Antipsychotic use among nursing home residents

Geographic Variation of Antidementia and Antipsychotic Medication Use Among US Nursing Home Residents With Dementia

BACKGROUND

Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms.

OBJECTIVE

The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use.

SETTING

US nursing homes (n=9735), hospital referral regions (HRR; n=289).

SUBJECTS

Long-stay residents with dementia (n=273,004).

METHODS

Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV).

RESULTS

Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCV STATE : 27.80%; PCV HRR : 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCV STATE : 37.44%; ChEI PCV STATE : 39.02%).

CONCLUSION

Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

BACKGROUND

Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD.

METHODS

In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses.

RESULTS

The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (β = -0.70, p < 0.001).

CONCLUSIONS

HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis

Importance

Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management.

Objective

To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults.

Design, Setting, and Participants

In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023.

Exposure

Incident dementia diagnosis.

Main Outcomes and Measures

The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date.

Results

The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase).

Conclusions and Relevance

In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

Impact of on-site pharmacists in residential aged care facilities on the quality of medicines use: a cluster randomised controlled trial (PiRACF study)

Residents of residential aged care facilities (RACFs) have a high prevalence of use of potentially inappropriate medications (PIMs) and resultant medicines-related harm. This study investigated the effect of an on-site pharmacist model on PIMs use and other medication outcomes for residents in RACFs. A multi-facility, non-blind, cluster randomised controlled trial, with randomisation at the facility level, was conducted. Fifteen facilities enrolled and participated in the study, 7 facilities (560 residents) were allocated to the intervention arm and 8 facilities (737 residents) were allocated to the control arm. Each facility in the intervention arm employed an on-site pharmacist for 12 months to perform medication management activities as part of an interdisciplinary care team. The primary outcome was the proportion of residents taking at least one PIM according to the 2019 Beers® Criteria. Using generalised linear mixed-effects models, accounting for confounders and clustering, there was a significant reduction in the proportion of residents prescribed at least one PIM (odds ratio 0.50, 95% confidence interval, 0.335-0.750; p = 0.001) in the intervention arm. There were also significant decreases in the Anticholinergic Cognitive Burden scale and chlorpromazine equivalent daily dose of antipsychotics. The on-site pharmacist intervention significantly improved the appropriateness of medicines use in RACFs.

Hospice agency characteristics associated with benzodiazepine and antipsychotic prescribing

BACKGROUND

Benzodiazepine and antipsychotic medications are routinely prescribed for symptom management in hospice patients, but have significant risks for older adults. We explored the extent to which patient and hospice agency characteristics are associated with variations in their prescribing.

METHODS

Cross-sectional analysis of hospice-enrolled Medicare beneficiaries aged ≥65 years in 2017 (N = 1,393,622 in 4219 hospice agencies). The main outcome was the hospice agency-level rate of enrollees with benzodiazepine and antipsychotic prescription fills divided into quintiles. Rate ratios were used to compare the agencies with the highest and lowest prescription across patient and agency characteristics.

RESULTS

In 2017, hospice agency prescribing rates varied widely: for benzodiazepines, from a median of 11.9% (IQR 5.9,22.2) in the lowest-prescribing quintile to 80.0% (IQR 76.9,84.2) in the highest-prescribing quintile; for antipsychotics, it ranged from 5.5% (IQR 2.9,7.7) in the lowest to 63.9% (IQR 56.1,72.0) in the highest. Among the highest benzodiazepine- and antipsychotic- prescribing hospice agencies, there was a smaller proportion of patients from minoritized populations (benzodiazepine: non-Hispanic Black rate ratio [RR] [Q5/Q1] 0.7, 95% CI 0.6-0.7, Hispanic RR 0.4, 95% CI 0.3-0.5; antipsychotic: non-Hispanic Black RR 0.7, 95% CI 0.6-0.8, Hispanic RR 0.4, 95% CI 0.3-0.5). A greater proportion of rural beneficiaries were in the highest benzodiazepine-prescribing quintile (RR 1.3, 95% CI 1.2-1.4), whereas this relationship was not present for antipsychotics. Larger hospice agencies were over-represented in the highest prescribing quintile for both benzodiazepines (RR 2.6, 95% CI 2.5-2.7) and antipsychotics (RR 2.7, 95% CI 2.6-2.8), as were for-profit agencies (benzodiazepine: RR 2.4, 95% CI 2.3-2.4; antipsychotic: RR 2.3, 95% CI 2.2-2.4). Prescribing rates varied widely across Census regions.

CONCLUSIONS

Prescribing in hospice settings varies markedly across factors other than the clinical characteristics of enrolled patients.

Pathways into Assisted Living Communities: Admission Limitations and Assessment Requirements Across the United States

OBJECTIVES

Limitations to admission play a critical role in shaping the composition of residents residing within licensed assisted living (AL) communities.

DESIGN

We document variation across 165 licensure classifications in how state agencies limit who AL communities may admit and what assessments are required to make those determinations.

SETTING AND PARTICIPANTS

AL regulations and licensed AL communities across all 50 states in 2018.

METHODS

We estimated the proportion of all licensed AL communities regulated by admission limitations and identified groups consisting of those that limit admission based on a health-related condition, specified behavior, mental health condition, and/or cognitive impairment as well as those that impose no limitations to admission. We also estimated the proportion of all licensed AL communities required to conduct assessments at time of admission.

RESULTS

The largest group of ALs (29% nationally) is governed by regulations limiting the admission of persons with a health condition. The next largest group of AL communities (23.6%) limit admissions based on health, specified behavior, mental health conditions, and cognitive impairment. In contrast, 11.1% of licensed AL communities have no regulations restricting admissions. We also found that more than 8 of every 10 licensed communities were required to have residents complete a health assessment at admission, but less than half were required to complete a cognitive assessment.

CONCLUSIONS AND IMPLICATIONS

The variation we observe implies that state agencies have created multiple licensure classifications that serve as a mechanism for sorting types of residents into settings based on their need (eg, health, mental health, cognitive). Although future research should investigate the implications of this regulatory diversity, the categories outlined here may be helpful to clinicians, consumers, and policy makers to better understand the options in their state and how various AL licensure classifications compare to one another.

Community, Social, and Facility Factors and Long-stay Antipsychotic Use

OBJECTIVES

Compare Virginia nursing homes in the top- and bottom-quintiles of antipsychotic use for variation in community, social, and facility factors.

METHODS

2018 CMS data ascertained Virginia nursing homes in the top and bottom quintiles for antipsychotic use. The Virginia Health Department provided social determinant of health (SDOH) statistics for each facility's county/city while claims identified facility demographics. Chi square and independent two-sample t-tests compared quintiles for regional, social, and demographic differences.

