Antipsychotic Use during the COVID-19 Pandemic in a Portuguese Dementia Outpatient Clinic

This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution.

Ethnic Disparities in Antipsychotic Drug Use in British Columbia: A Cross-Sectional Retrospective Study

Introduction People living with dementia (PLWD) take five more medications on average than those without dementia. This can increase the risk of medication-related harm, defined as any negative outcome, harm or injury caused by taking a medication. The aim of this systematic review was to identify studies that reported the prevalence of medication-related harm in PLWD and to assess its impact by evaluating various outcomes. Methods Twelve databases were searched from date of inception to April 2023. Papers published in English, reporting on the prevalence and/or adverse outcomes of medication-related harm in PLWD using any study design were eligible for inclusion. Methodological quality was assessed using the Cochrane Risk of Bias 2 tool for randomised controlled trials (RCTs) or the Risk of Bias in Non-randomised Studies of Exposures for non-randomised studies. A meta-analysis was conducted to determine combined hazard ratios (HRs) and 95% confidence intervals (CIs) on studies with similar harm-related outcomes using Review Manager software. Results Ninety-seven studies were included in the review; 93 were non-randomised studies and four were RCTs. Quality assessments found all four RCTs and the majority of non-randomised studies (n = 58) to be at a low risk of bias. Adverse health outcomes, including hospitalisations and mortality, were most frequently reported (n = 45 studies), with psychoactive medications (such as antipsychotic medications) being the most implicated class of medicines (n = 54 studies). Analysis showed that the use of antipsychotics was associated with a significantly increased mortality risk in six studies (n = 25,715 participants; HR = 1.42; 95% CI 1.10–1.84; p = 0.008). Conclusion This systematic review is the first to report the impact of medication-related harm among PLWD, with evidence to suggest that antipsychotic medication use is associated with mortality. However, the included studies had high heterogeneity, which made it difficult to draw comparisons between studies.

Teamwork Needed To Improve Medication Safety in PA/LTC

The objective of this study is to examine how nursing homes changed their use of antipsychotic and other psychoactive medications in response to Nursing Home Compare's initiation of publicly reporting antipsychotic use in July 2012. The study includes all state recertification surveys (n = 40,415) for facilities six quarters prior and post the initiation of public reporting. Using a difference-in-difference framework, the change in use of antipsychotics and other psychoactive medications is compared for facilities subject to public reporting and facilities not subject to reporting. The percentage of residents using antipsychotics, hypnotics, or any psychoactive medication is found to decline after public reporting. Facilities subject to reporting experienced an additional decline in antipsychotic use (-1.94 vs. -1.40 percentage points) but did not decline as much for hypnotics (-0.60 vs. -1.21 percentage points). Any psychoactive use did not vary with reporting status, and the use of antidepressants and anxiolytics did not change. Public reporting of an antipsychotic quality measure can be an effective policy tool for reducing the use of antipsychotic medications--though the effect many only exist in the short run.

This study describes the changing trends in antipsychotic use among youths aged 18 years and younger and in age subgroups (zero to five, six to 12, and 13 to 18 years) in the Florida Medicaid program. The study used Florida Medicaid claims data associated with approximately 1.2 million children and adolescent enrollees per year to describe monthly antipsychotic use from July 2002 to December 2005. A preliminary examination of trends indicated that antipsychotic use might be different for the periods before May 2004 and after April 2004. For this reason, piecewise regression was used to compare the trends for these two periods. This study found significant increases in the use of antipsychotic medications for all three age groups from July 2002 to April 2004. The greatest rate of growth was for the 13- to 18-year age group, and the least rate of growth was for the zero- to five-year age group. From May 2004 to December 2005 antipsychotic utilization trends were flat for youths age 18 years and younger and for the six- to 12-year and the 13- to 18-year age groups. For preschool-age children (the zero- to five-year age group), there was a slight but significant decline in antipsychotic use. Significant changes were also observed in the specific second-generation antipsychotic agents prescribed. Although risperidone remained the most frequently prescribed antipsychotic, its use declined significantly from May 2004 to December 2005. Olanzapine use also declined during this period. On the other hand, aripiprazole use increased significantly throughout the study period, with usage among the 13- to 18-year age group almost equaling that of risperidone by December 2005. The lack of growth in antipsychotic prescribing after the spring of 2004 represents a significant departure from historical trends. Although some in-state policies may have affected these trends, it appears that the timing and extent of the changes occurred shortly after the Food and Drug Administration required warnings on second-generation antipsychotic medications related to weight gain, glucose levels, and diabetes. They appeared immediately after the black box warning for pediatric antidepressant medications, and they appeared shortly after the Joint American Diabetes and American Psychiatric Association Consensus Statement. These factors suggest the existence of a prescribing community that is responsive to evidence and to professional and regulatory actions based on it.

