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

Abstract

Background In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long‐stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. Methods Using an 80% sample of fee‐for‐service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time‐series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011–June 30, 2012) and after (July 1, 2012–September 30, 2015) ARI implementation. Results We identified 874,487 long‐stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI‐associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI‐associated increases in non‐benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post‐ARI membership in the psychosis and Parkinson's cohorts. Conclusions Our study documents antipsychotic use significantly declined in non‐ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI‐associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make‐up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Trends in use of antipsychotics and psychoactive drugs in older patients after major surgery

“…Our study suggests that clinicians may have substituted haloperidol and benzodiazepines with other psychoactive drugs. Similar trends of decreasing antipsychotic use and increasing antiepileptic use have been reported in the U.S. nursing homes since the launch of the national antipsychotic reduction initiative in 2012 32 . In the postoperative period, the alternative drugs were quetiapine, trazodone, gabapentin, melatonin, ramelteon, and dexmedetomidine.…”

“…Similar trends of decreasing antipsychotic use and increasing antiepileptic use have been reported in the U.S. nursing homes since the launch of the national antipsychotic reduction initiative in 2012. 32 In the postoperative period, the alternative drugs were quetiapine, trazodone, gabapentin, melatonin, ramelteon, and dexmedetomidine. These alternative drugs exhibit a range of efficacy and toxicity with varying degrees of central nervous system adverse effects, such as sedation, dizziness, and gait instability.…”