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

Abstract

BackgroundThe 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.MethodsWe 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.ResultsNineteen 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.ConclusionsVariation 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-017-0428-1) contains supplementary material, which is available to authorized users.

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

“…The proportion of residents receiving inappropriate antipsychotics increased steadily until 2005, when the rates of residents receiving antipsychotics then began to decrease. This drop in the rate of inappropriate use is most likely a reflection of the FDA's black box warning issued in 2005, indicating the risk for increased mortality for so‐called off‐label use of antipsychotics . Additionally, between 2012 and 2013 we saw another sharp decrease in the rate of antipsychotics, most likely due to the CMS National Partnership to lower the use of antipsychotics and improve the care provided to dementia residents .…”

“…This drop in the rate of inappropriate use is most likely a reflection of the FDA's black box warning issued in 2005, indicating the risk for increased mortality for so‐called off‐label use of antipsychotics . Additionally, between 2012 and 2013 we saw another sharp decrease in the rate of antipsychotics, most likely due to the CMS National Partnership to lower the use of antipsychotics and improve the care provided to dementia residents . As a part of this National Partnership, CMS also added two quality measures to the NH Compare website focused on antipsychotic use in NH long‐stay residents .…”

“…Research suggests that in recent years, inappropriate antipsychotic use decreased from 24% in 2011 to 20% in 2013 . Nevertheless, reports show that the inappropriate use of antipsychotics in NHs, especially for residents with dementia, continues to be a widespread problem …”

“Tho’ much is taken, much abides”: A Good Life within Dementia

“…Interestingly, pharmaceutical interventions to decrease anxiety, agitation, and problematic behaviors come increasingly under fire for providing more risk than benefit. Using antipsychotic medications is particularly risky for people with dementia, with serious side effects including delirium, falls, broken hips, hospitalization, and death . Although nonpharmacological approaches were once seen as less scientific, solid data now support their use as the best first intervention to calm agitation and promote a sense of well‐being.…”

Elucidating the Mechanism(s) Underlying Antipsychotic- and Antidepressant-Mediated Fractures

“…Antipsychotic medications, originally designed and FDA-approved for the treatment of psychosis associated with schizophrenia and bipolar disorder, are increasingly prescribed off-label for diverse indications, often in vulnerable populations including children and the elderly. Because of the increasing rate of off-label prescribing, these are some of the most highly prescribed drugs, world-wide, resulting in a very large patient population exposed to these powerful psychiatric medications [1][2] . Second generation or atypical antipsychotics (AA) are known to cause endocrine and metabolic side effects including rapid onset obesity, dyslipidemia and diabetes.…”