The inappropriate and excessive use of antipsychotic medications to manage the behavioral and psychological symptoms of dementia1 is a pressing national concern. These symptoms can be acutely distressing for individuals and those around them, but managing them with off-label use of antipsychotic medications carries a high risk of serious or life-threatening adverse effects, as clearly indicated in “black box” warnings that the U.S. Food and Drug Administration has issued. Such medications can also negatively affect quality of life and functional independence without addressing the underlying causes of the symptoms. The National Partnership to Improve Dementia Care in Nursing Homes reported that, in 2011, as many as 24% of nursing home residents with dementia were prescribed antipsychotics.2 Galvanized by the mounting evidence, the Centers for Medicare and Medicaid Services (CMS) launched a national initiative that reduced antipsychotic medication use in nursing homes more than 20% by December 2014. In contrast, there is a conspicuous absence of visible action regarding antipsychotic use in assisted living, which provides care for almost 750,000 older adults3 (equivalent to half the size of the nursing home population)—an oversight noted in a recent Government Accountability Office (GAO) Report.4 As many as 90% of individuals in assisted living residences (ALRs) have some degree of age-related cognitive impairment, and more than 40% have moderate or severe cognitive impairment, but only a minority have severe mental illness.5, 6 Together, these statistics suggest that the majority of antipsychotic use in ALRs is off-label and therefore as inappropriate and dangerous as it is in nursing homes. Analysis of data from the first-ever national survey on ALRs found that 57% of residents with behavioral symptoms were prescribed a medication for their behaviors—22% of all ALR residents, similar to the proportion in nursing homes; the data also showed that 69% of ALRs regularly administered medications to control resident behaviors.6 In addition to concern regarding the proportion of ALRs in which these medications are routinely administered, the staffing configuration in assisted living complicates administration. ALRs are highly diverse, but in general are designed to provide 24-hour supervision, support with activities of daily living (most notably medication management), and at least two meals per day in a homelike environment that promotes dignity, autonomy, and choice.7 ALRs are not required to provide nursing services, and 46% do not have a registered or licensed practical nurse on staff. Furthermore, 21% of ALRs do not require staff to receive specialized trained before administering medications,6 even though untrained staff are twice as likely to commit medication errors as licensed nurses.8 Thus, in many ALRs, untrained staff are responsible for deciding when to administer “as needed” antipsychotic medications.9 Diversity among ALRs reflects, in part, that, unlike nursing homes, they are state as opposed to nationally regulated. In nursing homes, CMS has collaborated with state departments of health to achieve significant reductions in antipsychotic use through national advocacy and regulatory mechanisms. In ALRs, efforts must instead focus on ensuring that changes are promoted at the state and organizational level, such as through initiatives of the American Health Care Association's National Center for Assisted Living, which promoted efforts to reduce the off-label use of antipsychotics in ALRs by 15% by March 2015.10 There is also need to improve the use of nonpharmacological techniques to manage behavioral symptoms of dementia in ALRs through better staff training, support, management, and accountability. Such interventions—which leading organizations including the National Center for Assisted Living, the Alzheimer's Association, and the American Medical Directors Association's Society for Post-Acute and Long-Term Care Medicine have recommended—include environmental modifications, psychosocial and group activities, sensory interventions, and individualized care approaches.11 There is also a clear need for training (particularly for staff designated to handle medications) on the use and side effects of antipsychotics, not just on their proper administration. As the assisted living sector continues to evolve to meet the needs of the aging population, it is imperative to combat the problem of inappropriate antipsychotic medication use in these settings, informed by the successes achieved in nursing homes. Better evidence is needed regarding current medication practices and use of alternative interventions to inform policy and practice change regarding the treatment of behavioral symptoms of dementia in ALRs and to improve related quality of care and quality of life. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Zimmerman, Scales, Wiggins, Cohen, Sloane. Preparation of manuscript: Zimmerman, Scales, Wiggins, Cohen, Sloane. Sponsor's Role: Not applicable.