RESULTS

Quintiles averaged 3000 residents and 56 facilities. Facilities with the lowest rates of antipsychotic use were more likely to be privately owned and had fewer African-American and minority residents and more white residents. All 18 SDOH statistics were superior for the communities of facilities with the lowest antipsychotic rates. Nine of these differences were statistically significant, including the aggregated "Health Opportunity Index."

CONCLUSIONS

The antipsychotic prevalence rate for facilities in the top-quintile of antipsychotic use is fivefold the bottom-quintile's rate. Antipsychotic prescribing in nursing homes is associated with regional, demographic, and social factors not addressed by existing antipsychotic reduction measures, with vulnerable populations at greatest risk.

CLINICAL IMPLICATIONS

The efficacy of measures aimed at curbing long-stay antipsychotic prescribing could be improved by addressing SDOH including economic opportunities.

To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

OBJECTIVE

In nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.

DESIGN

Observational, cross-sectional AL data linked to publicly reported NH measures.

SETTING AND PARTICIPANTS

Random sample of 250 AL communities and the full sample of 3371 NHs in 7 states.

METHODS

We calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.

RESULTS

The prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = -0.03; 95% confidence interval (CI) -0.50 to -0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs' prescribing rates (b = 0.43; 95% CI 0.16-0.70; P = .002).

CONCLUSIONS AND IMPLICATIONS

This study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.

Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014

OBJECTIVE

The Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes focuses on but is not limited to long-term care (LTC) residents with dementia; the potential impact on residents with other diagnoses is unclear. We sought to determine whether resident subpopulations experienced changes in antipsychotic and mood stabilizer prescribing.

DESIGN

Repeated cross-sectional analysis of a 20% Medicare sample, 2011-2014.

SETTING AND PARTICIPANT

Fee-for-service Medicare beneficiaries with Part D coverage in LTC (n = 562,485) and a secondary analysis limited to persons with depression or bipolar disorder (n = 139,071).

METHODS

Main outcome was quarterly predicted probability of treatment with an antipsychotic or mood stabilizer.

RESULTS

From 2011 to 2014, the adjusted predicted probability (APP) of antipsychotic treatment fell from 0.120 [95% confidence interval (CI) 0.119-0.121] to 0.100 (95% CI 0.099-0.101; P < .001). Use decreased for all age, sex, and racial/ethnic groups; the decline was larger for persons with dementia (P < .001). The APP of mood stabilizer use grew from 0.140 (95% CI 0.139-0.141) to 0.185 (95% CI 0.184-0.186), growth slightly larger among persons without dementia (P < .001). Among persons with depression or bipolar disorder, the APP of antipsychotic treatment increased from 0.081 (95% CI 0.079-0.082) to 0.087 (95% CI 0.085-0.088; P < .001); APP of mood stabilizer treatment grew more, from 0.193 (95% CI 0.190-0.196) to 0.251 (0.248-0.253; P < .001). Quetiapine was the most commonly prescribed antipsychotic. The most widely prescribed mood stabilizer was gabapentin, prescribed to 70.5% of those who received a mood stabilizer by the end of 2014.

CONCLUSIONS AND IMPLICATIONS

The likelihood of antipsychotic and mood stabilizer treatment did not decline for residents with depression or bipolar disorder, for whom such prescribing may be appropriate but who were not excluded from the Partnership's antipsychotic quality measure. Growth in mood stabilizer use was widespread, and largely driven by growth in gabapentin prescribing.

Policy to Reduce Antipsychotic Use and Hospitalization of Nursing Home Residents With Dementia

OBJECTIVES

Following the 2012 launch of the National Partnership to Improve Dementia Care in Nursing Homes (the National Partnership), the use of antipsychotics has declined. However, little is known about the impact of this effort on quality of care and outcomes for nursing home (NH) residents with Alzheimer's disease and related dementia (ADRD). The objective of this study is to examine changes in hospitalizations for NH long-stay residents with ADRD after the launch of the National Partnership.

DESIGN

Observational cross-sectional study.

SETTING/PARTICIPANTS

NH residents who were newly admitted into NHs and became long-stay residents between January 2011 and March 2015 (n = 565,885).

METHODS

We estimated linear probability models to explore the relationship between the National Partnership and the likelihood of NH-originated hospitalizations for NH long-stay residents with ADRD, accounting for facility fixed effect, individual covariates, and concurrent changes in hospitalizations among residents without ADRD. We further stratified the analysis by NHs according to their prevalence of antipsychotic use at baseline (ie, prior to the National Partnership).

RESULTS

We detected a 0.7-percentage point relative increase (P value <.01) in risk-adjusted probabilities of hospitalizations among residents with ADRD compared with non-ADRD residents in the post-Partnership period. In the stratified analysis, we detected a 1.2-percentage point increase (P = .037) in the probability of hospitalizations among ADRD residents in NHs with high antipsychotic use at baseline but no significant change among those in NHs with low antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

Although the National Partnership may have reduced exposure to antipsychotics, our findings suggest this was related to an increase in hospitalization risk for residents with ADRD. Further research is needed to elucidate the reasons behind the observed relationship and to examine the impact of the National Partnership on other health outcomes.

Why deprescribing antipsychotics in older people with dementia in long-term care is not always successful: Insights from the HALT study

INTRODUCTION

Antipsychotic medications are commonly used to manage behavioural and psychological symptoms of dementia despite their side effects and harms. While the Halting Antipsychotic Use in Long-Term care (HALT) deprescribing trial was successful at reducing antipsychotic use, 19% of participants had their antipsychotics represcribed or never reached a dose of zero. The aim of this study was to investigate the reasons for represcription of antipsychotic medication and factors associated with ongoing antipsychotic use, relating to care staff requests and perceived behavioural changes.

MATERIALS AND METHODS

Thirty-nine of 133 HALT participants never ceased their antipsychotic medication or were represcribed a regular or pro re nata (PRN) antipsychotic after initial deprescribing. The views of nursing staff, general practitioner, and family on the circumstances leading up to these outcomes were collected via a questionnaire-based approach. This information was triangulated with observation and detailed file audit (including progress notes, medical notes, medication charts, incident reports, and hospital discharge summaries). A consensus panel reconstructed the represcribing context.

RESULTS

Nurses were the most common drivers of represcribing (63.2%), followed by family members (39.5%), GPs (23.7%), specialists (13.2%), and hospital staff (10.5%). There were multiple drivers for antipsychotic use in 46.2% of participants. Increased agitated and aggressive behaviours were the most commonly reported reasons for represcribing even though these changes were not identified over time on objective measures. Consent and dosage practices remained poor despite education.

DISCUSSION

Nursing staff are the key drivers of deprescribing particularly in response to perceived worsening agitation and aggression among male residents. The train-the-trainer model used in the HALT trial may have been insufficient on its own to improve staff competence and confidence in applying nonpharmacological approaches when responding to behaviour change.

