Original Study| Volume 15, ISSUE 12, P911-917, December 2014

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Use of Antipsychotic Drugs Among Residents With Dementia in European Long-Term Care Facilities: Results From the SHELTER Study

Published:September 25, 2014DOI:



      Behavioral and psychological symptoms of dementia (BPSD) are common reasons for use of antipsychotic drugs among older individuals with dementia. These drugs are not approved for such use and both the Food and Drug Administration and European Medicines Agency have issued warnings to limit such use.


      This study aimed to describe patterns of antipsychotic drug use in a sample of nursing home residents with dementia in 7 European countries and Israel.


      This cross-sectional, retrospective cohort study used data from the SHELTER study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument.


      Fifty-seven long-term care facilities participated from 8 countries, and the sample included 4156 long-term care residents from these settings. Individuals with dementia, both Alzheimer and non-Alzheimer types, were identified. Potential correlates of any antipsychotic and atypical versus conventional antipsychotic drug use among residents with dementia were identified using generalized estimation equation modeling.


      A total of 2091 individuals with dementia were identified. Antipsychotic drug use among these individuals varied by country, with overall prevalence of use being 32.8% (n = 662). Among antipsychotic users, 7 in 10 were receiving atypical agents. Generalized estimation equation analysis revealed that the strongest correlate of any antipsychotic drug use was severe behavioral symptoms, which increased the likelihood by 2.84. Correlates of atypical versus conventional antipsychotic drug use included psychiatric services, more than 10 medications, moderate behavioral symptoms, and female gender.


      Despite recommendations to avoid the use of antipsychotic drugs in patients with dementia, a large proportion of residents in European long-term care facilities continue to receive such agents. Future work should not only establish the appropriateness of such use through outcomes studies, but explore withdrawal strategies as well as alternative treatment modalities.


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        • Cohen-Mansfield J.
        • Billig N.
        Agitated behaviours in the elderly I: a conceptual review.
        J Am Geriatr Soc. 1998; 36: 7-12
        • O’Donnell B.F.
        • Drachman D.A.
        • Barnes H.J.
        • et al.
        Incontinence and troublesome behaviors predict institutionalization in dementia.
        J Geriatr Psychiatry Neurol. 1992; 5: 45-52
        • Steele C.
        • Rovner B.
        • Chase G.A.
        • et al.
        Psychiatric symptoms and nursing home placement of patients with Alzheimer’s disease.
        Am J Psychiatry. 1990; 147: 1049-1051
        • De Vugt M.E.
        • Stevens F.
        • Aalten P.
        • et al.
        A prospective study of the effects of behavioral symptoms on the institutionalization of patients with dementia.
        Int Psychogeriatr. 2005; 17: 577-589
        • Ryu S.H.
        • Ha J.H.
        • Park D.H.
        • et al.
        Persistence of neuropsychiatric symptoms over six months in mild cognitive impairment in community-dwelling Korean elderly.
        Int Psychogeriatr. 2011; 23: 214-220
        • Tan L.L.
        • Wong H.B.
        • Allen H.
        The impact of neuropsychiatric symptoms of dementia on distress in family and professional caregivers in Singapore.
        Int Psychogeriatr. 2005; 17: 253-263
        • Huang S.S.
        • Lee M.C.
        • Liao Y.C.
        • et al.
        Caregiver burden associated with behavioral and psychological symptoms of dementia (BPSD) in Taiwanese elderly.
        Arch Gerontol Geriatr. 2012; 55: 55-59
        • Hermann N.
        Recommendations for the management of behavioural and psychological symptoms of dementia.
        Can J Neuro Sci. 2001; 28: 96-107
      1. Food and Drug Administration. Public Health Advisory: Deaths with antipsychotics in elderly patients with behavioural disturbances. Available at: Accessed August 15, 2014.

      2. Food and Drug Administration. Public Health Advisory: Deaths with antipsychotics in elderly patients with behavioural disturbances, 2011 update. Available at: Accessed July 26, 2012.

      3. European Medicines Agency. Priorities for drug safety research: Safety aspects of antipsychotics in demented patients. Available at: Accessed July 26, 2012.

