African home nurse reviewing prescription bottle with patient
(Credit: Jose Luis Pelaez / Getty Images)

Decisions on administering as-needed antipsychotic medications in assisted living/ residential care communities are based on attitudes, underlying morality and perceived expertise, requiring a system-level perspective, according to a new study.

In a study published in Innovation in Aging, the journal of the Gerontological Society of America, discussed earlier this month in the Annals of Long-Term Care, researchers examined decision-making related to administering as-needed antipsychotic medications to assisted living/residential care residents who had a diagnosis of dementia or cognitive impairment. The study looked at decision drivers among direct care workers, nurses, administrators and consulting pharmacists.

Researchers conducted semi-structured interviews among 11 direct care staff members, licensed nurses, administrators/executive directors and pharmacists between May and August 2021. They found that decisions to administer antipsychotic medications involved attitudes, underlying morality and perceived expertise. 

Direct care staff members, the researchers found, are guided by rules, training and resident needs, whereas those not involved in the day-to-day care of residents are guided by professional standards, training and an awareness of the challenges presented by some behaviors.

The study raises practice and policy implications for the senior living setting, the study authors said.

“Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective, extending beyond direct care staff passing antipsychotic medications to residents,” study researchers concluded. 

About half (49%) of the nation’s assisted living/residential care residents have a diagnosis of Alzheimer’s disease or related dementia, and more than 70% of those residents experience behaviors that include aggression, agitation, anxiety, delusions, hallucinations and sleeplessness, the researchers said. Chronic or severe behaviors have implications for resident quality of life, family and caregiver burden, and care transitions, they noted.

In the early 2000s, studies showed that off-label use of antipsychotic medications in older adults living with dementia was associated with a higher risk of early mortality, leading the US Food and Drug Administration to issue a “black box” warning on use of antipsychotic use in older adults.

Although through the National Partnership for Quality Dementia Care the Centers for Medicaid & Medicare Services developed quality improvement efforts related to the use of those medications in nursing homes, evidence is lacking about antipsychotic medication use in assisted living/residential care facilities, staff training and use of nonpharmaceutical interventions, and potential discrimination against older adults whose behaviors are deemed “challenging,” the study authors said.

Reducing the off-label use of antipsychotics in assisted living communities has been an industry goal.

The Joint Commission’s assisted living accreditation program, launched in 2021, includes it as part of its performance measures. And the National Center for Assisted Living’s Quality Initiative also considers antipsychotic medication use among its criteria

The study was supported through a private donation to the Portland State University Foundation to support students studying gerontology.