Abstract
Objective
Antipsychotic reduction in nursing homes has been a focus of research and policy attention
for several decades; however, there is evidence that these initiatives may have had
unintended consequences, such as medication substitution and changes in diagnosis
coding. Our objectives were to describe temporal changes in the use of antipsychotics,
potential substitution medications, and diagnoses and symptoms used to establish the
appropriateness of antipsychotic prescribing.
Design
Repeated cross-sectional study design.
Setting and Participants
Individuals, 66 to 105 years of age, living in nursing homes in Ontario, Canada between
April 1, 2010 and December 31, 2019.
Methods
Linked health administrative and clinical data were used to estimate the quarterly
prevalence of dispensed antipsychotics, antidepressants, anticonvulsants, and benzodiazepines,
as well as diagnoses and symptoms (eg, schizophrenia and delusions) applied to establish
the appropriateness of antipsychotic use. Generalized linear models with generalized
estimating equations, binomial distribution, and identity link function estimated
the absolute changes over time among the population overall, by dementia diagnosis,
and by severity of aggressive behaviors and cognitive impairment.
Results
Among over 70,000 nursing home residents each quarter, we observed general declines
in antipsychotic (−0.70% per year [95% confidence limit (CL) −0.74%, −0.66%]) and
benzodiazepine use (−1.17% per year [95% CL -1.20%, −1.14%]), and increases in antidepressant
(0.89% per year [95% CL 0.84%, 0.94%]) and anticonvulsant use (1.06% per year [95%
CL 1.03%, 1.09%]). Although initially stable, the coding of delusions increased from
3.5% to 10.2% (1.18% per year [95% CL 1.12%, 1.24%]) between 2014 and 2019, whereas
schizophrenia remained stable. Increases in antidepressant use and recorded delusions
were more pronounced among residents with dementia and aggressive behaviors.
Conclusions and Implications
Medication substitution and changes in diagnosis/symptom coding may be potential unintended
consequences of initiatives to reduce inappropriate antipsychotic use. How this corresponds
to resident-level prescribing and clinical outcomes warrants further investigation.
Keywords
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Article info
Publication history
Published online: February 07, 2022
Footnotes
This study received funding from the Ontario Neurodegenerative Disease Research Initiative (ONDRI) through the Ontario Brain Institute, an independent nonprofit corporation, funded partially by the Ontario government. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Mr. Harris is supported by the Alzheimer Society Research Program (ASRP) Doctoral Award and the Drug Safety Cross-Disciplinary Training Program (DSECT). Dr. Austin is supported by a Mid-Career Investigator Award from the Heart and Stroke Foundation. Dr. Iaboni is supported by an Academic Scholar Award from the Department of Psychiatry, University of Toronto. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.
The authors declare no conflicts of interest.
Identification
Copyright
© 2022 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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June 15, 2022
June 2022 Issue: Drug Prescribing Dilemmas in Geriatric Medicine
Host: Dr. Karl Steinberg. Featuring Dr. Philip Sloane, Dr. Mallory Brown, special guest: Josh Niznik, PharmD. Recorded on May 25, 2022.
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