Elizabeth Carter, Ph.D., M.P.H.

Although the off-label use of antipsychotic medications has decreased in nursing home residents who have dementia, it has increased in those with dementia who live in assisted living communities or at home, according to a new analysis of insurance claims data released today by the AARP Public Policy Institute.

The report, titled “Off-Label Antipsychotic Use in Older Adults with Dementia: Not Just a Nursing Home Problem” and written by Elizabeth Carter, Ph.D., M.P.H., found that the rate of antipsychotic use among Medicare Advantage enrollees with dementia who live in the community (including in assisted living communities) increased by more than 6%, from 12.6% to 13.4%, between 2012 and 2015. Antipsychotic use was highest among certain groups: women, people aged 75 or more years, and those living in the South or Midwest.

Over the same period, the use of antipsychotic medications in nursing home residents decreased by approximately 34%, according to the National Partnership to Improve Dementia Care in Nursing Homes, wrote Carter, senior health services research adviser at the institute.

“Reducing the AP use rate among dementia patients living in the community is imperative, especially because many nursing home residents begin AP use prior to their arrival at the facility,” she wrote. “Our rising estimates of AP use indicate that still not enough is being done to solve this problem.”

De-identified data of those aged 65 or more years were obtained from the OptumLabs Data Warehouse, where Carter is a visiting fellow.

Industry efforts

In late 2017, the National Center for Assisted Living told McKnight’s Senior Living that 56 of its member communities had met its 2015 Quality Initiative goal of safely reducing the off-label use of antipsychotics by 15% or achieve an off-label usage rate of 5% or less.

“Efforts to reduce off-label antipsychotic use, such as the NCAL Quality Initiative, are an important first step,” Carter told McKnight’s Senior Living. “However, an optimal target rate of antipsychotic is unknown. It could be that 5% is still too high.”

The types of interventions implemented by the communities also are important, she said. “Were patients given non-drug, behavioral interventions, or were they simply switched to different medications, such as mood stabilizers?” Carter asked.

On a web page about the Quality Initiative’s goal related to antipsychotic medication, NCAL advises members to “look for non-pharmacologic interventions to enhance an individual’s quality of life” and to “help educate family members, healthcare partners and other community members about the risks associated with off-label use of antipsychotics.” The page includes additional resources as well.

NCAL began its Quality Initiative in 2012 with one goal being to reduce off-label antipsychotic use by 15% by December 2013. In 2015, the campaign was extended through March 2018, again with a goal of safely reducing off-label use of antipsychotic medications by 15%. In March, the campaign was extended for three more years, with one goal being to safely reduce the off-label use of antipsychotics to a rate of 15% or less.

NCAL’s sister organization, the American Health Care Association, has established goals for skilled nursing facilities, too. AHCA / NCAL members can view their progress toward meeting all campaign goals using the organization’s LTC Trend Tracker, a web-based data collection and benchmarking tool.

Argentum also has made memory care one of its five areas of focus, including efforts to “develop and share best practices” with its senior living community members.

‘Community-only’ adults

Carter told McKnight’s Senior Living that for her report, she defined “community-only” adults as they were defined in 2015 reports by the Government Accountability Office and the Centers for Medicare & Medicaid Services. Therefore, this group included assisted living communities and group homes.

Less than one percent of her sample for the analysis lived in such settings, however, she added. “The vast majority were living at home or with relatives,” Carter said.

“When using the ‘community-only’ classification for future research, I think it would make sense to report the antipsychotic use rates separately for those living in assisted living centers and other settings versus those living at home,” she added.