Objective To assess risks of mortality associated with use of individual antipsychotic drugs in elderly residents in nursing homes.Design Population based cohort study with linked data from Medicaid, Medicare, the Minimum Data Set, the National Death Index, and a national assessment of nursing home quality. Setting Nursing homes in the United States.Participants 75 445 new users of antipsychotic drugs (haloperidol, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone). All participants were aged ≥65, were eligible for Medicaid, and lived in a nursing home in 2001-5. Main outcome measuresCox proportional hazards models were used to compare 180 day risks of all cause and cause specific mortality by individual drug, with propensity score adjustment to control for potential confounders.Results Compared with risperidone, users of haloperidol had an increased risk of mortality (hazard ratio 2.07, 95% confidence interval 1.89 to 2.26) and users of quetiapine a decreased risk (0.81, 0.75 to 0.88). The effects were strongest shortly after the start of treatment, remained after adjustment for dose, and were seen for all causes of death examined. No clinically meaningful differences were observed for the other drugs. There was no evidence that the effect measure modification in those with dementia or behavioural disturbances. There was a dose-response relation for all drugs except quetiapine.Conclusions Though these findings cannot prove causality, and we cannot rule out the possibility of residual confounding, they provide more evidence of the risk of using these drugs in older patients, reinforcing the concept that they should not be used in the absence of clear need. The data suggest that the risk of mortality with these drugs is generally increased with higher doses and seems to be highest for haloperidol and least for quetiapine. IntroductionUp to a third of all elderly patients in nursing homes are treated with antipsychotic drugs. [1][2][3][4][5] In the past, inappropriate prescribing of antipsychotics in nursing homes has primarily been considered a marker of suboptimal care.6 7 Federal action thus focused primarily on defining and enforcing specific diagnostic criteria for the initiation and monitoring of these drugs (Omnibus Budget Reconciliation Act). 8 In recent years, evidence has accumulated that their use is a drug safety issue as well. After earlier warnings of increased risks of cerebrovascular events (with risperidone, olanzapine, and aripiprazole), 9 the Food and Drug Administration issued an advisory warning in 2005 that atypical antipsychotics were associated with a 60-70% increased risk of death compared with placebo in randomised controlled trials among older patients with dementia, and black box warnings were added to the labels of all atypical drugs. 10 Subsequent studies found risks at least as high among users of conventional antipsychotics, [11][12][13] RESEARCHpeople with dementia, the perceived need for some type of intervention in patients with severe persistent symptoms, ...

Background and Objectives Nearly one-third of nursing home residents in the US receive antipsychotic medications, yet important questions remain concerning their safety. We sought to compare the risk of major medical events in residents newly initiated on conventional or atypical antipsychotics. Design Cohort study, using linked Medicaid, Medicare, Minimum Data Set and Online Survey Certification and Reporting data. Propensity score-adjusted proportional hazards models were used to compare risks for medical events at a class and individual drug level. Setting Nursing homes in 45 US states. Participants 83,959 Medicaid eligible residents ≥65 who initiated antipsychotic treatment following nursing home admission in 2001-2005. Interventions Conventional and atypical antipsychotics. Outcome measures Hospitalization for myocardial infarction, cerebrovascular events, serious bacterial infections and hip fracture within 180 days of treatment initiation. Results Risks of bacterial infections (HR = 1.25, 95%CI 1.05-1.49) and possibly myocardial infarction (1.23, 95%CI 0.81-1.86) and hip fracture (1.29, 95%CI 0.95-1.76) were higher and risks of cerebrovascular events (0.82, 95%CI 0.65-1.02) were lower among patients initiating conventional compared to atypical agents. Little variation existed among individual atypical agents, except for a somewhat lower risk of cerebrovascular events with olanzapine (0.91, 95%CI 0.81-1.02) and quetiapine (0.89, 95%CI 0.79-1.02); a lower risk of bacterial infections (0.83, 95%CI 0.73-0.94) and possibly a higher risk of hip fracture (1.17, 95%CI 0.96-1.43) with quetiapine, all compared with risperidone. Dose-response relations were observed for all events (1.12, 95%CI 1.05-1.19 for high- vs low-dose for all events combined). Conclusion These associations underscore the importance of carefully selecting the specific antipsychotic agent and dose, and monitoring their safety, especially in nursing home residents who have an array of medical illnesses and receive complex medication regimens.

Significant variation in mortality risk across commonly prescribed antipsychotics suggests that antipsychotic selection and dosing may affect survival of older people living in the community.

OBJECTIVES To examine the evolution of depression identification and use of antidepressants in elderly long-stay nursing home residents from 1999 through 2007, and the associated sociodemographic and facility characteristics. DESIGN Annual cross-sectional analysis of merged resident assessment data from the Minimum Data Set (MDS) and facility characteristics from the Online Survey Certification and Reporting (OSCAR) data. SETTING Nursing homes in eight states (5,445 facilities). PARTICIPANTS Long-stay nursing home residents aged 65 and over (2,564,687 assessments). MEASUREMENTS Physician-documented depression diagnoses recorded in the MDS were used to identify residents with depression; antidepressant use was measured by MDS information about a resident’s receipt of an antidepressant in the seven days prior to assessment. RESULTS Both diagnosis of depression and antidepressant therapy among those diagnosed increased at a rapid rate. By 2007, 51.8% of residents were diagnosed with depression, among whom 82.8% received an antidepressant. Adjusted odds of treatment were higher for younger residents, whites, and those with moderate impairment of cognitive function. CONCLUSION This study demonstrates striking increases in depression diagnosis and treatment with antidepressant medications; however, disparities persist without clear evidence about underlying mechanisms. More research is needed to assess effectiveness of antidepressant prescribing.

High depression rates at admission and during the first year indicate a need to monitor and treat large numbers of American LTNH residents for depression. Reduced associations between demographics and depression as stays progress suggest other factors have increased roles in depression etiology.