Effort to Tackle Overuse of Antipsychotics in Older Adults Backfires

A partnership designed to decrease antipsychotic use in elderly patients may have led to increased use of medications with even worse risk/benefit profiles

Peter Simons
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A program designed to guide deprescribing of antipsychotic medications for older adults in long-term care appears to have replaced one problematic drug with another. According to research by Donovan Maust and colleagues at the University of Michigan, and published in JAMA Internal Medicine, antipsychotic prescribing has decreased considerably—but mood stabilizer prescribing has increased instead.

“The use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia,” Maust writes. “Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.”

Photo Credit: “Whack a mole,” Flickr

The partnership referred to here is the Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care in Nursing Homes. The focus of this program is to improve care for elderly patients in long-term care, but the program focuses mostly on deprescribing antipsychotics.

“Behavioral and environmental strategies, despite the growing evidence base and greater efficacy than antipsychotics, have not been routinely translated into long-term care settings,” Maust writes. “The key goal of the partnership is clearly to help correct this issue: through emphasizing reductions in antipsychotic prescribing by measuring and publicly reporting it, facilities might increase the use of evidence-based, nonpharmacologic alternatives.”

Unfortunately, because the partnership only measures antipsychotic use, and does not provide additional funding, training, or access to behavioral or environmental strategies, it may not be accomplishing its goal. Instead, it may be leading to increased prescribing of other, even less beneficial medications.

Additionally, Maust notes that the rates of antipsychotic use were already declining before the partnership program began—and that decline leveled out after the program started. That is, it appears that the program has not even been successful in substantially decreasing antipsychotic use (any more than would have likely occurred anyway).

The study included 637,426 older adults receiving health care through Medicare Part D.  Their health records were followed from January 1, 2009, to December 31, 2014. Antipsychotic use (such as Abilify and Risperdal) decreased—from 21.3% in 2009 to 11.5% in 2014. Mood stabilizer use (such as Lithium and Lamictal) increased—from 16.6% in 2009 to 20.1% in 2014.

By 2014, 19.9% of elderly patients were prescribed benzodiazepines (such as Xanax and Ativan). Because benzodiazepines were not covered by Part D in 2009, the researchers do not have data on how much this pattern changed over time.

Use of antidepressants (such as Prozac and Zoloft) also decreased in this population, from 52% in 2009 to 43.9% in 2014.

Among elderly patients with dementia, a similar pattern was found, except that rates of antipsychotics began much higher. By 2014, 20.3% of patients with dementia were on mood stabilizers, and 20.5% were on antipsychotics. Additionally, 21.5% of the patients with dementia were prescribed benzodiazepines, and 54.5% were prescribed antidepressants.

Maust and colleagues suggest that focusing solely on antipsychotic use may lead to increased use of medications with worse risk/benefit profiles. Future programs should also be sure to measure the use of other drugs as well. More support is needed for behavioral and environmental interventions for elderly patients in long-term care.

 

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Maust, D. T., Kim, M., Chiang, C., & Kales, H. C. (2018). Association of the Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care with the use of antipsychotics and other psychotropics in long-term care in the United States from 2009 to 2014. JAMA Internal Medicine. doi: 10.1001/jamainternmed.2018.0379 (Link)

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Peter Simons
MIA-UMB News Team: Peter Simons comes from a background in the humanities where he studied English, philosophy, and art. Now working on his PhD in Counseling Psychology, his recent research has focused on conflicts of interest in the psychopharmaceutical research literature, the use of antipsychotic medications in the treatment of depression, and the general philosophical and sociopolitical implications of psychiatric taxonomy in diagnosis and treatment.

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6 COMMENTS

    • Thank you for saying what must be said. The suffering it causes, the deaths, and the additional suffering for you and me when our elders are tortured and killed is so vast that it beggars the imagination. One case at a time, no one cares, no one can help you, no agency responds to complaints, no lawyer is interested, and the effect it has on the system is measured at “zero.”

      Zero times a billion is zero.

  1. Trading one neurotoxin for another is part of the problem, not part of the solution. The drug companies may be billing them as “safe and effective”, but they are anything but “safe and effective”. Drugs make things easier for the staff who would rather be dealing with sedated patients than the very real, and for good reason, distress of some of those under their “care”. I think you have to expect this kind of thing. The easiest thing to do, in these instances, is to find another drug. (Obviously, by doing so, they’ve gotten around the neuroleptic use issue that has come under fire.) It would not be so easy, perhaps, if nursing staff were adequately up on the harmful effects of such drugs, and why they are not a significant improvement over neuroleptics, but this is something that the schools of higher learning, buying into the panacea of the medical profession, chemical toxins, is feign to do.

  2. Which proves that the real problem is NOT the drugs themselves, it is the ATTITUDE that allows the idea of prescribing drugs for behavior problems to be accepted. The essential purpose of the DSM III and beyond was to provide cover and justification for drugging normal human beings for profit. Until we address that approach and eliminate it completely from anyone’s idea of “care,” stopping “overprescription” of one drug will simply lead to a new drug to replace it. It is the idea of labeling and drugging people whose behavior is inconvenient that has to go!