Antipsychotic prescribing in older Veterans Administration community living center patients

Gellad WF, Aspinall SL, Handler SM, Stone RA, Castle N, Semla TP, Good CB, Dysken M, Hanlon JT. Antipsychotic prescribing in older Veterans Administration community living center patients. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.

Related HSR&D Project(s)

• CDA 09-207 – Addressing Regional Variation in Drug Prescribing and Spending in the VA

Objectives: Antipsychotic medications are associated with potential adverse events among older patients. We estimated the prevalence of antipsychotic use by older Veterans Administration (VA) Community Living Center (CLC) patients and identified demographic, health status, and organizational factors associated with antipsychotic prescribing. Methods: We conducted a cross-sectional study of 3,692 Veterans over age 64, who were admitted between January 2004-June 2005 to 133 VA CLCs. These patients had at least a 90-day stay and one drug dispensing record and were not admitted for respite or palliative care. We used VA Pharmacy Benefits Management dispensing data to examine antipsychotic prescribing. We used ICD-9 codes from VA inpatient and outpatient files in the year before admission and the Minimum Data Set to identify evidence-based indications for the antipsychotic (e.g., schizophrenia, dementia with psychosis). Independent variables included patient demographics, health status, and facility characteristics (urban/rural, region of US, bed size, presence of Alzheimer's/Dementia Special Care Unit). We conducted multivariate analyses using Generalized Estimating Equations to identify the factors independently associated with receipt of an antipsychotic. Results: Overall, 25.7% (948/3692) of patients were prescribed an antipsychotic. Of these patients, 93% had regularly scheduled administration, and 80% received atypical agents. Only 59.3% of antipsychotic users had a documented evidence-based indication. Veterans with dementia but no psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR 1.10, 95% CI 0.82-1.47). Patients with aggressive behavior (OR 2.74, 95%CI 2.04-3.67), and those receiving anxiolytic/hypnotics (OR 2.30, 95%CI 1.64-3.23) or drugs for dementia (OR 1.52, 95% CI 1.21-1.92) had higher odds of being prescribed an antipsychotic. Veterans residing in an Alzheimer's/Dementia Special Care Unit were more likely to be prescribed an antipsychotic (OR 1.66, 95% CI 1.26-2.21). Implications: Antipsychotic prescribing is common in older VA CLC patients, including those without a documented evidence-based indication for use. The odds of use are increased in Veterans residing in Alzheimer's/Dementia Special Care Units and in those with aggressive behavior and taking concomitant anxiolytic/hypnotics. Impacts: Quality improvement efforts are needed in VA CLCs to reduce potentially inappropriate antipsychotic prescribing and increase the use of non-pharmacological behavior modification approaches.