Nursing Home Characteristics Associated with High and Low Levels of Antipsychotic, Benzodiazepine, and Opioid Prescribing to Residents with Alzheimer’s Disease and Related Dementias: A Cross-Sectional Analysis

  • Molly Candon
    Address correspondence to Molly Candon, PhD, Penn Center for Mental Health, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, Room 3014, Philadelphia, PA 19104, USA.
    Penn Center for Mental Health, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA

    Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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  • Julie Strominger
    Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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  • Evelyn Gotlieb
    Icahn School of Medicine at Mount Sinai, New York, NY, USA
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  • Donovan T. Maust
    Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA

    Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA

    Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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      We examined the association between nursing home (NH) characteristics and whether NHs had high or low levels of antipsychotic, benzodiazepine, or opioid prescribing to residents with Alzheimer’s disease and related dementias (ADRD). We then measured the likelihood that NHs who were high (low) prescribers of antipsychotics were also high (low) prescribers of benzodiazepines or opioids.


      A retrospective, cross-sectional analysis.

      Setting and Participants

      The sample included 448,128 Medicare beneficiaries diagnosed with ADRD, who resided in 13,151 NHs in 2017.


      Using Medicare claims, the Minimum Data Set, and LTCFocus, we measured the share of NH residents with ADRD who filled ≥1 antipsychotic, benzodiazepine, or opioid prescription in 2017. Using linear probability models with state-clustered SEs, we identified which NH characteristics were associated with being in the top (bottom) quartile of the prescribing distribution for each drug class. Finally, we measured whether NHs who were top-quartile (bottom-quartile) antipsychotic prescribers were more likely to be top-quartile (bottom-quartile) benzodiazepine or opioid prescribers.


      Across NHs, an average of 29.1% of residents with ADRD received an antipsychotic, 30.2% received a benzodiazepine, and 40.9% received an opioid. Smaller NHs and NHs with a larger share of Medicaid-enrolled residents were more likely to be top-quartile prescribers; NHs with more registered nursing care were more likely to be bottom-quartile prescribers. Antipsychotic prescribing tracked closely with benzodiazepine prescribing, but not opioid prescribing.

      Conclusions and Implications

      The overlap between antipsychotic and benzodiazepine prescribing and our finding that some NH characteristics were consistently associated with prescribing across drug classes may support the idea of an organizational culture of prescribing in NHs, which could inform efforts to improve prescribing quality in NHs. Our results also highlight benzodiazepine and opioid use for ADRD, which were more commonly prescribed than antipsychotics in NHs but have received less regulatory attention.