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

Several antidementia medications have been approved for symptomatic treatment of cognitive and functional impairment due to Alzheimer disease. Antipsychotics are often prescribed off-label for behavioral symptoms. The aim of this study was to describe the basis for regional variation in antidementia and antipsychotic medication use. US nursing homes (n=9735), hospital referral regions (HRR; n=289). Long-stay residents with dementia (n=273,004). Using 2018 Minimum Data Set 3.0 linked to Medicare data, facility information, and Dartmouth Atlas files, we calculated prevalence of use and separate multilevel logistic models [outcomes: memantine, cholinesterase inhibitor (ChEI), antipsychotic use] estimated adjusted odds ratios (aOR) and 95% CIs for resident, facility, and HRR characteristics. We then fit a series of cross-classified multilevel logistic models to estimate the proportional change in cluster variance (PCV). Overall, 20.9% used antipsychotics, 16.1% used memantine, and 23.3% used ChEIs. For antipsychotics, facility factors [eg, use of physical restraints (aOR: 1.08; 95% CI: 1.05-1.11) or poor staffing ratings (aOR: 1.10; 95% CI: 1.06-1.14)] were associated with more antipsychotic use. Nursing homes in HRRs with the highest health care utilization had greater antidementia drug use (aOR memantine: 1.68; 95% CI: 1.44-1.96). Resident/facility factors accounted for much regional variation in antipsychotics (PCV STATE : 27.80%; PCV HRR : 39.54%). For antidementia medications, HRR-level factors accounted for most regional variation (memantine PCV STATE : 37.44%; ChEI PCV STATE : 39.02%). Regional variations exist in antipsychotic and antidementia medication use among nursing home residents with dementia suggesting the need for evidence-based protocols to guide the use of these medications.

Objective: Examination of the impact of the COVID-19 pandemic on rates of antipsychotic medication use, initiation and discontinuation, among newly admitted long-term care residents. Design: Repeated cross-sectional study. Settings and Participants: Long-term care home residents in Alberta, British Columbia and Ontario, Canada assessed with the Minimum Data Set (MDS) 2.0 assessment. The cohort was segmented according to admission during the pandemic (March 2020/2021) and 2 pre-pandemic (March 2018/2019 and March 2019/2020) periods. Methods: Multivariable logistic regression models were fit to characterize the association between long-term care admission during the COVID-19 pandemic and the use of antipsychotic medications. A second set of logistic regression models were fit among residents with follow-up assessments to characterize the association between long-term care admission and antipsychotic initiation/discontinuation at follow-up. All models were adjusted for resident characteristics including sex, age group, Aggressive Behaviour Scale score, Cognitive Performance Scale score, and diagnoses of Alzheimer’s disease and related dementias, anxiety disorder, depression, and bipolar disorder. Results: 21 612 residents admitted during the pandemic and over 30 000 in each pre-pandemic period were included. Antipsychotic use increased during the pandemic period among newly admitted residents from both community (adjusted odds ratio [aOR] 1.20-1.29) and hospital settings (aOR 1.21-1.23). Residents admitted during the pandemic period were more likely to have antipsychotic medications initiated (aOR 1.25-1.26) and less likely to have had them discontinued (aOR 0.74-0.76) at the time of follow-up assessment. Conclusion and Implications: Multiple factors contributed to the observed increase in antipsychotic medication use among newly admitted long-term care home residents during the COVID-19 pandemic: increased medication use at the time of admission, increased medication initiation at follow-up, and decreased medication discontinuation at follow-up. A whole-systems approach that extends beyond long-term care into hospital and community settings is necessary to address this prevalent issue.

