Abstract
COVID-19 has had devastating effects on the health and well-being of older adult residents and health care professionals in nursing homes. Uncertainty about the associated consequences of these adverse effects on the use of medications common to this care setting remains. To examine the association between the COVID-19 pandemic and prescription medication changes among nursing home residents. This population-based cohort study with an interrupted time-series analysis used linked health administrative data bases for residents of all nursing homes (N = 630) in Ontario, Canada. During the observation period, residents were divided into consecutive weekly cohorts. The first observation week was March 5 to 11, 2017; the last observation week was September 20 to 26, 2020. Onset of the COVID-19 pandemic on March 1, 2020. Weekly proportion of residents dispensed antipsychotics, benzodiazepines, antidepressants, anticonvulsants, opioids, antibiotics, angiotensin receptor blockers (ARBs), and angiotensin-converting enzyme (ACE) inhibitors. Autoregressive integrated moving average models with step and ramp intervention functions tested for level and slope changes in weekly medication use after the onset of the pandemic and were fit on prepandemic data for projected trends. Across study years, the annual cohort size ranged from 75 850 to 76 549 residents (mean [SD] age, 83.4 [10.8] years; mean proportion of women, 68.9%). A significant increased slope change in the weekly proportion of residents who were dispensed antipsychotics (parameter estimate [β] = 0.051; standard error [SE] = 0.010; P < .001), benzodiazepines (β = 0.026; SE = 0.003; P < .001), antidepressants (β = 0.046; SE = 0.013; P < .001), trazodone hydrochloride (β = 0.033; SE = 0.010; P < .001), anticonvulsants (β = 0.014; SE = 0.006; P = .03), and opioids (β = 0.038; SE = 0.007; P < .001) was observed. The absolute difference in observed vs estimated use in the last week of the pandemic period ranged from 0.48% (for anticonvulsants) to 1.52% (for antipsychotics). No significant level or slope changes were found for antibiotics, ARBs, or ACE inhibitors. In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, although absolute differences were small. There were no significant changes for antibiotics, ARBs, or ACE inhibitors. Studies are needed to monitor whether changes in pharmacotherapy persist, regress, or accelerate during the course of the pandemic and how these changes affect resident-level outcomes.
Highlights
The COVID-19 pandemic has had a devastating effect on the quality of care and lives of at-risk older adults.[1,2] Persons of advanced age with complex chronic conditions, many of whom reside in nursing homes, have high rates of infection[3,4] and adverse health-related outcomes with COVID-19.5,6 In economically advantaged countries, 50% to 80% of COVID-19–related early deaths occurred among older adults in congregate care settings such as nursing homes.[7]
No significant level or slope changes were found for antibiotics, angiotensin receptor blockers (ARBs), or angiotensin-converting enzyme (ACE) inhibitors
In this population-based cohort study, statistically significant increases in the use of antipsychotics, benzodiazepines, antidepressants, anticonvulsants, and opioids followed the onset of the COVID-19 pandemic, absolute differences were small
Summary
The COVID-19 pandemic has had a devastating effect on the quality of care and lives of at-risk older adults.[1,2] Persons of advanced age with complex chronic conditions, many of whom reside in nursing homes, have high rates of infection[3,4] and adverse health-related outcomes with COVID-19.5,6 In economically advantaged countries, 50% to 80% of COVID-19–related early deaths occurred among older adults in congregate care settings such as nursing homes.[7]. A particular concern is that these challenges may have led to a rise in the overuse, misuse, and/or underuse of medications commonly targeted by quality improvement initiatives in the nursing home setting. Worries remain about the potential for increased use of psychotropic medications (eg, antipsychotics, benzodiazepines, and antidepressants) among residents during the pandemic, possibly in response to an increase in depression, anxiety, and responsive behaviors coupled with less access to nonpharmacological interventions.[17,18,19] Using Ontario databases, Stall et al[19] reported small absolute increases (1.0% to 1.6%) in the mean monthly proportion of nursing home residents dispensed antipsychotics and antidepressants (including trazodone hydrochloride) during the period from March 1 to September 30, 2020, relative to January 1 to February 29, 2020. Beyond psychotropics,[19,20,21,22] other therapies of interest that have yet to be investigated in this population include opioids, anticonvulsants, and antibiotics.[20,23,24,25,26] In addition, the initial widespread media reports about the potential risks of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) in relation to COVID-19 may have temporarily altered prescribing patterns for these agents among older residents[27,28,29,30] despite subsequent evidence against these early claims.[31,32,33,34] A recent US study[35] reported an initial peak in prescription dispensations from March 15 to 21, 2020, followed by a drop for several medications (including antibiotics), dispensations declined less and remained more stable for ACE inhibitors and ARBs
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