Antipsychotic Prescribing Decreased in VA Nursing Homes, but Prescribing Alternative Drugs, such as Opioids, Increased
The FDA has not approved any drugs for the treatment of behavioral and psychological symptoms of dementia; however, there is widespread prescribing of psychotropic and opioid medications for these patients. Due to safety concerns associated with antipsychotics, VA and the Centers for Medicare and Medicaid Services (CMS) created initiatives to reduce off-label use in patients with dementia in nursing homes. While CMS reported reductions in antipsychotic prescribing, the impact of prescribing antipsychotic and other central nervous system (CNS)-active medications (i.e., benzodiazepines, opioids, and antiepileptics) in the VA healthcare system is unclear. Therefore, this study sought to evaluate national trends in prescribing these medications for Veterans with dementia residing in VA nursing homes, as well as how use has changed over time. Using VA data, investigators identified 35,742 Veterans with dementia who had resided in a VA nursing home for more than 30 days, then assessed the quarterly prevalence of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing from FY2009 through FY2018. Investigators also examined comorbid clinical conditions.
- Antipsychotic use for residents with dementia in VA nursing homes steadily decreased between FY2009 and FY2018 (from 34% to 28%), with similar declines in anxiolytic prescribing (from 34% to 27%). Over the same period, prescribing of antiepileptics, antidepressants, and opioids increased significantly: from 27% to 43%, 57% to 63%, and 33% to 41%, respectively.
- The decline in prescribing antipsychotics was most significant following VA’s Psychotropic Drug Safety Initiative (2013-2018).
- The overall prescribing of non-antipsychotic psychotropic medications grew from 75% to 81%.
- Prescribing of memory medications declined throughout the study – from 32% to 22%, representing an 11% absolute decline. Memory medications were the least prescribed medication class for Veterans with dementia throughout the study period.
- Initiatives focused on improving care for nursing home residents should: 1) monitor the use of all CNS-active medication and other potentially sedating treatments used for sedation in dementia; and 2) consider how to incentivize the use of evidence-based non-pharmacological alternatives.
- Findings on prescription rates may not be directly comparable to those in community nursing homes given the differences in the structure of VA community living centers, such as the presence of a national formulary and the range of psychosocial services available to Veterans.
This study was funded by HSR&D (IIR 15-330). Drs. Maust, Chang, Kim, and Zivin are part of HSR&D’s Center for Clinical Management Research (CCMR) in Ann Arbor, MI.
Gerlach L, Maust D, Kales H, Chang M, Kim H, Wiechers I, and Zivin K. Evaluation of Antipsychotic Reduction Efforts in Patients with Dementia in Veterans Health Administration Nursing Homes. American Journal of Psychiatry. May 26, 2022; online ahead of print.