Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications

Abstract

Background Antiepileptics are commonly prescribed to nursing home residents with Alzheimer's disease and related dementias (ADRD) but there is little scientific support for their use in this population. It is unclear whether different antiepileptics are targeting different indications. Methods Using the Minimum Data Set and Medicare data, including Part D pharmacy claims, we constructed annual cohorts of residents with ADRD with long‐term stays in nursing homes from 2015 to 2019. For each year, we measured the proportion of residents with ADRD in nursing homes nationwide with at least one antiepileptic prescription. We also measured trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing. Finally, we examined how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain. Results Our study sample includes 973,074 persons living with ADRD who had a long‐term stay in a nursing home, which was defined as at least 3 months. The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain. Conclusions Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining. Examining antiepileptic prescribing to residents with ADRD who had disruptive behaviors and/or reported pain suggests that two of the most common antiepileptics, valproic acid and gabapentin, are being used in clinically distinct ways. Antiepileptic prescribing of questionable risk–benefit for dementia care warrants further scrutiny.

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease

“…7,[11][12][13][14][15] Although the few studies which have examined this concern in the general and ADRD nursing facility populations have found limited evidence of compensatory therapeutic substitution, use of anticonvulsants has increased since ARI implementation. 7,11,[13][14][15] In particular, a recent study suggests increased use of specific antiepileptic agents (i.e., valproate and gabapentin) in residents with dementia in nursing homes as a response to decreased antipsychotic use. 15 Several studies also report an increase in the prevalence of exempted diagnoses, especially schizophrenia.…”

“…7,11,[13][14][15] In particular, a recent study suggests increased use of specific antiepileptic agents (i.e., valproate and gabapentin) in residents with dementia in nursing homes as a response to decreased antipsychotic use. 15 Several studies also report an increase in the prevalence of exempted diagnoses, especially schizophrenia. 3,12,[15][16][17] Recently, the Office of the Inspector General (OIG) questioned the accuracy of schizophrenia diagnoses in nursing homes, noting an uptick in newly-admitted schizophrenia cases among residents without prior history.…”

“…15 Several studies also report an increase in the prevalence of exempted diagnoses, especially schizophrenia. 3,12,[15][16][17] Recently, the Office of the Inspector General (OIG) questioned the accuracy of schizophrenia diagnoses in nursing homes, noting an uptick in newly-admitted schizophrenia cases among residents without prior history. 18 As well, the rationale for omitting bipolar, psychosis, Parkinson's disease, and other conditions from exempt status remains unclear, as antipsychotics are Food and Drug Administration (FDA)-approved and/or widely accepted as significant adjuvants for optimal disease management for these conditions.…”

“…Public reporting of the long-term care antipsychotic quality measures in Nursing Home Compare began in July 2012 and is the date consistently used by CMS and other researchers in evaluation of the ARI. 1,2,[6][7][8][11][12][13][14][15] We chose January 2011 as our study start date to avoid changes in MDS 2.0-3.0 conversion that impacted our cohort definitions. Likewise, we ended our observation period at September 30, 2015 to avoid diagnostic coding discrepancies due to implementation of ICD-10-CM on October 1, 2015.…”

Anticonvulsant use in persons living with dementia: When is it justified?

“…Based on the available evidence, no good justification exists for using valproic acid to manage BPSD. Despite that, 13.4% of NH residents with ADRD received valproic acid in 2019, including 21% of those with disruptive behavior disorders 1 . One might speculate that this is being used for indications other than BPSD, such as migraine prophylaxis or bipolar disorder, but the prevalence of these conditions cannot explain away this level of use 3,4 .…”