Given significant concerns about risks and benefits, the VA and the Centers for Medicare and Medicaid Services (CMS) have each embarked on initiatives to reduce off-label use of antipsychotic medications (APs) for the behavioral and psychological symptoms of dementia (BPSD). The percent of residents on APs in nursing homes (in the VA, Community Living Centers or CLCs) is used by policymakers as the main quality indicator for BPSD. In addition to Nursing Homes/CLCs, policymakers are also concerned with high rates of AP use in community settings. Policies focused entirely on reducing AP use may have caused "unintended consequences," such as providers shifting patients to alternative psychotropic classes with even less evidence of benefit and similar risks, including benzodiazepines, mood stabilizers, and antidepressants. Rather than substituting other psychotropics, multiple expert bodies recommend the use of behavioral and environmental interventions as the preferred alternative to APs for BPSD. This study will examine the system- and facility-level consequences of VA and non-VA initiatives related to dementia intended to reduce AP prescribing.
The objectives of this study are to: (1) determine system-level VA national trends in psychotropic use among patients with dementia since the first black-box warning (2005) to 2014; (2) examine CLC level variables that may be associated with antipsychotics prescribing in dementia; and (3) validate additional quality indicators for VA patients with dementia for both CLC's and community settings.
For Aim 1, our research team will conduct interrupted time-series analyses using VA national health system administrative data to examine the impact of initiatives to reduce antipsychotic use in dementia. AIM 2: CLC's will be classified into quintiles and will be compared on variables that may reflect both unintended and desired consequences in quality of care for CLC residents with BPSD. AIM 3: Informed by the findings from Aims 1 and 2 regarding factors that are associated with quality of care for Veterans with dementia, we will use a two-round modified Delphi panel of experts and stakeholders in dementia care and BPSD to validate additional potential quality indicators.
No findings to report at this time.
Behavioral symptoms of dementia are universal, found in all types and stages of dementia. The results of this study may benefit those Veterans, their families, providers, and policymakers by helping to understand the impact of current initiatives to reduce antipsychotic prescribing and also describe the potential unintended consequences of such efforts.
- Kales HC, Gitlin LN, Lyketsos CG. When Less is More, but Still Not Enough: Why Focusing on Limiting Antipsychotics in People With Dementia Is the Wrong Policy Imperative. Journal of The American Medical Directors Association. 2019 Sep 1; 20(9):1074-1079.