The Minimum Data Set Agitated and Reactive Behavior Scale: Measuring Behaviors in Nursing Home Residents With Dementia

OBJECTIVES

Interventions aimed at managing agitated and aggressive behaviors in dementia without the use of antipsychotics are currently being tested in nursing homes (NHs). Researchers and clinicians require a measure that can capture the severity of residents' behaviors. We test the internal consistency and construct validity of the Agitated and Reactive Behavior Scale (ARBS), a measure created using data from mandatory NH assessments.

DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

The 2016 national sample of 15,326 Centers for Medicare and Medicaid Services-certified NHs. The analytic sample included 489,854 new admissions and 765,367 long-stay residents (at least 90 days in NH). All participants have a dementia diagnosis.

METHODS

Minimum Data Set (MDS), version 3.0. The ARBS is a composite measure of (1) physical behavioral symptoms directed at other people; (2) verbal behavioral symptoms directed at other people; (3) other behavioral symptoms not directed at other people; and (4) rejection of care. Variables used to establish construct validity included degree of cognitive impairment, use of medications for managing agitation and aggression, and co-occurring conditions associated with agitated and aggressive behaviors (eg, schizophrenia, depression, or delirium).

RESULTS

This report has 3 important findings: (1) the ARBS score has borderline-adequate internal consistency (α = .64-.71) in the national population NH residents with dementia; (2) only 18% of new admissions and 21% of long-stay residents with dementia evidence any agitated or aggressive behaviors in the last week, as rated in the MDS assessment; and (3) the ARBS demonstrates good construct validity; it increases with cognitive impairment, treatment with relevant medications, and co-occurring psychiatric conditions and symptoms.

DISCUSSION

Nationally available MDS data may significantly underestimate the prevalence of agitated and aggressive behaviors among NH residents with dementia.

CONCLUSIONS AND IMPLICATIONS

Researchers conducting pragmatic trials of non-pharmaceutical interventions to manage behaviors in NH residents with dementia should consider the likely underdetection of these behaviors in the available MDS data.

Assessing the Relative Contribution of Resident Versus Facility Characteristics Associated With Antipsychotic Medication Receipt Among Nursing Facility Residents

OBJECTIVE

In 2012 Centers for Medicare and Medicaid Services (CMS) launched a multifaceted initiative aimed at reducing the unnecessary use of antipsychotic medications in nursing facilities due to evidence these medications are associated with little or uncertain benefit and substantial risk. Yet, little is known about whether efforts to reduce antipsychotic medication should be focused on residents with targeted characteristics, or on nursing facility regulation (eg, staffing levels). Our objective was to identify the relative contribution of resident and facility characteristics to potentially inappropriate antipsychotic use.

METHODS

We examined 1,156,875 long stay residents in 14,699 US nursing facilities in 2014 and predicted resident antipsychotic use controlling sequentially for resident and facility characteristics and calculated the incremental variation explained.

RESULTS

We found significant variability in unadjusted rates of potentially inappropriate antipsychotic use among nursing facilities (mean=18.0%; interquartile range: 11.3%-23.7%; SD: 11.1). Regression results indicated that 93% of the explained variation in antipsychotic use was attributed to resident characteristics and 7% was attributed to facility-level factors. At the facility level, worker hours per resident day was not significantly associated with antipsychotic use. Simulations indicated that applying the effect sizes achieved by the best performing facilities to the existing case mix across all nursing facilities would result in no more than a 1 percentage point change in population-level antipsychotic use.

CONCLUSIONS

Efforts to reduce antipsychotic use may have greater impact by developing new clinical strategies to address specific diagnoses rather than regulations related to facility-level attributes.

Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use

OBJECTIVES

Given an aging human immunodeficiency virus (HIV) population, we aimed to determine the prevalence of HIV for long-stay residents in US nursing homes (NHs) between 2001 and 2010 and to compare characteristics and diagnoses of HIV-positive (HIV+) and negative (HIV-) residents. Also, for residents with dementia diagnoses, we compared antipsychotic (APS) medication receipt by HIV status.

DESIGN

A cross-sectional comparative study.

SETTING

NHs in the 14 states accounting for 75% of persons living with HIV.

PARTICIPANTS

A total of 9 245 009 long-stay NH residents.

MEASUREMENTS

Using Medicaid fee-for-service claims data in the years 2001 to 2010, together with Medicare resident assessment and Chronic Condition Warehouse data, we identified long-stay (more than 89 days) NH residents by HIV status and dementia presence. We examined dementia presence by age groups and APS medication receipt by younger (aged younger than 65 years) vs older (aged 65 years or older) residents, using logistic regression.

RESULTS

Between 2001 and 2010, the prevalence of long-stay residents with HIV in NHs increased from 0.7% to 1.2%, a 71% increase. Long-stay residents with HIV were younger and less often female or white. For younger NH residents, rates of dementia were 20% and 16% for HIV+ and HIV- residents, respectively; they were 53% and 57%, respectively, for older residents. In adjusted analyses, younger HIV+ residents with dementia had greater odds of APS medication receipt than did HIV- residents (AOR = 1.3; 95% confidence interval [CI] = 1.2-1.4), but older HIV residents had lower odds (AOR = 0.9; 95% CI = 0.8-0.9).

CONCLUSION

The prevalence of long-stay HIV+ NH residents has increased over time, and given the rapid aging of the HIV population, this increase is likely to have continued. This study raises concern about potential differential quality of care for (younger) residents with HIV in NHs, but not for those aged 65 years and older. These findings contribute to the evidence base needed to ensure high-quality care for younger and older HIV+ residents in NHs.

A Needs Assessment of Family Physicians to Inform Development of Educational Resources on Antipsychotic Use in Dementia

OBJECTIVES

Objectives of this study were to (1) assess the needs and preferred resources of Iowa physicians to inform the development of educational resources for best practice dementia care and (2) compare the responses of nursing home medical directors with nonmedical directors.

METHODS

Of 498 physicians, 101 (20%) completed and returned the survey. Family physicians were obtained from a list of family physicians from the Iowa Board of Medical Examiners. Respondent answers were summarized and presented as total numbers and percentages in tables. Significant differences between medical directors and nonmedical directors were evaluated using chi-square tests, Fisher exact tests, and Wilcoxon rank-sum tests.

RESULTS

Medical directors and nonmedical directors had similar preferences for resources used and information needs. Online resources, pocket guides, a handbook, consulting pharmacists, and facility in-services were the most commonly preferred sources of new information. Medical directors were significantly more aware of the Food and Drug Administration warning on antipsychotic use in dementia and treated more nursing home patients. No differences were observed between groups related to confidence in and use of nondrug strategies instead of antipsychotics to manage behavioral symptoms of dementia.

CONCLUSION

The results of this survey illustrate physician preferences for information and resources on the management of behavioral and psychological symptoms in dementia. Information was used to inform the development of resources to aid physicians and other health care providers in making decisions about managing these symptoms.

