Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review (original) (raw)
Related papers
Unexplained Variation Across US Nursing Homes in Antipsychotic Prescribing Rates
Archives of Internal Medicine, 2010
Background: Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. We assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing.
International Journal of Geriatric Psychiatry, 2010
The use of antipsychotics to treat people with behavioural and psychological symptoms associated with dementia is controversial, especially in long-stay settings. We assessed the relationship between behaviour, function and antipsychotic use in people with dementia in a long-stay psychiatric unit and designated elderly mentally ill (EMI) nursing homes over a 15-year period. Method: Sequential cross-sectional studies assessing twelve behaviours and seven measures of function for each patient. Antipsychotic and antidepressant use was obtained from current prescription records. Results: Regular antipsychotic use in hospital fell between 1990 and 1998. In 1998 use in nursing homes was significantly greater than in hospital, and increased between 1998 and 2005. Noisiness/verbal aggression (NVA) was the only behaviour more commonly associated with regular antipsychotic use over that timescale. Those with low levels of core symptoms (p ¼ 0.021) and high dependency patients (p ¼ 0.001) were more likely to be receiving regular antipsychotics in nursing homes than in hospital. Depression was not treated well even when identified. Conclusion: Compared to a long-stay hospital setting, antipsychotic drug use for people with dementia in nursing homes has risen and become less systematic. This cannot be explained by increasing core behaviour symptoms or differences in physical dependency.
Impact of programs to reduce antipsychotic and anticholinergic use in nursing homes
Alzheimer's & Dementia: Translational Research & Clinical Interventions, 2017
Introduction: Antipsychotics are used for managing behavioral and psychological symptoms of dementia (BPSD) but have risks. Anticholinergics can worsen outcomes in dementia. The Improving Antipsychotic Appropriateness in Dementia Patients educational program (IA-ADAPT) and Centers for Medicare and Medicaid Services Partnership to Improve Dementia Care (CMS Partnership) promote improved care for BPSD. The purpose of this study was to evaluate the impact of these programs on medication use and BPSD among nursing home residents. Methods: This quasi-experimental longitudinal study used Medicare and assessment data for Iowa nursing home residents from April 2011 to December 2012. Residents were required to be eligible for six continuous months for inclusion. Antipsychotic use and anticholinergic use were evaluated on a monthly basis, and changes in BPSD were tracked using assessment data. Results are presented as odds ratios (ORs) per month after exposure to the IA-ADAPT or the start of the CMS Partnership. Results: Of 426 eligible Iowa nursing homes, 114 were exposed to the IA-ADAPT in 2012. Nursing home exposure to the IA-ADAPT was associated with reduced antipsychotic use (OR [95% CI] 5 0.92 [0.89-0.95]) and anticholinergic use (OR [95% CI] 5 0.95 [0.92-0.98]), reduced use of excessive antipsychotic doses per CMS guidance (OR [95% CI] 5 0.80 [0.75-0.86]), increased odds of a potentially appropriate indication among antipsychotic users (OR [95% CI] 5 1.04 [1.00-1.09]), and decreased documentation of verbal aggression (OR [95% CI] 5 0.96 [0.94-0.99]). Facilities with two or more IA-ADAPT exposures had greater reductions in antipsychotic and anticholinergic use than those with only one. The CMS Partnership was associated with reduced antipsychotic use (OR [95% CI] 5 0.96 [0.94-0.98]) and decreased documentation of any measured BPSD (OR [95% CI] 5 0.98 [0.97-0.99]) as well as delirium specifically (OR [95% CI] 5 0.98 [0.96-0.99]). Discussion: This study suggests that the IA-ADAPT and the CMS Partnership improved medication use with no adverse impact on BPSD.
