Addressing Dementia-Related Behaviors Before, During, and After the Pandemic—Disrupting the Behavior-to-Prescribing Reflex

Abstract

Behavioral and psychological symptoms of dementia (BPSD), including depression, anxiety, and psychosis, are ubiquitous among people living with dementia and agnostic to the etiology and stage of illness. 1 Behavioral and psychological symptoms of dementia are associated with poor outcomes for people living with dementia, including reduced quality of life, increased health care use, and nursing home placement as well as worsened caregiver outcomes, including loss of income and employment, increased time providing care, and heightened risk for depression and stress. 1 The COVID-19 pandemic created conditions for the worsening of BPSD. While the pandemic's disruptions were universally difficult, people living with dementia and their caregivers were particularly sensitive to the disruptions, as outlets for social interaction and respite closed and usual care routines were severely curtailed. 2 Moreover, increased confinement, isolation, and boredom along with confusion over mask wearing, hand washing and other requirements resulted in increased caregiver burden.With or without this pandemic, most caregivers and health care professionals have little knowledge about BPSD and ways to prevent, reduce, or manage them. Although there is limited evidence of efficacy, psychotropic medications, including antipsychotics, antiepileptics, and antidepressants, are widely prescribed internationally to address BPSD almost as a reflexive reaction. 1 However, the primary outcome of this prescribing is probably simply generalized sedation of people living with dementia. Among psychotropic medications, antipsychotics appear to have the strongest evidence for efficacy, albeit modest, yet they do not typically address the BPSD that families report as most challenging, such as the rejection of needed care or repetitive vocalizations. 1 Antipsychotic use rates reached highs in the early 2000s, with up to 24% to 32% of nursing home residents receiving these medications. 3 At the same time, evidence mounted for concerns about adverse effects, including mortality, and international regulatory agencies issued warnings about this medication class. In response, countries launched efforts to reduce the use of these medications in nursing homes.Antipsychotic prescribing did decline in the wake of these efforts. However, subsequent data show that these reductions had unintended negative consequences: other medications-with even less efficacy and similar concerns for safety and adverse effects-were increasingly prescribed. 4 These include antiepileptics (specifically gabapentin and valproic acid and derivatives) and antidepressants. 5

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

“…Recent research has shown that the antipsychotic prescribing among individuals with ADRD has even increased during the COVID-19 pandemic in multiple countries including France, Italy, South Korea, the United Kingdom, and the United States, 32 which suggests that despite years of regulatory attempts to reduce antipsychotic prescribing, antipsychotics remain the primary treatment providers use to management of BPSD. 33 To reduce inappropriate use of antipsychotics among HHC patients living with ADRD who demonstrate BPSD, they should be provided access to receive behavioral interventions and their family caregivers should be educated on the most appropriate ways to manage BPSD. HHC nurses, while conducting medication review, should be encouraged to report inappropriate or long-term use of antipsychotics to the patient's prescribers to advocate for deprescribing and the use of nonpharmacological interventions.…”

“…Because antipsychotics are not the first‐line therapy for BPSD and their use is associated with adverse outcomes in patients living with ADRD, this finding suggests the possibility of their inappropriate use. Recent research has shown that the antipsychotic prescribing among individuals with ADRD has even increased during the COVID‐19 pandemic in multiple countries including France, Italy, South Korea, the United Kingdom, and the United States, 32 which suggests that despite years of regulatory attempts to reduce antipsychotic prescribing, antipsychotics remain the primary treatment providers use to management of BPSD 33 . To reduce inappropriate use of antipsychotics among HHC patients living with ADRD who demonstrate BPSD, they should be provided access to receive behavioral interventions and their family caregivers should be educated on the most appropriate ways to manage BPSD.…”

Considerations Regarding Antipsychotic Drug Prescriptions Among People With Dementia During the COVID-19 Pandemic—Reply

“…By applying common analytics to multiple databases that cover a large population, we conducted a comprehensive assessment across different health care systems and world regions in a single study. Our study generated initial evidence on the potential antipsychotic use reflex in a timely manner to inform health policy and clinical practice . The study also provides a basis for further in-depth investigations.…”