Off-label antipsychotic use rising among community-dwelling dementia patients

Elizabeth A. Carter

Although off-label antipsychotic drug use has declined in nursing homes due to efforts from the CMS, use of these drugs has increased slightly among patients with dementia living in the community, according to a report issued by the AARP Public Policy Institute.

“Antipsychotics are often given inappropriately to older adults with dementia. Recently, there has been a lot of attention to this problem among nursing home residents,” Elizabeth A. Carter, PhD, MPH, OptumLabs visiting fellow at the AARP Public Policy Institute, told Healio Psychiatry. “I’d read a report showing a 30% drop in the use of antipsychotic drugs among nursing home residents with dementia between 2012 and 2015 but I couldn’t find any data on the use of antipsychotics among older adults living outside of nursing homes.”

The U.S. Government Accountability Office found that 33% of Medicare Part D beneficiaries with dementia who resided in a nursing home and 14% of those who did not live in a nursing home were prescribed an antipsychotic medication in 2012, according to the report. Replicating this analysis, the CMS found similar results.

Using administrative claims data obtained from the OptumLabs Data Warehouse, Carter calculated annual rates of antipsychotic use among community-only adults living in any location other than a nursing home aged 65 and older who had dementia and were enrolled in Medicare Advantage plans for at least 1 year between 2012 to 2015. Patients with schizophrenia, bipolar disorder, Tourette syndrome and Huntington’s disease, and thus commonly prescribed antipsychotics, were excluded from analysis.

In this sample, analysis revealed that antipsychotic use increased by more than 6% from 2012 to 2015, from 12.6% to 13.4%. Those with dementia aged 75 and older were more likely than those aged 65 to 74 years to have a prescription for antipsychotics (12.8% vs. 12%). Antipsychotic use was higher among women compared with men (16.2% vs. 14.2%) and lowest in the West census region.

“I did not find a corresponding decline in antipsychotic use in my sample of older adults with dementia living in the community, suggesting not enough is being done in outpatient clinical settings to solve this problem,” Carter told Healio Psychiatry.

“Clinicians may want to pause before ordering an antipsychotic drug for a dementia patient and ask ‘Is this in my patient’s best interest?’ Due to the serious side effects of these drugs among older adults with dementia, prescribing guidelines encourage clinicians to avoid antipsychotics unless behavioral interventions have failed, and the older adult is danger of harming him or herself or others,” she continued. “Disruptive behavior among older adults with dementia is often a sign of an unmet need. Addressing that unmet need, rather than medicating the patient, may be the best course of care.” – by Savannah Demko

References:

Carter EA. Spotlight 32, April 2018. “Off-label antipsychotic use in older adults with dementia: Not just a nursing home problem.” www.aarp.org/APDstudy. Accessed on April 23, 2018.

Disclosures: Carter is a OptumLabs visiting fellow at the AARP Public Policy Institute.