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

Abstract

Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing. OBJECTIVE To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care. DESIGN, SETTING, AND PARTICIPANTS This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637 426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018. MAIN OUTCOMES AND MEASURES Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics). RESULTS Among the 637 426 individuals in the study (446 538 women and 190 888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31 056 of 145 841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of-0.53% (95% CI,-0.63% to-0.44%; P < .001) until the start of the partnership. At that point, the quarterly rate of decline decreased to-0.29% (95% CI,-0.39% to-0.20%; P < .001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; P = .003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; P < .001; rate change, 0.14%; 95% CI, 0.10%-0.18%; P < .001), reaching 71 492 of 355 716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75 841 of 145 841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; P < .001). Findings were similar when limited to patients with dementia. CONCLUSIONS AND RELEVANCE Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, 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. 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.

Inappropriate Antipsychotic Use: The Impact of Nursing Home Socioeconomic and Racial Composition

“…Additionally, this study only examined antipsychotics. Future studies should consider other psychotropic medications 29 and account for the underreporting of antipsychotics by utilizing drug claims data. 30 Furthermore, there is a significant concern that NHs are diagnosing residents with schizophrenia to reduce rates of inappropriate antipsychotic use, 7 which may be happening disproportionately by race; however, we are unable to account for this in our work.…”

Comparing Three Methods for Reducing Psychotropic Use in Older Demented Spanish Care Home Residents

“…Data from the EMR also allowed us to determine whether, during a particular week, a patient was prescribed any of three psychotropic drug classes commonly used for chemical restraint: antipsychotic drugs (antipsychotics), benzodiazepines and “Z‐medications” (anxiolytics), and sedative antidepressants (antidepressants). While our main interests were antipsychotic and anxiolytic use, we also evaluated the antidepressant use because one study found increased sedative antidepressant use concurrent with efforts to reduce antipsychotics in the United States between 2009 and 2014 …”

“…Such overuse in nursing home settings is considered a human rights issue in the United States, where substantial variation in psychotropic medication prescribing patterns exists . Those findings encouraged the Centers for Medicare and Medicaid Services to enter a partnership with federal and state agencies that sought to reduce psychotropic medication use among nursing home residents with dementia, a successful endeavor …”

Measuring Effects of Nondrug Interventions on Behaviors: Music & Memory Pilot Study

“…We measured agitated and aggressive behaviors in three ways: (1) directly observing residents' behaviors; (2) interviewing staff members about residents' behaviors; and (3) using available administrative data on residents' behaviors. The tool used to directly observe resident behaviors was the Agitation Behavior Mapping Instrument (ABMI).…”

“…1 Addressing these behaviors without the use of chemical restraints is a growing focus of policy makers and funders, including the Centers for Medicare and Medicaid Services. 2 The Alzheimer's Association's official position statement on dementia-related behaviors recommends nonpharmacological approaches for addressing behaviors, but notes "large population-based trials rigorously supporting the evidence of benefit for non-pharmacological therapies are presently lacking,"3(p2) and the quality of existing studies of musicbased interventions for people with dementia varies greatly. 4 In this short report, we present the findings from a pilot study of one popular nonpharmacological, music-based intervention, Music & Memory.…”