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A federal initiative to reduce unnecessary antipsychotic medication prescribing in long-term care facilities failed to reduce prescriptions in assisted living residents with dementia, a new study of prepandemic data has found. The results are in sharp contrast to successes seen in long-stay nursing homes, investigators say.

Within four years’ of its launch in 2012, the National Partnership to Improve Dementia Care in Nursing Homes led to a 30% decrease in antipsychotics prescriptions among long-stay nursing home residents with Alzheimer’s disease and related dementias, the Centers for Medicare & Medicaid Services reported at the time. But at the national level, those nursing home results were not mirrored in the assisted living population, according to the new study, published Aug. 19 in the Journal of the American Geriatrics Society.

Stark comparison

To make the comparison, investigators from the University of Michigan and Brown University used a 20% sample of fee-for-service Medicare beneficiaries with Part D from the years before and after the partnership, up to 2017. It is the first study of its kind, they said. 

The prescriptions percentage for each medication class was relatively lower for assisted living residents with Alzheimer’s and related dementias than for their long-stay nursing home peers. But the federal partnership program had no apparent effect on antipsychotic and other psychotropic drug prescribing for the assisted living residents. What’s more, there was a “slight increase” in mood stabilizer and / or anticonvulsant medication prescribing in the assisted living population, mainly for gabapentin (known by brand names such as Gralise, Horizant and Neurontin), the researchers reported. 

Training, oversight needed

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

The assisted living community accreditation program launched in 2021 by the Joint Commission 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, McKnight’s Senior Living has reported. Recent years’ criteria for award recipients have included the use of off-label antipsychotic medications in 15% of residents or less.

Although assisted living residents living with Alzheimer’s and related dementias may be cared for by the same prescribers as their nursing home peers, differences in federal and state oversight may have played a big role in the relative success of the national partnership program in those two settings, the current study’s investigators concluded.

Nursing homes likely benefited from the training of staff and surveyors, stakeholder engagement and new public reporting efforts, they said. In addition, “there is wide variation in state-level regulation of antipsychotic use for behavioral disturbances in ADRD in AL facilities, from little regulation to regulation on par with nursing home standards,” study lead Julie P. W. Bynum, MD, MPH, wrote.

Federal policy can work

The potential dangers of antipsychotic and other psychotropic medication use in people with Alzheimer’s and related dementias can occur regardless of setting, Bynum and colleagues cautioned. But the findings suggest that federal policy with multiple interventions can affect antipsychotic medication prescribing in older adults with Alzheimer’s and related dementias.

“Strategies to decrease antipsychotic prescribing in AL residents with ADRD should include multiple stakeholders, such as prescribers, healthcare providers, patients and care partners, to ensure safe medication use and prevent harm,” the authors wrote.

“Given the observed increase in mood stabilizer / anticonvulsant prescribing, future monitoring for all psychotropic medication prescribing among AL residents with ADRD may better reflect quality dementia care than antipsychotic prescribing alone,” they concluded.