Antipsychotic Drug Dispensations in Older Adults, Including Continuation After a Fall-Related Hospitalization: Identifying Adherence to Screening Tool of Older Persons' Potentially Inappropriate Prescriptions Criteria Using the Nova Scotia Seniors' Pharmacare Program and Canadian Institute for Health's Discharge Databases

Purpose

Despite well-established concerns regarding adverse drug effects, antipsychotics are frequently prescribed for older adults. Our first objective was to identify trends in antipsychotic dispensations to older Nova Scotians. STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions) criteria identify antipsychotic use in those with a history of falls as potentially inappropriate. Our second objective was to identify trends, predictors, and adherence with this STOPP criteria by identifying continued antipsychotic dispensations following a fall-related hospitalization.

Methods

A descriptive cross-sectional cohort study of Nova Scotia Seniors’ Pharmacare Program (NSSPP) beneficiaries ≥ 66 years with at least one antipsychotic dispensation annually from April 1, 2009 to March 31, 2014 was completed. As well, unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 were linked to fall-related hospitalizations recorded in the Canadian Institute for Health Information Discharge Abstract Database. The relationship of age, sex, fiscal year, days supply and length-of-stay were studied to identify predictors of continued antipsychotic dispensation post-discharge. Descriptive statistics and multivariate logistic analysis were performed. Odds ratios for the association of risk factors and adherence to STOPP criteria were calculated.

Findings

We identified that in each year observed, there were 6% of eligible NSSPP beneficiaries that received at least one antipsychotic dispensation. Approximately 70% of antipsychotic dispensations were for second generation agents, primarily quetiapine and risperidone. Of the unique beneficiaries with at least one antipsychotic dispensation in the four-year period between April 1, 2009 and March 31, 2013 who survived a fall-related hospitalization over 75% were dispensed an antipsychotic in the 100 days following hospital discharge. Logistic regression showed no statistically significant association between potentially inappropriate therapy and potential predictors in multivariate analysis.

Implications

In each year from 2009 to 2014, 6% of Nova Scotia Seniors’ Pharmacare beneficiaries were dispensed at least one antipsychotic prescription. Over 75% of the older adults who received an antipsychotic dispensation in the 100 days prior to a fall-related hospitalization, continued the drug class after discharge. This demonstrates that despite the recommendations of quality indicators such as the STOPP criteria, antipsychotics are continued in individuals at a high risk of falling. Future investigations are needed to inform health team, system, and policy interventions to improve concordance with this antipsychotic specific STOPP criterion when appropriate.

Longitudinal Trends and Variation in Antipsychotic Use in Older Adults After Cardiac Surgery

OBJECTIVES

To evaluate temporal trends and between-hospital variation in off-label antipsychotic medication (APM) use in older adults undergoing cardiac surgery.

DESIGN

Retrospective cohort study.

SETTING

National administrative database including 465 U.S. hospitals.

PARTICIPANTS

Individuals aged 65 and older without known indications for APMs who underwent cardiac surgery from 2004 to 2014 (N=293,212).

MEASUREMENTS

Postoperative exposure to any APMs and potentially excessive dosing were examined. Hospital-level APM prescribing intensity was defined as the proportion of individuals newly treated with APMs in the postoperative period.

RESULTS

The rate of APM use declined from 8.8% in 2004 to 6.2% in 2014 (p<.001). Use of haloperidol (parenteral 7.0% to 4.5%, p<.001; oral: 1.9% to 0.5%, p<.001), and risperidone (1.1% to 0.3%, p<.001) declined, whereas quetiapine use tripled (0.6% to 1.9%, p=.03). Hospital APM prescribing intensity varied widely, from 0.3% to 35.6%, across 465 hospitals. Treated individuals at higher-prescribing hospitals were more likely to receive APMs on the day of discharge (highest vs lowest quintile: 15.1% vs 9.6%; p<.001) and for a longer duration (4.8 vs 3.7 days; p<.001) than those at lower-prescribing hospitals. Delirium was the strongest risk factor for APM exposure (odds ratio=9.73, 95% confidence interval=9.02-10.5), whereas none of the hospital characteristics were significantly associated. The rate of potentially excessive dosing declined (60.7% to 44.9%, p<.001), and risk factors for potentially excessive dosing were similar to those for any APM exposure.

CONCLUSIONS

Our findings suggest highly variable prescribing cultures and raise concerns about inappropriate use, highlighting the need for better evidence to guide APM prescribing in hospitalized older adults after cardiac surgery.

CMS Strategies To Reduce Antipsychotic Drug Use In Nursing Home Patients With Dementia Show Some Progress

The Centers for Medicare and Medicaid Services initiated three strategies (in March and July 2012 and in May 2013) to reduce the use of unnecessary antipsychotic medications in nursing homes, especially their widespread use to control behavioral symptoms of dementia. We examined 86,163 state recertification surveys conducted at 15,055 facilities in the period January 1, 2009-March 31, 2015. We found that these strategies were associated with increases in citations for only one of two targeted deficiencies (unnecessary drug use) and only after the third strategy (revisions to the federal guidelines for the citations) was implemented. Each strategy was associated with a modest but significant reduction in antipsychotic prevalence in the general nursing home population. Initial reductions were greater in the ten states with the highest prevalence of antipsychotic use in nursing homes, compared to the ten states with the lowest prevalence. Use of other psychoactive medications, some of which are potential substitutes for antipsychotics, varied with each strategy and by state. Continuous monitoring and consistent enforcement are needed to ensure the continued decline in unnecessary use of antipsychotics and psychoactive medications in nursing homes.

Association of the Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014

IMPORTANCE

The Centers for Medicare & Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing.

OBJECTIVE

To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care.

DESIGN, SETTING, AND PARTICIPANTS

This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637 426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018.

MAIN OUTCOMES AND MEASURES

Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics).

RESULTS

Among the 637 426 individuals in the study (446 538 women and 190 888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31 056 of 145 841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of -0.53% (95% CI, -0.63% to -0.44%; P < .001) until the start of the partnership. At that point, the quarterly rate of decline decreased to -0.29% (95% CI, -0.39% to -0.20%; P < .001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P = .003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; P < .001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P < .001), reaching 71 492 of 355 716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75 841 of 145 841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; P < .001). Findings were similar when limited to patients with dementia.

CONCLUSIONS AND RELEVANCE

Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, the use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia. Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.

IAGG/IAGG GARN International Survey of End-of-Life Care in Nursing Homes

This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and "end of life," and a series of questions related to the following areas-attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home.

Perceptions vs. evidence: therapeutic substitutes for antipsychotics in patients with dementia in long-term care

OBJECTIVE

To compare differences between clinician perceptions of therapeutic substitutes for antipsychotics prescribed to patients with dementia in long term care (LTC) and published evidence.