        • Mitka M.
        CMS seeks to reduce antipsychotic use in nursing home residents with dementia.
        JAMA. 2012; 308: 119-121
        • Liperoti R.
        • Mor V.
        • Lapane K.L.
        • et al.
        The use of atypical antipsychotics in nursing homes.
        J Clin Psychiatry. 2003; 64: 1106-1112
        • Briesacher B.A.
        • Limcangco M.R.
        • Simoni-Wastila L.
        • et al.
        The quality of antipsychotic drug prescribing in nursing homes.
        Arch Intern Med. 2005; 165: 1280-1285
        • Bronskill S.E.
        • Anderson G.M.
        • Sykora K.
        • et al.
        Neuroleptic drug therapy in older adults newly admitted to nursing homes: incidence, dose and specialist contact.
        J Am Geriatr Soc. 2004; 52: 749-755
        • Rochon P.A.
        • Stukel T.A.
        • Bronskill S.E.
        • et al.
        Variation in nursing home antipsychotic prescription rates.
        Arch Intern Med. 2007; 167: 676-683
        • Chen Y.
        • Briesacher B.
        • Field T.
        • et al.
        Unexplained variation across US nursing homes in antipsychotic prescribing rates.
        Arch Intern Med. 2010; 170: 89-95
        • Wetzels R.B.
        • Zuidema S.U.
        • de Jonghe J.F.M.
        • et al.
        Prescribing patterns of antipsychotic drugs in nursing home residents with dementia.
        Int Psychogeriatr. 2011; 23: 1249-1259
        • Richter T.
        • Mann E.
        • Meyer G.
        • et al.
        Prevalence of psychotropic medication use among German and Austrian nursing home residents: A comparison of 3 cohorts.
        J Am Med Dir Assoc. 2012; 13: 187.e7-187.e13
        • Azermai M.
        • Elseviers M.
        • Petrovic M.
        • et al.
        Assessment of antipsychotic prescribing in Belgian nursing home.
        Int Psychogeriatr. 2011; 23: 1240-1248
        • Alanen H.-M.
        Antipsychotic use among older persons in long-term institutional and home care (Psykoosilääkkeiden käyttö vanhusten pitkäaikaisessa laitos-ja kotihoidossa).
        ([dissertation]) Tampere University Press, Tampere, Finland2007
        • Ballard C.
        • Hanney M.L.
        • Theodoulou M.
        • et al.
        The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomized placebo-controlled trial.
        Lancet Neurol. 2009; 8: 151-157
        • Onder G.
        • Carpenter I.
        • Finne-Soveri H.
        • et al.
        Assessment of nursing home residents in Europe: The Services and Health for Elderly in Long TERm care (SHELTER) study.
        BMC Health Serv Res. 2012; 12: 5
        • Hirdes J.P.
        • Ljunggren G.
        • Morris J.N.
        • et al.
        Reliability of the interRAI suite of assessment instruments: A 12-country study of an integrated health information system.
        BMC Health Serv Res. 2008; 8: 277
        • Gray L.C.
        • Berg K.
        • Fries B.E.
        • et al.
        Sharing clinical information across care settings: the birth of an integrated assessment system.
        BMC Health Serv Res. 2009; 9: 71
        • Landi F.
        • Sgadari A.
        • Zuccala G.
        • et al.
        A brief training program on resident assessment instrument improves motivation of nursing home staff.
        J Nutr Health Aging. 1999; 3: 24-28
        • Foebel A.D.
        • Hirdes J.P.
        • Heckman G.A.
        • et al.
        • on behalf of the ideas PNC Investigators
        Diagnostic data for neurological conditions in standardized assessments in home care, nursing home and mental health care settings: A validity study.
        BMC Health Serv Res. 2013; 13: 457
        • Morris J.N.
        • Fries B.E.
        • Morris S.A.
        Scaling ADLs within the MDS.
        J Gerontol A Biol Sci Med Sci. 1999; 54: M546-M553
        • Morris J.N.
        • Fries B.E.
        • Mehr D.R.
        • et al.
        MDS Cognitive Performance Scale.
        J Gerontol. 1994; 49: M174-M182
        • Perlman C.M.
        • Hirdes J.P.
        The aggressive behavior scale (ABS): A new scale to measure aggression based on the MDS.
        J Am Geriatr Soc. 2008; 56: 2298-2303
        • Burrows A.
        • Morris J.N.
        • Simon S.
        • et al.
        Development of a Minimum Data Set-Based Depression Rating Scale for use in nursing homes.
        Age Ageing. 2000; 29: 165-172
        • Pekkarinen L.
        • Elovainio M.
        • Sinervo T.
        • et al.
        Nursing working conditions in relation to restraint practices in long-term care units.
        Med Care. 2006; 44: 1114-1120
        • Feng Z.
        • Hirdes J.P.
        • Smith T.F.
        • et al.
        Use of physical restraints and antipsychotic medications in nursing homes: A cross-national study.
        Int J Geriatr Psychiatry. 2009; 24: 1110-1118
        • Finne-Soveri H.
        • Hammar T.
        • Noro A.
        Measuring quality of long-term institutional care in Finland.
        Eurohealth. 2010; 16: 8-10