Prescribing of Antipsychotic Medications for Dementia Dropped Overall at

VA Nursing Homes, but Psychotropic and Opioid Prescriptions Increased

Lauren B. Gerlach, DO, MS, Assistant Professor in the Department of Psychiatry at the University of Michigan

ANN ARBOR, MI — VHA nursing homes are prescribing fewer antipsychotic and anxiolytic (anti-anxiety) medications for dementia patients, but the overall prescribing of other psychotropic and opioid medications increased, according to a new study.

The U.S. Food and Drug Administration (FDA) has not approved any drugs for the behavioral and psychological symptoms of dementia, and the agency has issued warnings of the dangers associated with off-label use of antipsychotic medications to treat dementia-related psychosis. Concerns about patient safety have led to efforts to reduce medication risks for nursing home residents with dementia.

VHA and the Centers for Medicare and Medicaid Services (CMS) have worked to reduce the off-label use of antipsychotics in patients with dementia in nursing homes, and CMS has reported reductions in antipsychotic prescriptions.

A recent study published in The American Journal of Psychiatry evaluated national trends in prescribing antipsychotic and other Central Nervous System (CNS)-active medications for community living center (CLC) patients with dementia in the VHA.¹

Using national VA data, the study included nearly 36,000 veterans with dementia residing in VHA nursing homes for more than 30 days. Patients in this analysis were predominately male (98%) and non-Hispanic white (75%) with a mean age of 81 years. The authors used an interrupted time-series design and assessed the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid and memory medication prescribing from FY2009 through FY2018.

“Sedative medications such as antipsychotics, including medications like haloperidol, quetiapine and risperidone, are associated with significant risks for patients with dementia including falls, sedation and an increased risk of death prompting boxed warnings (the strongest type of drug safety warning) from the U.S. FDA in 2005 and 2008,” Lauren B. Gerlach, DO, MS, corresponding author of the study and assistant professor in the Department of Psychiatry at the University of Michigan, told U.S. Medicine. “In addition to the significant risks with these medications, there is only modest evidence that they are helpful in reducing the behavioral symptoms such as agitation, anxiety or aggression for which they are commonly prescribed in dementia.”

These medication-related harms are a concern for all patients with dementia, Gerlach said in an email. Previous research in this area has focused mainly on community nursing home settings funded by Medicare. There has been limited work to evaluate if federal prescribing initiatives outside of the VA have influenced prescribing within VA nursing homes and how this impacts care for veterans with dementia.

“Our study found that while there have been significant reductions in prescribing of sedative medication such as antipsychotics and benzodiazepines among veterans with dementia over the past decade, this has been matched by parallel increases in prescribing of other medication classes such as antiepileptics, sedative antidepressants and opioids,” Gerlach explained. “The concern is that these alternative medications are even less beneficial in treating behavioral disturbances in dementia and are also associated with significant harmful medication side effects. These types of prescribing patterns are not confined to the VA, and similar patterns of prescribing have been seen in studies evaluating national CMS nursing homes as well as internationally in Canada.”

Prescribing of antipsychotics in VHA nursing homes declined from 33.7% to 27.5% from FY2009 to FY2018. Also, anxiolytic prescribing declined from 33.5% to 27.1% during this time period, the study reports.

Successful Reductions

“While we observed successful reductions in antipsychotic and benzodiazepine prescribing among veterans with dementia in VA Community Living Centers (CLCs), this was matched by parallel increases in other medication classes including antiepileptic, sedating antidepressants and opioids—medications with even less evidence of benefit in dementia,” Gerlach continued. “Antiepileptic prescribing increased by 16.5% which was largely driven by increased prescribing of gabapentin—a medication with little evidence of benefit in dementia—which doubled over the study period.”

According to the study, prescribing of antiepileptics, antidepressants and opioids increased significantly during this period (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 largest 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%.

Gains have been made in reducing potentially dangerous use of medications such as antipsychotics and benzodiazepines, but this has been largely substituted with other medication classes that are less closely regulated in nursing home facilities nationally, Gerlach advised.

The widespread prescribing of psychotropic and opioid medications to dementia patients could represent off-label attempts to address the behavioral and psychological symptoms of dementia.

Policies singularly focused on driving down antipsychotic use in nursing homes without considering other medications in context might contribute to increased prescribing of alternative medications that are less likely to help patients and potentially just as dangerous. Nursing home policies should consider monitoring a broader range of medications used for sedation in dementia and consider how to incentivize the use of evidence-based non-pharmacologic alternatives, Gerlach added.

A number of organizations, including the American Geriatrics Society, the American Association of Geriatric Psychiatry and the American Psychiatric Association, have recommended non-pharmacological strategies as first-line treatments for addressing the behavioral and psychological symptoms of dementia.

“Non-pharmacologic or behavioral interventions have been shown across multiple studies to be more effective in treating behavioral disturbances in dementia,” Gerlach concluded. “These include patient, environmental and caregiver supportive interventions to determine the triggers to behaviors and help care partners determine strategies to address these behaviors. These interventions require staff training to learn such techniques as well as time to implement such strategies, which can be challenging in long-term care settings nationally.”