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        • Harris-Kojetin L.
        • Sengupta M.
        • Lendon J.P.
        • Rome V.
        • Valverde R.
        • Caffrey C.
        Long-term care providers and services users in the United States, 2015–2016. National Center for Health Statistics.
        Vital Health Stat. 2019; 3
        • Fashaw S.A.
        • Thomas K.S.
        • McCreedy E.
        • Mor V.
        Thirty-year trends in nursing home composition and quality since the passage of the Omnibus Reconciliation Act.
        J Am Med Dir Assoc. 2020; 21: 233-239
        • US Government Accountability Office
        Antipsychotic drug use: HHS has initiatives to reduce use among older adults in nursing homes, but should expand efforts to other settings.
        Date: 2015
        Date accessed: April 27, 2022
        • Gurwitz J.H.
        • Bonner A.
        • Berwick D.M.
        Reducing excessive use of antipsychotic agents in nursing homes.
        JAMA. 2017; 318: 118-119
        • Svarstad B.L.
        • Mount J.K.
        Chronic BZD use in nursing homes: effects of federal guidelines, resident mix, and nurse staffing.
        J Am Geriatr Soc. 2001; 49: 1673-1678
        • Castle N.G.
        • Hanlon J.T.
        • Handler S.M.
        Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in US nursing homes from 1996 through 2006.
        Am J Geriatr Pharmacother. 2009; 7: 143-150
        • Cioltan H.
        • Alshehri S.
        • Howe C.
        • et al.
        Variation in use of antipsychotic medications in nursing homes in the United States: a systematic review.
        BMC Geriatr. 2017; 17: 32
        • Hughes C.M.
        • Lapane K.L.
        • Mor V.
        Influence of facility characteristics on use of antipsychotic medications in nursing homes.
        Med Care. 2000; 38: 1164-1173
        • Hunnicutt J.N.
        • Baek J.
        • Alcusky M.
        • et al.
        Geographic variation in the initiation of commonly used opioids and dosage strength in United States nursing homes.
        Med Care. 2018; 56: 847-854
        • Chen Y.
        • Briesacher B.A.
        • Field T.S.
        • Tjia J.
        • Lau D.T.
        • Gurwitz J.H.
        Unexplained variation across US nursing homes in antipsychotic prescribing rates.
        Arch Intern Med. 2010; 170: 89-95
        • Daneman N.
        • Gruneir A.
        • Newman A.
        • et al.
        Antibiotic use in long-term care facilities.
        J Antimicrob Chemother. 2011; 66: 2856-2863
        • Rochon P.A.
        • Stukel T.A.
        • Bronskill S.E.
        • et al.
        Variation in nursing home antipsychotic prescribing rates.
        Arch Intern Med. 2007; 167: 676-683
        • Hughes C.M.
        • Lapane K.
        • Watson M.C.
        • Davies H.T.O.
        Does organisational culture influence prescribing in care homes for older people?.
        Drugs Aging. 2007; 24: 81-93
        • Huybrechts K.F.
        • Rothman K.J.
        • Brookhart M.A.
        • et al.
        Variation in antipsychotic treatment choice across US nursing homes.
        J Clin Psychopharmacol. 2012; 32: 11-17
        • Tjia J.
        • Gurwitz J.H.
        • Briesacher B.A.
        Challenge of changing nursing home prescribing culture.
        Am J Geriatr Pharmacother. 2012; 10: 37-46
        • Dorsey E.R.
        • Rabbani A.
        • Gallagher S.A.
        • et al.
        Impact of FDA black box advisory on antipsychotic medication use.
        Arch Intern Med. 2010; 170: 96-103
        • 2019 American Geriatrics Society Beers Criteria® Update Expert Panel
        American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.
        J Am Geriatr Soc. 2019; 67: 674-694
        • Wang P.S.
        • Bohn R.L.
        • Glynn R.J.
        • Mogun H.
        • Avorn J.
        Hazardous BZD regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture.
        Am J Psychiatry. 2001; 158: 892-898
        • O'Mahony D.
        • O'Sullivan D.
        • Byrne S.
        • O'Connor M.N.
        • Ryan C.
        • Gallagher P.
        STOPP/START criteria for potentially inappropriate prescribing in older people: version 2.
        Age Ageing. 2015; 44 (Erratum in: Age Ageing. 2018;47:489): 213-218
        • Kales H.C.
        • Gitlin L.N.
        • Lyketsos C.G.
        Assessment and management of behavioral and psychological symptoms of dementia.
        BMJ. 2015; 350: h369
        • Maust D.T.
        • Strominger J.
        • Bynum J.P.W.
        • et al.
        Prevalence of psychotropic and opioid prescription fills among community-dwelling older adults with dementia in the US.
