The persistence of a pandemic-associated increase in antipsychotic, antidepressant and anticonvulsant medication use in assisted living residents — and a greater increase in antipsychotic use in dementia care settings — raises concerns about the risks for residents, say the authors of a study published in the January issue of JAMDA–The Journal of Post-Acute and Long-Term Care Medicine.
Prescriptions for antipsychotic medications in assisted living communities increased during the first two years of the COVID-19 pandemic, especially in residents living with dementia, according to the researchers. They examined the proportion of assisted living residents in Alberta, Canada, who were prescribed an antipsychotic, antidepressant, benzodiazepine, anticonvulsant or opioid medication between January 2018 and December 2021.
Antipsychotic medication use prevalence increased to a larger degree than antidepressant use and was approximately 8% higher for memory care compared with other assisted living residents during the latter two pandemic waves — wave 3 (March to May 2021) and wave 4 (September to December 2021). Assisted living residents not living in memory care settings also showed a statistically significant but small increase in anticonvulsant use during the pandemic waves 2 (September to November 2020, and December 2020 to February 2021) through 4.
For both assisted living and memory care residents, the pandemic was associated with a statistically significant decrease in benzodiazepine use and no significant change in opioid use, they found.
The study results revealed that the increase in antipsychotic use among assisted living residents in dementia care (3.5% to 7%) was larger than estimates previously reported for nursing home residents living with dementia (more than 1.7%).
“The significantly greater increase in antipsychotic use among residents of dementia care was surprising given our hypothesis that the presence of specialized dementia care staff and environments might mitigate behavioral changes and antipsychotic use in this population,” the authors noted.
Lead author Colleen Maxwell, PhD, a professor in the University of Waterloo School of Pharmacy in Ontario, told McKnight’s Senior Living that she and colleagues believe that the substantial challenges and losses faced by assisted living communities and nursing homes during the pandemic partially explain the increase in use of the medications. Those challenges included staffing shortages, declines in services and comprehensive integrated care, loss of family caregivers, an increase in resident pain and mental health conditions due to pandemic-related restrictions, and difficulties in implementing nonpharmacologic interventions to address pain, sleep, mental health concerns and responsive behaviors among residents.
The researchers also said that the increased use of antipsychotic medications in assisted living likely was “inappropriate.” Although they acknowledged that the mental health distress that assisted living residents likely experienced, as well as the lack of nonpharmacologic alternatives early in the pandemic, might have supported the short-term use of antidepressants and antipsychotics, their use remained elevated throughout the pandemic.
“Prior to the pandemic, there is strong evidence that once started, these medications tend to persist beyond what might be considered an appropriate period of treatment, leading to an increased risk of polypharmacy / hyperpolypharmacy and medication-related adverse events,” Maxwell said.
She added that when faced with public health crises, it is important that the senior living industry direct careful attention to implementing strategies for the appropriate oversight and administration of high-risk medications, particularly among at-risk residents and those living with dementia.
A spokesperson from the American Health Care Association / National Center for Assisted Living told McKnight’s Senior Living that the groups have been active partners in a national effort to reduce the unnecessary use of antipsychotics in assisted living and skilled nursing and has made progress in the past decade, including focusing more on nonpharmacologic interventions.
“Along with prescribing physicians and family decision-makers, we must continue to educate ourselves about these conditions and the proper use of medications, as well as explore and promote innovative memory care techniques to help individuals with dementia thrive,” the spokesperson said.
A continuing challenge in assisted living
More than two-thirds of assisted living residents have dementia or cognitive impairment, and antipsychotics commonly are prescribed off-label for behaviors that include aggression, agitation, anxiety, delusions, hallucinations and sleeplessness, according to a 2023 study also published in JAMDA, by researchers from Brown University and the University of Michigan.
In the early 2000s, studies showed that the off-label use of antipsychotic medications for 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 the use of the drugs in this population.
The Centers for Medicare & Medicaid Services, through the National Partnership for Quality Dementia Care, developed quality improvement efforts related to the use of antipsychotics in nursing homes. But evidence was 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 were deemed challenging, according to a study published in early 2023.
Reducing the off-label use of antipsychotics in assisted living communities has been a goal of the senior living industry. One of the performance measures used by an assisted living community accreditation program launched in 2021 by The Joint Commission is medication management, specifically, off-label antipsychotic drug use. The National Center for Assisted Living’s Quality Initiative also lists antipsychotic medication use among its goals.
