Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition

Fashaw, Shekinah; Chisholm, Latarsha; Mor, Vincent; Meyers, David J.; Liu, Xinliang; Gammonley, Denise; Thomas, Kali S.

doi:10.1111/jgs.16316

Cited by 23 publications

(12 citation statements)

References 28 publications

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“…We found that valproic acid and antipsychotics were more likely to be prescribed to residents with ADRD and disruptive behaviors, while gabapentin and opioids were more likely to be prescribed to residents with ADRD and reported pain. While our study's focus was on the relationship between clinical symptoms and prescribing outcomes, we further demonstrated the important role that demographics, including age, gender, and race/ethnicity, play in prescribing 20 …”

Section: Discussionmentioning

confidence: 86%

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

Candon

Strominger

Gerlach

et al. 2022

J American Geriatrics Society

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Background Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications. Methods Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long‐term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain. Results Our study sample includes 973,074 persons living with ADRD who had a long‐term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain. Conclusions Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny.

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Section: Discussionmentioning

confidence: 86%

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

Candon

Strominger

Gerlach

et al. 2022

J American Geriatrics Society

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“…To date, studies evaluating disparities in inappropriate long-stay drug utilization are rare and results are mixed. Some inquiries have suggested that facilities with higher rates of African American residents were more likely to use risky psychoactive medications, and that African Americans were more likely to be prescribed such drugs, while others have not (Fashaw et al, 2020; Miller et al, 2006). Teasing out confounding facility and community factors may be part of the challenge as there is literature suggesting minorities may be more likely to be residing in long-stay facilities with lower incomes, fewer resources, decreased staffing, and lower scores for quality of care, all of which are qualities thought to be associated with higher rates of inappropriate psychoactive use (Feng et al, 2011; Mor et al, 2004; Rivera-Hernandez et al, 2019).…”

Section: Discussionmentioning

confidence: 99%

Long-Stay Mood Stabilizer Use Increasing as Prescription of Antipsychotics Decreases

et al. 2023

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Abstract. This retrospective cohort analysis of claims data used logistic regression to evaluate change in antipsychotic and antiepileptic mood stabilizer prescription frequencies in Virginia nursing homes among residents with and without seizure-epilepsy between the years 2011 and 2016. Over that period, prescription of antipsychotics decreased 13.1% to 5.6% in the long-stay population, while the use of antiepileptic mood stabilizers increased significantly 27.0%, to an 8.6% prevalence rate. These gains were entirely among residents without epilepsy. African-Americans and males were at significantly increased risk for the prescription of mood stabilizers. Growth in long-stay antiepileptic mood stabilizer use is unrelated to seizure-epilepsy, as these changes in prescription occurred only among residents without seizure-epilepsy. More antiepileptic mood stabilizers are now being prescribed to nursing-home residents without epilepsy than antipsychotics in the nursing-home population overall.

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“…15 Several studies also report an increase in the prevalence of exempted diagnoses, especially schizophrenia. 3,12,[15][16][17] Recently, the Office of the Inspector General (OIG) questioned the accuracy of schizophrenia diagnoses in nursing homes, noting an uptick in newly-admitted schizophrenia cases among residents without prior history. 18 As well, the rationale for omitting bipolar, psychosis, Parkinson's disease, and other conditions from exempt status remains unclear, as antipsychotics are Food and Drug Administration (FDA)-approved and/or widely accepted as significant adjuvants for optimal disease management for these conditions.…”

Section: Why Does This Paper Matter?mentioning

confidence: 99%

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease

Wastila

Qato

Fleming

et al. 2023

J American Geriatrics Society

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Background In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long‐stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. Methods Using an 80% sample of fee‐for‐service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time‐series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011–June 30, 2012) and after (July 1, 2012–September 30, 2015) ARI implementation. Results We identified 874,487 long‐stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI‐associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI‐associated increases in non‐benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post‐ARI membership in the psychosis and Parkinson's cohorts. Conclusions Our study documents antipsychotic use significantly declined in non‐ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI‐associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make‐up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

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Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition

Cited by 23 publications

References 28 publications

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

Long-Stay Mood Stabilizer Use Increasing as Prescription of Antipsychotics Decreases

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease

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