriptions show significantly higher mortality for all types of psychotropic medication relative to no prescription and (in subsequent paired comparisons) daily prescription.

**Figures 1**–**5** illustrate the magnitude of these findings, which are present in both men and women.

The findings from this analysis replicate in a multivariate context those from separate analyses of each psychotropic medication. We conclude, therefore, that associations between PRN prescription and higher mortality are independent for each type of psychotropic medication. Compared to previous research, the findings of lower mortality with daily antipsychotic and antidepressant prescription are unusual for the former but not the latter. However, we have no reason to doubt their validity, based as they are on census level data from an entire province. It is possible that confounding factors that contribute to earlier reports of augmented mortality with antipsychotic medication include failures to distinguish daily from intermittent usage and to identify adherence to daily prescription regimens. The presence of either confound might overturn protective effects associated with antipsychotic medication.

**9**

**Figure 3.**

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

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

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

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

*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

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

**Figure 1.**

**Figure 2.**

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

**Figure 1.** *Proportionate mortality by antipsychotic frequency in men and women.*

**Figure 2.** *Proportionate mortality by antidepressant frequency in men and women.*

#### **Figure 3.**

*Aging - Life Span and Life Expectancy*

Male

No antipsychotic

No antidepressant

No analgesic

No anxiolytic

No hypnotic

*final assessment.*

**Table 2.**

activity limitation, as indexed by higher scores on the activities of daily living scale. The findings for psychotropic medications show significantly lower mortality for daily antipsychotic and antidepressant prescription compared with no prescriptions. The findings for PRN prescriptions show significantly higher mortality for all types of psychotropic medication relative to no prescription and (in subsequent

*Fixed effect odds ratios including daily, PRN and No psychotropic predictors of mortality within 90 days of the* 

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

Intercept 0.21 0.000 0.19 0.23 Female 0.68 0.000 0.64 0.73

Age at assessment 1.03 0.000 1.03 1.04 Activities of daily living 1.49 0.000 1.46 1.53 Cognitive performance 0.98 0.144 0.96 1.01 Daily antipsychotic 0.92 0.040 0.85 1.00 PRN antipsychotic 1.59 0.000 1.28 1.96

Daily antidepressant 0.78 0.000 0.72 0.83 PRN antidepressant 1.37 0.004 1.11 1.69

Daily analgesic 0.98 0.555 0.91 1.05 PRN analgesic 1.72 0.000 1.53 1.93

Daily anxiolytic 0.99 0.899 0.89 1.11 PRN anxiolytic 1.40 0.000 1.20 1.64

Daily hypnotic 1.08 0.301 0.93 1.25 PRN hypnotic 1.77 0.000 1.31 2.40

**Lower Upper**

**Figures 1**–**5** illustrate the magnitude of these findings, which are present in both

The findings from this analysis replicate in a multivariate context those from separate analyses of each psychotropic medication. We conclude, therefore, that associations between PRN prescription and higher mortality are independent for each type of psychotropic medication. Compared to previous research, the findings of lower mortality with daily antipsychotic and antidepressant prescription are unusual for the former but not the latter. However, we have no reason to doubt their validity, based as they are on census level data from an entire province. It is possible that confounding factors that contribute to earlier reports of augmented mortality with antipsychotic medication include failures to distinguish daily from intermittent usage and to identify adherence to daily prescription regimens. The presence of either confound might

overturn protective effects associated with antipsychotic medication.

paired comparisons) daily prescription.

men and women.

**8**

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