Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes

• Published in: The American journal of psychiatry 2022-08, Vol.179 (8), p.544-552
• Main Authors: Gerlach, Lauren B., Maust, Donovan T., Kales, Helen C., Chang, Myron, Kim, H. Myra, Wiechers, Ilse R., Zivin, Kara
• Format: Article
• Language: English
• Subjects: Aged; Analgesics, Opioid - therapeutic use; Anti-Anxiety Agents - therapeutic use; Anticonvulsants - therapeutic use; Antidepressive Agents - therapeutic use; Antipsychotic Agents - therapeutic use; Antipsychotics; Dementia; Dementia - drug therapy; Humans; Medicare; Nursing Homes; Prescription drugs; Psychotropic Drugs - therapeutic use; United States; Veterans; Veterans Health
• ISSN: 0002-953X; 1535-7228
• DOI: 10.1176/appi.ajp.21060591

Objective:The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA.Methods:The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018.Results:Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%.Conclusions:Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.