Educating Nursing Home Staff in Dementia Sensitive Communication: Impact on Antipsychotic Medication Use

Accessible summary Attention deficit hyperactivity disorder (ADHD) is often missed/underdiagnosed in people with intellectual disability compared to people without intellectual disability. The presence of intellectual disability, autism and challenging behaviour should raise the suspicion of ADHD as comorbid neurodevelopmental disorder. Treatment of ADHD in people with intellectual disability may reduce the need for antipsychotic medications. AbstractThe diagnosis of ADHD is often missed or misdiagnosed in people with intellectual disability. Despite a significant growth in literature on the diagnosis and treatment of ADHD in people without intellectual disability, there have been few studies on ADHD in people with intellectual disability. In this paper, we describe a group of adults with intellectual disability and ADHD disorder open to a specialist community intellectual disability service. We examined the frequency and dose of antipsychotic use and considered whether ADHD disorder medication is associated with a reduced use of psychotropic medication. The study found a high incidence of autism in people with intellectual disability and ADHD. Men with intellectual disability were given the diagnosis of ADHD more often compared to women with intellectual disability. Only 64% of people with ADHD and intellectual disability taking ADHD medication were on antipsychotic medications compared to 93% of people with ADHD and intellectual disability without ADHD medications. This generates several hypotheses such as whether antipsychotic medications are prescribed to control ADHD symptoms, whether use of ADHD medications can reduce the use of antipsychotic medications and/or whether antipsychotics are used to treat underlying psychiatric comorbidities in people with ADHD. Randomised controlled trials are needed to answer the question whether use of ADHD medication reduces the use of antipsychotic medication in people with intellectual disability and ADHD. Further studies are also needed to explore reason for not using ADHD medication in certain patients with ADHD and intellectual disability and what treatment options are effective in treating psychiatric comorbidities in people with ADHD and intellectual disability.

Antipsychotic medications are regularly prescribed in care home residents for the management of behavioural and psychological symptoms of dementia (BPSD) despite questionable efficacy, important adverse effects, and available non-pharmacological interventions. Prescription rates are related to organisational factors, staff training and job satisfaction, patient characteristics, and specific interventions. Psychosocial intervention programmes aimed at reducing the prescription of antipsychotic drugs are available. These programmes may target care home residents (e.g. improving communication and interpersonal relationships) or target staff (e.g. by providing skills for caring for people with BPSD). Therefore, this review aimed to assess the effectiveness of these interventions, updating our earlier review published in 2012. To evaluate the benefits and harms of psychosocial interventions to reduce antipsychotic medication use in care home residents compared to regular care, optimised regular care, or a different psychosocial intervention. We used standard, extensive Cochrane search methods. The latest search date was 14 July 2022. We included individual or cluster-randomised controlled trials comparing a psychosocial intervention aimed primarily at reducing the use of antipsychotic medication with regular care, optimised regular care, or a different psychosocial intervention. Psychosocial interventions were defined as non-pharmacological intervention with psychosocial components. We excluded medication withdrawal or substitution interventions, interventions without direct interpersonal contact and communication, and interventions solely addressing policy changes or structural interventions. We used standard Cochrane methods. Critical appraisal of studies addressed risks of selection, performance, attrition and detection bias, as well as criteria related to cluster randomisation. We retrieved data on the complex interventions on the basis of the TIDieR (Template for Intervention Description and Replication) checklist. Our primary outcomes were 1. use of regularly prescribed antipsychotic medication and 2. Our secondary outcomes were 3. mortality; 4. BPSD; 5. quality of life; 6. prescribing of regularly psychotropic medication; 7. regimen of regularly prescribed antipsychotic medication; 8. antipsychotic medication administered 'as needed'; 9. physical restraints; 10. cognitive status; 11. depression; 12. activities of daily living; and 13. We used GRADE to assess certainty of evidence. We included five cluster-randomised controlled studies (120 clusters, 8342 participants). We found pronounced clinical heterogeneity and therefore decided to present study results narratively. All studies investigated complex interventions comprising, among other components, educational approaches. Because of the heterogeneity of the results, including the direction of effects, we are uncertain about the effects of psychosocial interventions on the prescription of antipsychotic medication. One study investigating an educational intervention for care home staff assessed the use of antipsychotic medication in days of use per 100 resident-days, and found this to be lower in the intervention group (mean difference 6.30 days, 95% confidence interval (CI) 6.05 to 6.66; 1152 participants). The other four studies reported the proportion of participants with a regular antipsychotic prescription. Of two studies implementing an intervention to promote person-centred care, one found a difference in favour of the intervention group (between-group difference 19.1%, 95% CI 0.5% to 37.7%; 338 participants), while the other found a difference in favour of the control group (between-group difference 11.4%, 95% CI 0.9% to 21.9%; 862 participants). One study investigating an educational programme described as "academic detailing" found no difference between groups (odds ratio 1.06, 95% CI 0.93 to 1.20; 5363 participants). The fifth study used a factorial design to compare different combinations of interventions to supplement person-centred care. Results showed a positive effect of medication review, and no clear effect of social interaction or exercise. We considered that, overall, the evidence about this outcome was of low certainty. We found high-certainty evidence that psychosocial interventions intended primarily to reduce antipsychotic use resulted in little to no difference in the number of falls, non-elective hospitalisations, or unplanned emergency department visits. Psychosocial interventions intended primarily to reduce antipsychotic use also resulted in little to no difference in quality of life (moderate-certainty evidence), and BPSD, regular prescribing of psychotropic medication, use of physical restraints, depression, or activities of daily living (all low-certainty evidence). We also found low-certainty evidence that, in the context of these interventions, social interaction and medication review may reduce mortality, but exercise does not. All included interventions were complex and the components of the interventions differed considerably between studies. Interventions and intervention components were mostly not described in sufficient detail. Two studies found evidence that the complex psychosocial interventions may reduce antipsychotic medication use. In addition, one study showed that medication review might have some impact on antipsychotic prescribing rates. There were no important adverse events. Overall, the available evidence does not allow for clear generalisable recommendations.