        JAMA. 2020; 324: 706-708
        • Mehta H.B.
        • Kuo Y.F.
        • Raji M.
        • Li S.
        • Westra J.
        • Goodwin J.S.
        Time trends in opioid use by dementia severity in long-term care nursing home residents.
        J Am Med Dir Assoc. 2021; 22: 124-131.e1
        • Jensen-Dahm C.
        • Gasse C.
        • Astrup A.
        • Mortensen P.B.
        • Waldemar G.
        Frequent use of opioids in patients with dementia and nursing home residents: A study of the entire elderly population of Denmark.
        Alzheimers Dement. 2015; 11: 691-699
        • Shen C.
        • Zhao X.
        • Dwibedi N.
        • Wiener R.C.
        • Findley P.A.
        • Sambamoorthi U.
        Opioid use and the presence of Alzheimer's disease and related dementias among elderly Medicare beneficiaries diagnosed with chronic pain conditions.
        Alzheimers Dement. 2018; 7: 661-668
        • LTCFocus Public Use Data
        Sponsored by the National Institute on Aging (P01 AG027296) through a cooperative agreement with the Brown University School of Public Health.
        Date accessed: April 27, 2022
        • Centers for Medicare & Medicaid Services
        Provider of services current files.
        • Centers for Medicare & Medicaid Services
        Nursing Home Compare.
        • Centers for Medicare & Medicaid Services
        Chronic conditions data warehouse. Condition categories.
        • Research Data Assistance Center
        Long term care Minimum Data Set (MDS) 3.0.
        (Available from)
        Date accessed: April 27, 2022
        • Gorges R.J.
        • Konetzka R.T.
        Factors associated with racial differences in deaths among nursing home residents with COVID-19 infection in the US.
        JAMA Netw Open. 2021; 4: e2037431
        • Yabroff K.R.
        • Kirby J.
        • Zodet M.
        Association of insurance gains and losses with access to prescription drugs.
        JAMA Intern Med. 2017; 177: 1531-1532
        • Cook B.L.
        • Wang Y.
        • Sonik R.
        • et al.
        Assessing provider and racial/ethnic variation in response to the FDA antidepressant box warning.
        Health Serv Res. 2019; 54: 255-262
        • Morden N.E.
        • Chyn D.
        • Wood A.
        • Meara E.
        Racial inequality in prescription opioid receipt - role of individual health systems.
        N Engl J Med. 2021; 385: 342-351
        • Liu Y.
        • Colditz G.A.
        • Kozower B.D.
        • et al.
        Association of Medicaid Expansion under the Patient Protection and Affordable Care Act with non–small cell lung cancer survival.
        JAMA Oncol. 2020; 6: 1289-1290
        • Huang F.L.
        Alternatives to logistic regression models when analyzing cluster randomized trials with binary outcomes.
        Prev Sci. Published online April 6, 2021. doi:;
        • Hellevik O.
        Linear versus logistic regression when the dependent variable is a dichotomy.
        Qual Quant. 2007; 43: 59-74
        • Institute of Medicine (US) Committee on Nursing Home Regulation
        Monitoring nursing home performance. In: Improving the Quality of Care in Nursing Homes.
        National Academies Press (US). 1986;
        • Cameron C.A.
        • Miller D.L.
        A practitioner’s guide to cluster-robust inference.
        J Hum Resources. 2015; 50: 317-372
        • Fashaw S.
        • Chisholm L.
        • Mor V.
        • et al.
        Inappropriate antipsychotic use: the impact of nursing home socioeconomic and racial composition.
        J Am Geriatr Soc. 2020; 68: 630-636
        • Weech-Maldonado R.
        • Lord J.
        • Pradhan R.
        • et al.
        High Medicaid nursing homes: organizational and market factors associated with financial performance.
        Inquiry. 2019; 56 (:46958018825061)
        • Mikelyte R.
        • Abrahamson V.
        • Hill E.
        • Wilson P.M.
        Factors influencing trends in opioid prescribing for older people: a scoping review.
        Prim Health Care Res Dev. 2020; 21: e36
        • Cook B.
        • Creedon T.
        • Wang Y.
        • et al.
        Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse.
        Drug Alcohol Depend. 2018; 187: 29-34
        • Husebo B.S.
        • Ballard C.
        • Cohen-Mansfield J.
        • Seifert R.
        • Aarsland D.
        The response of agitated behavior to pain management in persons with dementia.
        Am J Geriatr Psychiatry. 2014; 22: 708-717
        • Corbett A.
        • Husebo B.
        • Malcangio M.
        • et al.
        Assessment and treatment of pain in people with dementia.
        Nat Rev Neurol. 2012; 8: 264-274