Antipsychotic Use in Nursing Home Residents With Dementia
Objectives To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs).
Design Qualitative, descriptive study.
Setting Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions.
Participants Individuals diagnosed with dementia who received an antipsychotic medication.
Measurements Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources.
Results Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited.
Conclusion The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.
Antipsychotic medications have serious risks, including the risk of premature death when used in older adults with dementia living in nursing homes (NHs). Despite studies highlighting the potential for serious side effects and a lack of efficacy in this population, antipsychotic use in nursing homes remains high. Data from the 2004 National Nursing Home Survey (NNHS) revealed that 32.9% of NH residents with dementia received at least one antipsychotic medication. More-recent data from the Centers for Medicare and Medicaid Services (CMS) indicate that similar patterns persist; in 2011, 23.9% of all long-stay NH residents received at least one antipsychotic medication.
A variety of resident, facility, corporate, and state regulatory factors may influence antipsychotic use, as well as other aspects of care of residents with behavioral and psychological symptoms of dementia (BPSD). Studies have identified substantial variation in prescribing rates across states and regions and have raised concerns about the appropriateness of prescribing in NHs. A 2005 study using national data revealed that 27.6% of NH residents received at least one prescription for an antipsychotic medication; 23.4% of those were prescribed an antipsychotic medication without any appropriate clinical indication, and 17.2% had daily doses that exceeded recommended levels. A recent review of deficiency citations for noncompliance with federal regulations related to unnecessary drug use revealed that surveyors often identify a lack of proper documentation in the medical record regarding why these medications are prescribed.
The persistently high and potentially inappropriate use of antipsychotics in NH residents has led to renewed concerns from advocates and others about the basis for prescribing these agents, particularly in people with dementia. Despite a few recent studies that have begun to explore factors influencing antipsychotic use, the reasons why some residents of NHs are prescribed an antipsychotic medication remain unclear.
In 2011, CMS formed the National Partnership to Improve Dementia Care in response to an Office of the Inspector General (OIG) report on atypical antipsychotic use in NHs, as well as concerns from elder advocacy organizations and others. The OIG report referenced Food and Drug Administration (FDA) black box warnings for atypical and conventional antipsychotic medications (issued in 2005 and 2008, respectively). CMS provided limited contract funding for a qualitative study of the use of antipsychotic medications for elderly NH residents with dementia. The current study examined the reasons identified for use of these medications in NH residents with dementia, using medical record review and interviews with NH leadership, direct care staff, consultants, and family members.
Abstract and Introduction
Abstract
Objectives To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs).
Design Qualitative, descriptive study.
Setting Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions.
Participants Individuals diagnosed with dementia who received an antipsychotic medication.
Measurements Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources.
Results Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited.
Conclusion The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy.
Introduction
Antipsychotic medications have serious risks, including the risk of premature death when used in older adults with dementia living in nursing homes (NHs). Despite studies highlighting the potential for serious side effects and a lack of efficacy in this population, antipsychotic use in nursing homes remains high. Data from the 2004 National Nursing Home Survey (NNHS) revealed that 32.9% of NH residents with dementia received at least one antipsychotic medication. More-recent data from the Centers for Medicare and Medicaid Services (CMS) indicate that similar patterns persist; in 2011, 23.9% of all long-stay NH residents received at least one antipsychotic medication.
A variety of resident, facility, corporate, and state regulatory factors may influence antipsychotic use, as well as other aspects of care of residents with behavioral and psychological symptoms of dementia (BPSD). Studies have identified substantial variation in prescribing rates across states and regions and have raised concerns about the appropriateness of prescribing in NHs. A 2005 study using national data revealed that 27.6% of NH residents received at least one prescription for an antipsychotic medication; 23.4% of those were prescribed an antipsychotic medication without any appropriate clinical indication, and 17.2% had daily doses that exceeded recommended levels. A recent review of deficiency citations for noncompliance with federal regulations related to unnecessary drug use revealed that surveyors often identify a lack of proper documentation in the medical record regarding why these medications are prescribed.
The persistently high and potentially inappropriate use of antipsychotics in NH residents has led to renewed concerns from advocates and others about the basis for prescribing these agents, particularly in people with dementia. Despite a few recent studies that have begun to explore factors influencing antipsychotic use, the reasons why some residents of NHs are prescribed an antipsychotic medication remain unclear.
In 2011, CMS formed the National Partnership to Improve Dementia Care in response to an Office of the Inspector General (OIG) report on atypical antipsychotic use in NHs, as well as concerns from elder advocacy organizations and others. The OIG report referenced Food and Drug Administration (FDA) black box warnings for atypical and conventional antipsychotic medications (issued in 2005 and 2008, respectively). CMS provided limited contract funding for a qualitative study of the use of antipsychotic medications for elderly NH residents with dementia. The current study examined the reasons identified for use of these medications in NH residents with dementia, using medical record review and interviews with NH leadership, direct care staff, consultants, and family members.
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