2014
Background: Antipsychotic medications are commonly used to manage the behavioral and psychological symptoms of dementia. Several large studies have demonstrated an association between treatment with antipsychotics and increased morbidity and mortality in people with dementia. Aims: To assess the effectiveness of interventions used to reduce inappropriate prescribing of antipsychotics to the elderly with dementia in residential care. Method: Systematic searches were conducted in 12 electronic databases. Reference lists of all included studies and forward citation searching using Web of Science were also conducted. All quantitative studies with a comparative research design and studies in which recognized methods of qualitative data collection were used were included. Articles were screened for inclusion independently by 2 reviewers. Data extraction and quality appraisal were performed by 1 reviewer and checked by a second with discrepancies resolved by discussion with a third if necessary. Results: Twenty-two quantitative studies (reported in 23 articles) were included evaluating the effectiveness of educational programs (n ¼ 11), in-reach services (n ¼ 2), medication review (n ¼ 4), and multicomponent interventions (n ¼ 5). No qualitative studies meeting our inclusion criteria were identified. Eleven studies were randomized or controlled in design; the remainder were uncontrolled before and after studies. Beneficial effects were seen in 9 of the 11 studies with the most robust study design with reductions in antipsychotic prescribing levels of between 12% and 20%. Little empirical information was provided on the sustainability of interventions. Conclusion: Interventions to reduce inappropriate prescribing of antipsychotic medications to people with dementia resident in care homes may be effective in the short term, but longer more robust studies are needed. For prescribing levels to be reduced in the long term, the culture and nature of care settings and the availability and feasibility of nondrug alternatives needs to be addressed.
Variability between nursing homes in prevalence of antipsychotic use in patients with dementia
International Psychogeriatrics, 2013
ABSTRACTBackground:Antipsychotic drugs (APD) are widely prescribed for people with dementia residing in long term care facilities (LTCFs). Concern has been expressed that such prescribing is largely inappropriate. The objective of this study is to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics.Methods:A point prevalence study was conducted using data from the VU University Resident Assessment Instrument (VURAI) database from nursing homes and residential care facilities in the Netherlands. Patients were selected who had a diagnosis of dementia. LTCF and patient characteristics were extracted from the VURAI; facility-level resident satisfaction surveys were provided by the National Institute for Public Health.Results:In total, 20 LTCFs providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. In facilities with...
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2010
To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey. Cross-sectional analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication. More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication wer...
Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes
Aging & Mental Health, 2014
Objectives: Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use. Method: A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions. Results: Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement. Discussion: Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement.
The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2009
Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. Retrospective analysis using sequential multivariate Cox proportional hazards models. Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. A total of 2,363 LTC Medicare beneficiaries, 1999-2002. Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. AP use rose markedly from 1999 to 2002 (26.4%-35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors,...
International Journal of Geriatric Psychiatry, 2018
Objectives: To assess factors related to antipsychotic (AP) use in skilled nursing facilities for newly admitted residents aged 18 to 49, 50 to 64, 65 to 84, and 85 years or older. Methods: Retrospective, population-level, Minimum Data Set (MDS) 2.0 data from the United States during the year of 2009 were used. Over 1 million residents were included. Fourteen clinically relevant variables were identified through a literature search. Antipsychotic use was defined as APs dispensed daily for the prior 7 days. Logistic regression was used to identify clinically relevant variables, which were then ranked based on magnitude of their association with APs. Results: Bipolar disorder and schizophrenia were consistently related to AP use across age groups. For older age groups, off-label indications such as cognitive impairment, dementia, behavioral symptoms, and physical restraint use were more closely related to AP use, while delusions and hallucinations decreased in strength. Higher proportions of APs were found in all diseases and symptoms in nonelderly adults, with the exception of physical restraint use. Concurrent physical restraint and AP use was highest for older adults aged 65 to 84 at 36%. Conclusions: Correlates of AP use varied by age, with stronger associations between on-label conditions and AP use among younger adults and off-label conditions among older adults. Several less conventional determinants, namely, Parkinson disease, traumatic brain injury, and the use of physical restraints were identified to increase the likelihood of AP use. This study highlights the importance of monitoring for adverse effects for residents of all ages.