METHODS

A mixed-methods approach that included a drug information search, online survey of 55 LTC clinicians and a comprehensive literature review was used. For 41 pharmacologic antipsychotic substitute candidates identified, LTC clinicians rated the likelihood they would substitute each for patients with dementia and identified non-pharmacologic antipsychotic substitutes. The quality of evidence supporting the most likely antipsychotic substitutes was assessed using a modified GRADE approach.

RESULTS

Among 36 (65%) of LTC clinicians responding, the pharmacologic candidates deemed likely or somewhat likely to be substituted for an antipsychotic were: valproic acid, serotonin modulator antidepressants, short-acting benzodiazepines, serotonin reuptake inhibitor antidepressants, alpha-adrenoceptor antagonist, buspirone, acetaminophen, serotonin-norepinephrine reuptake inhibitor antidepressants, memantine, and a cholinesterase inhibitor. High quality evidence supporting these substitutions existed for only memantine and cholinesterase inhibitors, while high quality evidence cautioning against this substitution existed for valproic acid. Activities and music therapy were the most commonly cited non-pharmacologic substitutes but the supporting evidence for each is sparse.

CONCLUSION

Perceptions of LTC clinicians regarding substitutes for antipsychotics in LTC patients with dementia vary widely and are often discordant with published evidence.

Where Are Antipsychotics Prescribed in Nursing Homes Initiated?

OBJECTIVES

To describe the settings of care in which antipsychotics that nursing home (NH) residents received were likely to have been initiated.

DESIGN

Cross-sectional.

SETTING

Iowa NHs.

PARTICIPANTS

Fee-for-service Medicare beneficiaries who had NH stays between January 1, 2011, and December 31, 2014, and had new use of antipsychotics during their NH stays, defined as no antipsychotic use in NHs in the last 6 months.

MEASUREMENTS

A linked dataset of Chronic Condition Data Warehouse Medicare claims and Long-Term Care Minimum Data Set (MDS) 3.0 was used to determine care settings of antipsychotic initiations.

RESULTS

Of 7,496 residents with new antipsychotic use in NHs, 4,794 (64.0%, 95% confidence interval (CI) = 62.9-65.0%) initiated them in NHs, 1,392 (18.6%, 95% CI 17.7-19.5%) appeared to have had them initiated in hospitals, and 1,310 (17.5%, 95% CI = 16.6-18.3%) had antipsychotics first dispensed as outpatients. Antipsychotics were commonly prescribed during the early NH stays, and 3,026 (40.4%, 95% CI = 39.3-41.5%) of the entire sample received antipsychotic therapy within the first 7 days after NH admissions. Fifty-eight percent (n = 4,348) of the study residents initiating antipsychotics had potentially appropriate antipsychotic indications according toMDS records.

CONCLUSION

Most residents initiated antipsychotic therapy in NHs, confirming that NH providers are appropriate primary target of interventions to reduce antipsychotic initiation in their residents. However, many antipsychotics were continued from other settings, indicating a need to evaluate the necessity of continued antipsychotic treatment after such transitions of care. J Am Geriatr Soc 66:1082-1088: 2018.

High prevalence of prescription of psychotropic drugs for older patients in a general hospital

BACKGROUND

Many elderly patients receive psychotropic drugs. Treatment with psychotropic agents is associated with serious side effects including an increased risk of falls and fractures. Several psychotropic drugs are considered potentially inappropriate for treatment of the elderly.

METHODS

A retrospective chart review was conducted covering all patients aged ≥ 65 years who were admitted to Evangelisches Krankenhaus Göttingen-Weende between 01/01/2013 and 03/31/2013. Psychotropic drugs reviewed for included benzodiazepines, Z-drugs, antidepressants and neuroleptics, but not drugs for sedation during artificial ventilation or pre-medication before surgery. Potentially inappropriate drugs were identified according to the PRISCUS list. To assess which factors were associated with the administration of psychotropic drugs, univariate and multivariable logistic regression analyses were performed.

RESULTS

The charts of 2130 patients (1231 women) were analyzed. 53.9% of all patients received at least one psychotropic medication (29.5% benzodiazepines, 12.6% Z-drugs, 22.2% antidepressants, 11.9% neuroleptics). The mean number of psychotropic drugs prescribed per patient with at least one prescription was 1.6. Patients treated in the geriatric department most often received antidepressants (45.0%), neuroleptics (20.6%) and Z-drugs (27.5%). Benzodiazepines and Z-drugs were prescribed mostly as medication on demand (77.7% of benzodiazepines, 73.9% of Z-drugs). Surgical patients most frequently received benzodiazepines (37.1%). Nearly one-third of all patients ≥ 65 years was treated with at least one potentially inappropriate psychotropic medication. The mean number of potentially inappropriate psychotropic medications per patient with at least one psychotropic prescription was 0.69. The percentage of patients with potentially inappropriate psychotropic medication was highest in the surgical departments (74.1%). Female gender (adjusted OR 1.36; 95% CI 1.14 to 1.63), stay in the Department of Geriatrics (2.69; 2.01 to 3.60) or the interdisciplinary intensive care unit (1.87; 1.33 to 2.64) and age ≥ 85 years (1.33; 1.10 to 1.60) were associated with psychotropic drug treatment.

CONCLUSIONS

A high percentage of patients aged ≥ 65 years received psychotropic drugs. The chance that a potentially inappropriate psychotropic drug would be administered was highest in the surgical departments. Antidepressants, neuroleptics and Z-drugs were used surprisingly often in geriatric medicine. Educational strategies could reduce the use of psychotropic drugs and the prescription of potentially inappropriate medications.

Halting Antipsychotic Use in Long-Term care (HALT): a single-arm longitudinal study aiming to reduce inappropriate antipsychotic use in long-term care residents with behavioral and psychological symptoms of dementia

BACKGROUND

Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management.

METHODS

LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations.

CONCLUSION

While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Antipsychotic Use in Dementia

Antipsychotics are necessary for many older adults to treat major mental illnesses or reduce distressing psychiatric symptoms. Current controversy exists over the role of antipsychotics in the management of neuropsychiatric symptoms (NPS) in persons with dementia. Although some NPS may be appropriately and safely treated with antipsychotics, a fine balance must be achieved between the benefits of these medications, which are often modest, and adverse events, which may have significant consequences. Approximately one-third of all persons with dementia are currently prescribed antipsychotic medications, and there is significant variation in the use of antipsychotics across care settings and providers. Reducing the inappropriate or unnecessary use of antipsychotics among persons with dementia has been the focus of increasing attention owing to better awareness of the potential problems associated with these medications. Several approaches can be used to curb the use of antipsychotics among persons with dementia, including policy or regulatory changes, public reporting, and educational outreach. Recently, there has been encouraging evidence of a downward trend in the use of antipsychotics in many long-term care settings, although prescribing rates are still higher than what is likely optimal. Although reducing the inappropriate use of antipsychotics is a complex task, psychiatrists can play an important role via the provision of clinical care and research evidence, contributing to improved care of persons with dementia in Canada and elsewhere.

Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review

BACKGROUND

The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use.

METHODS

We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic.

RESULTS

Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality.

CONCLUSIONS

Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement.

Informed Family Member Involvement to Improve the Quality of Dementia Care in Nursing Homes

OBJECTIVES

To describe the extent to which nursing homes engaged families in antipsychotic initiation decisions in the year before surveyor guidance revisions were implemented.

DESIGN

Mixed-methods study based on semistructured interviews.

SETTING

U.S. nursing homes (N = 20) from five CMS regions (III, IV, VI, VIII, IX).

PARTICIPANTS

Family members of nursing home residents (N = 41).

MEASUREMENTS

Family member responses to closed- and open-ended questions regarding involvement in resident care and antipsychotic initiation. Two researchers used a content analytical approach to code open responses to themes of family involvement in behavior management, decision-making, knowledge of risks and benefits, and informed consent.

RESULTS

Fifty-four percent of family members felt highly involved in decisions about behavior management. Forty-two percent recalled being asked how to manage resident behavior without medication, and 17% recalled receipt of information about antipsychotic risks and benefits. Sixty-six percent felt highly involved in the process of initiating antipsychotic medication; 24% reported being asked for input into the antipsychotic initiation decision and knowing before the antipsychotic was started.

CONCLUSION

Under existing federal regulations but before guidance revisions were implemented in 2013, more than 40% of families reported being involved in nonpharmacological behavior management of family members, but fewer than one in four reported being involved throughout the entire antipsychotic prescribing process. Interventions that standardize family engagement and promote adherence to existing federal regulations are needed. This discussion builds on these findings to weigh the policy options of greater enforcement of existing regulations versus enactment of new legislation to address this challenging issue.

Trends, correlates, and disease patterns of antipsychotic use among elderly persons in Taiwan

INTRODUCTION

We used the population-based database to investigate the trends, correlates, and disease patterns of antipsychotic use among elderly people in Taiwan.

METHODS

The National Health Research Institutes provided a database of 1,000,000 random subjects for health service studies. We analyzed a sample of subjects over the age of 65 years from 1997 to 2005. The trends in and factors associated with antipsychotic use were detected. We also examined the proportions of antipsychotics used for psychiatric and medical disorders.

RESULTS

The 1-year prevalence of antipsychotic use in elderly persons increased from 9.8% in 1997 to 12.8% in 2005. The prevalence of first-generation antipsychotic (FGA) use increased from 9.8% to 11.6%, and the prevalence of second-generation antipsychotic (SGA) use increased greatly from 0.01% to 2.02%. Higher prevalence of both FGAs and SGAs were associated with age and higher Charlson Comorbidity Index scores. Psychiatric disorders were commonly found in SGA users (80.8%), whereas only 19.3% of the FGA users had psychiatric disorders. Among the major psychiatric disorders, greater proportions of antipsychotic use were for senile and presenile organic psychotic conditions, other organic psychotic conditions, and affective psychoses. FGAs were much more commonly prescribed for nonpsychiatric disorders, including diseases of symptoms, signs, and ill-defined conditions, the digestive system, and the respiratory system.

DISCUSSION

The prevalence of antipsychotic use, particularly the use of SGAs, increased greatly from 1997 to 2005 among elderly persons in Taiwan. SGAs were most used by subjects with psychiatric disorders, and FGAs were most used by those with nonpsychiatric disorders.

System struggles and substitutes: A qualitative study of general practitioner and psychiatrist experiences of prescribing antipsychotics to children and adolescents

There are significant controversies regarding rising antipsychotic prescription trends in children and adolescents. Many pharmacoepidemiology trend studies have been published, and interpretations of these data are helpful in explaining what is happening in prescribing practices, but not why these patterns exist. There is a lack of qualitative data in this area, and the experience of prescribing antipsychotics to children and adolescents has not been adequately researched. We conducted a qualitative study using an interpretive phenomenological analysis of physicians' experiences of antipsychotic prescribing to children and adolescents. Prescribers participated in individual interviews and a focus group. We used a staged approach for data analysis of transcriptions. In all, 11 physicians including psychiatrists and general practitioners participated in our study. We identified themes related to context, role and identity, and decision-making and filtering Struggles with health system gaps were significant leading to the use of antipsychotics as substitutes for other treatments. Physicians prescribed antipsychotics to youth for a range of indications and had significant concerns regarding adverse effects. Our results provide knowledge regarding the prescribers' experience of antipsychotics for children and adolescents. Important gaps exist within the health system that are creating opportunities for the initiation and continued use of these agents.

Treatment patterns and characteristics of older antipsychotic users in Germany

The aim of this study was to investigate the characteristics and treatment patterns of older antipsychotic (AP) users in Germany. We carried out a cohort study in the German Pharmacoepidemiological Research Database and identified new AP users aged at least 65 years between 2005 and 2011. Possible indications, comedication, and information on persistence and adherence, concurrent multiple use, and switch of APs were assessed. Overall, 298,847 individuals were included in the cohort. Almost 70% entered the cohort with a typical antipsychotic (TAP). Melperone (23.4%) was used most frequently, followed by promethazine (18.3%), sulpiride (11.0%), and risperidone (10.3%). AP users had a low prevalence of schizophrenia and bipolar disorders in contrast to dementia. Initiators of atypical antipsychotics had more treatment episodes compared with TAPs (median 3 vs. 2), but lower median persistence (14 vs. 22 days). Persistence was also lower in patients with, rather than without, dementia. The overall percentage of concurrent multiple use and switch to other APs was low with 5.6%, but higher in patients with, rather than without, dementia. In conclusion, APs were used for a broad range of indications, mostly other than schizophrenia and bipolar disorders. Low persistence and a high number of treatment episodes suggest frequent 'as-needed' treatment, especially in dementia patients.

Antipsychotic Drug Use Is Not Associated With Long-Term Mortality Risk in Norwegian Nursing Home Patients

OBJECTIVES

To assess the long-term mortality risk associated with antipsychotic drug (AP) use in nursing homes.

DESIGN

A longitudinal study with 5 assessments over a 75-month follow-up period.

SETTING

A representative sample of nursing home patients in 4 Norwegian counties.

PARTICIPANTS

At baseline, 1163 patients were included. At the last follow-up, 98 patients were still alive.

MEASUREMENTS

Prevalent drug use at each assessment was registered. Level of dementia, neuropsychiatric symptoms, level of functioning, medical health, and use of restraints were recorded at each assessment. A Cox regression model with time-dependent psychotropic drug use as the main predictor was estimated and adjusted for confounders.