Guidelines recommend short-term targeted use of antipsychotic medications for behavioral and psychological symptoms of dementia only when other strategies have failed. Antipsychotic prescribing in dementia is common internationally, but data on duration of use are limited. Our objectives were to determine duration, time to initiation, and prevalence of antipsychotic use among people with dementia. This work was a retrospective dynamic cohort study of people aged 65 years or above with dementia in 68 residential aged facilities during the period spanning from 2014 to 2017. Medication administration records were used to identify antipsychotic medication use. Medication outcomes (prevalence, duration, and time to initiation) were estimated using regression. Covariates included comorbidities and sociodemographic and facility characteristics. A total of 5825 residents with dementia were identified. The annual prevalence of antipsychotic use ranged from 27.6% to 32.6%. Mean time to initiation after admission was 308.4 days (for female individuals) and 173.2 days (for male individuals). An overall 65% of people who used antipsychotics did so for >3 months even without psychiatric comorbidities; mean durations were 212.74 (95% confidence interval: 170.24, 255.25) days (for female individuals) and 216.10 (95% confidence interval: 165.31, 266.89) days (for male individuals) at median ages. Antipsychotics are often used longer than recommended. Current guidelines and restrictions may be insufficient to limit antipsychotic medication use. Further efforts are needed to ensure that antipsychotic medications are used as recommended in dementia.

The prevalence of metabolic disturbances associated with long-term use of antipsychotic medications has been widely reported in the literature. The use of atypical antipsychotics for the treatment of delirium in the intensive care unit (ICU) has gained popularity due to a lower potential for adverse effects compared with conventional antipsychotics. However, current studies evaluating safety and efficacy of antipsychotics in the ICU setting do not include metabolic parameters as a potential adverse effect that requires monitoring. It is thought that long-term adverse effects of antipsychotics may be out of context for the intensive care setting. A literature review was conducted to investigate the prevalence of acute hyperglycemia associated with short-term use of antipsychotics, with the purpose of reviewing evidence that hyperglycemia may occur even with short-term use of atypical antipsychotics. A MEDLINE search for acute hyperglycemia from short-term use of antipsychotics resulted in studies involving animal models and healthy volunteers. These studies indicate that acute hyperglycemia may occur after short-term treatment. A review of the literature shows preliminary evidence to suggest that atypical antipsychotics impact glucose sensitivity and induce insulin resistance even after a single dose. Although no studies have been conducted evaluating the impact of hyperglycemia in critically ill patients from the short-term use of atypical antipsychotics for the treatment of delirium, the potential to affect clinical outcomes exist and warrants further research in this area.