Antipsychotics study proves value of reduction efforts, leaders say

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Mark Olfson, M.D., M.P.H., left, and Michael Schoenbaum, Ph.D.
Mark Olfson, M.D., M.P.H., left, and Michael Schoenbaum, Ph.D.

A newly published study on the use of antipsychotic medications in older adults “suggest[s] a need to focus on new ways to treat the underlying causes of agitation and confusion in the elderly,” according to lead author Mark Olfson, M.D., M.P.H., of Columbia University.

The latest data used in the study are from 2010, and the government and senior living operators have launched efforts to reduce the off-label use of antipsychotic medications since then. The findings, therefore, senior living industry representatives say, reinforce the necessity of initiatives they have put in place.

Olfson; Marissa King, Ph.D., of Yale University, and Michael Schoenbaum, Ph.D., of the National Institute of Mental Health looked at antipsychotic prescriptions filled between 2006 and 2010. The data set used was not limited to any one setting or diagnosis but did include information from residential care settings such as assisted living communities and skilled nursing centers.

Findings of the study, published Oct. 21 in Journal of Clinical Psychiatry:

  • The fraction of older adults treated with antipsychotic medications increases with age, despite known risks of serious side effects.

  • More than three-fourths of older adults receiving an antipsychotic prescription in 2010 had no documented clinical psychiatric diagnosis during the year.

  • Among those who had a diagnosed mental disorder and/or dementia, nearly half of the oldest patients who had been prescribed antipsychotic medications had dementia, despite FDA warnings that antipsychotics increase mortality in older adults.

  • Among older adults who had used antipsychotic medications, around half had used the drugs for more than 120 days in the year.

  • The percentage of people receiving an antipsychotic prescription in 2010 increased with age after age 65. The percentage with an antipsychotic prescription was about twice as high among people aged 80 to 84 years as it was among those aged 65 to 69 years.

The study results did not necessarily surprise the researchers, Schoenbaum told McKnight's Senior Living, since their efforts were inspired in part by existing information about patterns of use of these medications in older adults. But the findings are concerning nonetheless, he added. “There are circumstances for which these medications are indicated, but they're clearly being used more widely than indicated, and they're used more widely in populations where there's a lot of risk associated with using them,” Schoenbaum said.

In a sense, Olfson told McKnight's Senior Living, part of the study's value is that it can serve as a national baseline for future efforts. “It is important to track use of antipsychotics in older adults over time,” he said.

The study does not include data beyond 2010, Schoenbaum said, because that was the year that researchers negotiated with IMS Health to use its data. Since that time, however, the government and senior living industry have initiated efforts aimed at reducing off-label use of antipsychotic medications and finding alternative ways to address agitation and other behaviors in those with dementia.

“When you look at five years ago compared to today, we've already come a long way on this issue,” Lindsay Schwartz, Ph.D., senior director of workforce and quality improvement for the National Center for Assisted Living, told McKnight's Senior Living.

This past May, NCAL extended its quality campaign through March 2018. One of the campaign's four major goals is to reduce the off-label use of antipsychotic medications by 15% or to achieve and maintain off-label use at 5% or less.

“Since launching the quality initiative, long term care providers have made extraordinary progress in reducing the off-label use of antipsychotics, and tens of thousands of resident lives have been improved,” Schwartz said. Awareness still needs to be raised among providers outside of senior living, however—among psychiatrists and other physicians who prescribe the medications, for instance, she added. “We all need to partner together to make sure antipsychotics are being used properly and that person-centered care is priority.”

LeadingAge has offered webinars, workshops and its own initiative recognizing optimum dementia care across settings, Cheryl Phillips, M.D., the organization's senior vice president of public policy and advocacy, told McKnight's Senior Living. The initiative, she added, includes nursing homes and also assisted living and home- and community-based settings, highlighting settings that manage challenging behaviors well and have a low, if any, use of antipsychotic medications.

Phillips, a geriatric physician, said that doctors, nurses and families used to believe that the medications were appropriate for managing behaviors, not understanding that alternatives existed and that in some cases the behaviors were avoidable to begin with, “when you really understand a person with dementia.” The study, she said, “really reiterates why the initiatives to improve dementia care are so important, and, frankly, why they need to be important across settings, not just in the nursing home.”

Among additional efforts since 2010 related to reducing the off-label use of antipsychotic medication is the National Partnership to Improve Dementia Care in Nursing Homes, which the Centers for Medicare and Medicaid Services established in 2012. The partnership includes federal and state agencies, providers, advocacy groups and caregivers. Also, in 2013, the Advancing Excellence in America's Nursing Homes Campaign established as one of its nine quality goals the reduction of inappropriate use of the drugs.

More is needed, however, according to the researchers. Their study cites the report by the Government Accountability Office, made public earlier this year, that recommended that the U.S. Department of Health and Human Services expand outreach and educational efforts related to antipsychotic medications beyond nursing homes to include assisted living communities, homes and other settings.

“Establishing goals to reduce off label use of antipsychotics in nursing homes is a welcomed step in the right direction,” Olfson said. “Although the use of antipsychotics is particularly prevalent in nursing homes, however, more than 70% of the over 1 million older adults who receive antipsychotics in the [United States] are treated outside of institutional settings. For this reason, broader-based approaches will likely be needed as well.”

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