RESULTS

In unadjusted Cox regression, a lower mortality risk was associated with the use of other psychotropic drugs, but not APs, compared with nonusers. In the adjusted analysis, neither use of APs nor other psychiatric drugs was associated with increased mortality risk. Higher age, male gender, not being married, medical disease burden, lower level of functioning, more severe degree of dementia, and a higher number of drugs were all associated with increased mortality risk.

CONCLUSION

In this long-term study of nursing home patients, AP drug use was not associated with increased risk of mortality. This is in line with results from earlier studies of clinical samples, but contrasts with results from randomized controlled trials and registry-based studies. The findings should be interpreted with caution. Taking into account the modest benefit and high risk of adverse effects of AP drug use, nonpharmacological treatment remains the first-line treatment approach.

Approaches to Gradual Dose Reduction of Chronic Off-Label Antipsychotics Used for Behavioral and Psychological Symptoms of Dementia

OBJECTIVE

Little is known about how to best taper antipsychotics used in patients with dementia. To address this gap, we reviewed published antipsychotic discontinuation trials to summarize what is known about tapering strategies for antipsychotics used with older adults with dementia. We further developed pharmacokinetic-based gradual dose reduction (GDR) protocols based on antipsychotic half-lives.

DATA SOURCES

MEDLINE, EMBASE, and International Pharmaceutical Abstracts were searched up to October 2014 to identify intervention studies reporting the behavioral and psychological symptoms of dementia outcomes resulting from discontinued off-label use of antipsychotics in nursing facility populations. Recently published pharmacokinetic reviews and standard pharmacology texts were used to determine antipsychotic drug half-lives for the pharmacokinetic-based GDR protocols.

STUDY SELECTION

For the review, studies with an intervention resulting in antipsychotic medication discontinuation or tapering were eligible, including randomized controlled trials and pre- and post-intervention studies.

DATA EXTRACTION

When available, we extracted the protocols used for antipsychotic GDR from each study included in the review.

DATA SYNTHESIS

We found that clinical trials used different approaches to antipsychotic discontinuation, including abrupt discontinuation, slow tapers (more than two weeks), and mixed strategies based on drug dosage. None of the published trials described an approach based on pharmacokinetic principles. We developed a two-stage GDR protocol for tapering antipsychotic medications based on the log dose-response relationship; each stage was designed to result in a 50% dose reduction prior to discontinuation. This pharmacologically based strategy for patients chronically prescribed antipsychotics resulted in recommendations for slow tapers.

CONCLUSION

Our theoretically derived GDR recommendations suggest a different approach than previously published in clinical trials. Further study is needed to evaluate the effect of this approach on patients.

A Review Exploring the Relationship Between Nursing Home Staffing and Antipsychotic Medication Use

Staffing level requirements for nursing homes exist at state and federal levels in the United States. While quality of care measures may include antipsychotic (AP) prescribing, the appropriate use of APs as chemical restraints in nursing homes continues to be debated. Although the two variables appear to be related, improved research methods and availability of accurate staffing data will be needed to understand causal relationships regarding AP use for facility dwelling patients.

Improving antipsychotic prescribing practices in nursing facilities: The role of surveyor methods and surveying agencies in upholding the Nursing Home Reform Act

BACKGROUND

Inappropriate prescribing of antipsychotics is a longstanding challenge to providing high quality care in nursing facilities. The 1987 Nursing Home Reform Act (NHRA) had an initial impact in reducing inappropriate prescribing, but rates returned to pre-NHRA levels. While the recent Partnership to Improve Dementia Care in Nursing Homes (Partnership) initiative has been successful in reducing the prescribing of antipsychotics in skilled nursing facilities/nursing facilities (NF), it is not known how this guidance initiative impacted prescribing practices and other care processes concerning NF residents with dementia.

OBJECTIVES

The objectives of this study were to explore surveyor observations of NF care practices subsequent to participation the Partnership guidance program and to use a social ecological framework to estimate how these observations were influenced by individual, organizational, and contextual factors.

METHODS

A total of 320 NF surveyors responded to a 49-item questionnaire designed in collaboration with CMS officials and state surveying agency personnel, and distributed by state agency directors. Three outcome variables: measuring improvements in clinical care, deficiencies in clinical care, and falsification of records in response to the Partnership initiative, were created from survey responses. A four-level social ecological framework describing the NF surveyor's environment was used to identify potential influences on surveyors' care observations. Logistic regression was used to evaluate the relationship between environment and outcome variables.

RESULTS

Surveyors observed both improvements in clinical care, including 80.6% reporting nursing facility providers responding to consultant pharmacists' recommendations, and deficits in clinical care in response to the Partnership initiative. Furthermore, 39.7% of surveyors observed a new, but false, diagnosis of psychosis (as defined by the surveyor). Surveyor characteristics and methods and surveying agency and culture were found to substantially impact the success of the Partnership initiative. The most distal level of the framework evaluated in this study, state contextual effects, was found not to impact care observations.

CONCLUSIONS

There is substantial variation in surveyor observations of changes to clinical care in response to the Partnership guidance initiative. Further investigation is needed into the type and severity of falsification of records observed by nursing facility surveyors. When constructing interventions to care for residents in NFs, policymakers must consider the environment in which surveyors operate.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing

OBJECTIVES

To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN

Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING

Forty-one NHs in Connecticut.

PARTICIPANTS

NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS

Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing.

RESULTS

Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader.

CONCLUSION

NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear.

Policies to protect persons with dementia in assisted living: déjà vu all over again?

Continued growth in the number of individuals with dementia residing in assisted living (AL) raises concerns about their safety and protection. In this Forum, we review current AL practices relevant to residents with dementia and present a rationale for examining the government role in protecting these individuals within this context. Since public oversight of AL is currently a state prerogative, we assess states' regulatory activity across 3 domains closely related to safety and protection of persons with dementia: environmental features, staffing, and use of chemical restraints. We then step back to consider the state policymaking environment and assess the feasibility of developing a minimum standard of regulations from one state to the next. This Forum concludes with a historical comparison between the contemporary AL market and the nursing home care market prior to the Nursing Home Reform Act of 1987, and we discuss how an increased amount of federal interest could improve existing state efforts to protect persons with dementia residing in AL.

Use of medications of questionable benefit in advanced dementia

IMPORTANCE

Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.

OBJECTIVES

To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.

MAIN OUTCOMES AND MEASURES

Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.

RESULTS

Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.

CONCLUSIONS AND RELEVANCE

Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.

Emergency department visits by adults for psychiatric medication adverse events

IMPORTANCE

In 2011, an estimated 26.8 million US adults used prescription medications for mental illness.

OBJECTIVE

To estimate the numbers and rates of adverse drug event (ADE) emergency department (ED) visits involving psychiatric medications among US adults between January 1, 2009, and December 31, 2011.

DESIGN AND SETTING

Descriptive analyses of active, nationally representative surveillance of ADE ED visits using the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance system and of drug prescribing during outpatient visits using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.

