Image of different colored pills spilled onto a flat surface
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A new study of nearly 500,000 nursing home residents who were prescribed antipsychotic medications has found an increase in negative behaviors compared to those who were not given such drugs.
The analysis captured results over a 22-year span — from 2000 to 2022 — and found that about 68% of residents taking antipsychotics had more behavior challenges in check-ups, including a higher percentage of Alzheimer’s disease or related dementia (72.2% vs 51.7%); cognitive impairment (26.5% vs 15.2%); symptoms of depression (26.9% vs 17.6%) and frailty (24.0% vs 19.8%).
The results were not necessarily surprising, some sector experts said, noting that the numbers support decades of research and also present clear areas for facilities to improve person-centered care.
“This information should be incorporated into all quality assurance and performance improvement efforts to appropriately reduce unnecessary medication use of all types,” Michael Wasserman, MD, geriatrician and Post-Acute and Long-Term Care Medical Association board member, told McKnight’s Long-Term Care News Monday.
Other experts said they see some parts of the study as misdirected and feeding the erroneous all-or-nothing notion that antipsychotic prescriptions are bad and have no place in the treatment of behavioral disturbances such as dementia and psychosis.
“There is no doubt that in somepatients, sometimes, their severely distressing symptoms can benefit from treatment with antipsychotic medications,” Karl Steinberg, MD, chief medical officer at Mariner Health Central and medical director at Scripps Home Health Services, told McKnight’s Long-Term Care News. “If that weren’t the case, the FDA would not have recently approved an antipsychotic medication as the first drug ever indicated for dementia-related agitation.”
The study reignites the conversation around medication deprescribing, which has been at the forefront of directives aimed at improving resident care in recent years.
For example, a recent collaboration between the United Hospital Fund and seven New York nursing homes spurred an 8% decrease in the number of potentially harmful medications prescribed to nursing home residents.
During the six-month test period, the nursing homes saw a decline in the number of residents who received 10 or more medications, as well as an increase in resident safety and quality of life.
There’s more to be uncovered when it comes to deciding whether to wean residents off of medications they may have grown accustomed to.
“Given the shortcomings of this study, more research is needed to determine if antipsychotics — especially the newer antipsychotics that have been approved for use in behavioral and psychological symptoms of dementia — are indeed making a difference in our residents’ lives,” added Post-Acute and Long-Term Care Medical Association President Rajeev Kumar.
Considering the individual
Ultimately, it’s about finding harmony between a patient’s treatment and their goals and preferences, Wasserman said.
He noted that some residents do benefit from the safe administration of such drugs — about 3% to 4%, based on his experience. But more important than analyzing the number of patients taking a medication, is the quality of clinician training, he feels.
“It’s time that we focus on the root cause of why these medications are overprescribed to vulnerable older adults,” he said. “That includes looking at whether physicians are adequately trained in geriatrics and long term care medicine. The answer to that is that they’re not, either in medical school or residency.”
Kumar affirmed that providers should exercise great caution when issuing antipsychotics and should consider treatments with fewer adverse effects when possible. Steinberg agreed and added that careless, one-off prescribing is never the answer.
“There’s no compelling reason to stop considering antipsychotics as part of our armamentarium when severe distress is being expressed in a nursing home resident with dementia and/or psychosis,” Steinberg said. “[But], I completely agree that historically, antipsychotics have been overutilized in nursing homes. We should always attempt nonpharmacologic interventions before resorting to drugs.”