PARTICIPANTS

Medical records from national probability samples of ED and outpatient visits by adults 19 years or older were reviewed and analyzed.

EXPOSURES

Antidepressants, antipsychotics, lithium salts, sedatives and anxiolytics, and stimulants.

MAIN OUTCOMES AND MEASURES

National estimates of ADE ED visits resulting from therapeutic psychiatric medication use and of psychiatric medication ADE ED visits per 10,000 outpatient visits at which psychiatric medications were prescribed.

RESULTS

From 2009 through 2011, there were an estimated 89,094 (95% CI, 68,641-109,548) psychiatric medication ADE ED visits annually, with 19.3% (95% CI, 16.3%-22.2%) resulting in hospitalization and 49.4% (95% CI, 46.5%-52.4%) involving patients aged 19 to 44 years. Sedatives and anxiolytics, antidepressants, antipsychotics, lithium salts, and stimulants were implicated in an estimated 30,707 (95% CI, 23,406-38,008), 25,377 (95% CI, 19,051-31,704), 21,578 (95% CI, 16,599-26,557), 3620 (95% CI, 2311-4928), and 2779 (95% CI, 1764-3794) respective ADE ED visits annually. Antipsychotics and lithium salts were implicated in 11.7 (95% CI, 10.1-13.2) and 16.4 (95% CI, 13.0-19.9) ADE ED visits per 10,000 outpatient prescription visits, respectively, compared with 3.6 (95% CI, 3.2-4.1) for sedatives and anxiolytics, 2.9 (95% CI, 2.3-3.5) for stimulants, and 2.4 (95% CI, 2.1-2.7) for antidepressants. The commonly used sedative zolpidem tartrate was implicated in 11.5% (95% CI, 9.5%-13.4%) of all adult psychiatric medication ADE ED visits and in 21.0% (95% CI, 16.3%-25.7%) of visits involving adults 65 years or older, in both cases significantly more than any other psychiatric medication.

CONCLUSIONS AND RELEVANCE

Psychiatric medications are implicated in many ADEs treated in US EDs. Efforts to reduce ADEs should include adults of all ages but might prioritize medications causing high numbers and rates of ED visits.

Associated factors with antipsychotic use in long-term institutional care in eight European countries: Results from the RightTimePlaceCare study

OBJECTIVES

To determine factors associated with the antipsychotic (AP) prescription for people with dementia (PwD) recently admitted to institutional long-term care facilities (LTCFs) and to ascertain differences in the use of this medication in 8 European countries.

DESIGN

An exploratory cross-sectional study.

SETTING

LTCFs from 8 European countries (Estonia, Finland, France, Germany, The Netherlands, Spain, Sweden, and England).

PARTICIPANTS

A total of 791 PwD recently admitted to an LTCF and their caregivers.

MEASUREMENTS

Baseline data from RightTimePlaceCare survey was used. Patients' medical conditions, neuropsychiatric symptoms, physical and cognitive status, and medications were recorded. Multiple logistic regression models were used to assess associations with the AP use.

RESULTS

A group of 296 patients (37.4%) of 791 patients recently admitted received AP medication. The prevalence of the use of 1 or more APs varied between study countries, ranging from 12% in Sweden to 54% in Spain. Factors independently associated with the AP use were living in Sweden [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.05-0.30], Finland (OR 0.26, 95% CI 0.14-0.48), Germany (OR 2.75, 95% CI 1.55-4.86) and Estonia (OR 6.79, 95% CI 3.84-12.0). The odds of AP use decreased with the presence of a dementia specific unit in the LTCF (OR 0.60, 95% CI 0.39-0.92), but was higher among residents with a hyperactivity behavior (OR 2.12, 95% CI 1.41-3.18).

CONCLUSION

The current study shows that more than one-third of the residents recently admitted received APs and that prescription frequency across countries varied significantly. This study raises the possibility that the presence of a dementia-specific unit might play a role in the AP use. Further studies should investigate this association and seek better understanding of what will achieve optimal quality of AP use among newly admitted residents in LTCF.

The effects of public reporting on physical restraints and antipsychotic use in nursing home residents with severe cognitive impairment

OBJECTIVES

To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment.

DESIGN

Retrospective analysis of NH clinical assessment data from 1999 to 2008 comparing NHs subject to public reporting of physical restraints with nonreporting NHs.

SETTING

Medicare- and Medicaid-certified NHs in the United States.

PARTICIPANTS

Observations (N = 3.9 million) on 809,645 residents with severe cognitive impairment in 4,258 NHs in six states.

INTERVENTION

Public reporting of physical restraint use rates.

MEASUREMENTS

Use of physical restraints and antipsychotic medications.

RESULTS

Physical restraint use declined significantly from 1999 to 2008 in NH residents with severe cognitive impairment. The decline was larger in NHs that were subject to reporting of restraints than in those that were not (-8.3 vs -3.3 percentage points, P < .001). Correspondingly, antipsychotic use in the same residents increased more in NHs that were subject to public reporting (4.5 vs 2.9 percentage points, P < .001). Approximately 36% of the increase in antipsychotic use may be attributable to public reporting of physical restraints.

CONCLUSION

This analysis suggests that public reporting of physical restraint use had the unintended consequence of increasing use of antipsychotics in NH residents with severe cognitive impairment.

Psychotropic and Cognitive-Enhancing Medication Use and Its Documentation in Contemporary Long-term Care Practice

Background: In long-term care (LTC) settings, use of psychotropic medications to manage behavioral and psychological symptoms of dementia and use of cognitive enhancers are commonplace. It is important that these medications are properly used to ensure resident well-being, and thus, it is paramount to understand use of these medications in contemporary practice to develop appropriate quality improvement initiatives. Objective: To characterize psychotropic and cognition-enhancing medication use LTC residents and current trends in documentation. Methods: Cross-sectional chart review of residents aged >65 years with dementia receiving psychotropic medications and/or cognitive enhancers. Results: From 180 residents, 84 (82% female) met inclusion criteria (average age 86 years). The prevalence of psychotropic medication use was as follows: cognitive enhancers, 71%; antidepressants, 98%; antipsychotics, 61%; sedative hypnotics, 23%. Quetiapine was the most commonly used antipsychotic (48%), followed by risperidone (28%) and olanzapine (15%), all of which were dosed within accepted guidelines. The duration of therapy ranged from 2 to 5 years for antipsychotic medications and 1¼ to 3 years for antidepressants. Documentation documentation rates were hightest for psychotropics versus cognitive enhancers. There was no documentation of attempts to lower doses or discontinue psychotropic medications or cognitive enhancers. Conclusions: Many, but not all psychotropics used were acceptable choices. The duration of therapy appears to be excessive for antipsychotic medications. Documentation of ongoing need for medications varied and could be improved on to better assess residents’ medication regimens. Further research will inform efforts to enhance the care of these residents.