Antipsychotics Still Widely Used in U.S. Nursing Homes

Many Americans in nursing homes still get powerful antipsychotic medications, despite recent attempts by the U.S. government to rein in the practice, two new studies show.

The practice can control problem behaviors, but can also threaten physical health. Since the FDA instituted a "black box" warning in 2005, one study found a 19% decrease in the prescription of atypical antipsychotics in elders with dementia. But the researchers found that in 2008, antipsychotics still represented 9% of all prescriptions in this group.

"The [2005] safety warning pertained to an increased risk of death among individuals using these drugs, so the public health ramifications of use of these drugs in elderly people with dementia, often in nursing homes, which we consider a vulnerable population, is concerning," says E. Ray Dorsey, MD, an assistant professor of neurology at the University of Rochester Medical Center and lead author of one of the studies in the Archives of Internal Medicine.

Antipsychotics are widely used "off label" to control difficult behavior in elderly people with dementia. Indeed, Dorsey says he suspects that the vast majority of the use documented in his research is "off label."

In the United States, no antipsychotics are approved to calm behavior, although one such drug, risperidone (Risperdal), is approved for that indication in Canada. Black box warnings are rare for off-label use.

"There's a real disconnect between the evidence and the prescribing patterns," says Becky A. Briesacher, coauthor of the second study in the same issue, and an associate professor of medicine at the University of Massachusetts Medical School in Worcester.

Briesacher's study concluded that seniors who were admitted to nursing homes that already had high rates of prescribing antipsychotics were more likely to get these drugs as well, indicating that an "organizational culture" may be driving the trend.

Dorsey's study looked mainly at atypical antipsychotic drug use. The researchers looked at the number of times the subject of antipsychotics was brought up during doctors' office visits.

Between the beginning of January 2003 and March 2005, these mentions accelerated at a rate of 34% per year, 16% among elders with dementia. In the year after the advisory was issued, mention of atypical drugs dropped 2% overall and 19% among the dementia population. The declines were evident within one month of the warning.

And by 2008, antipsychotic use among this older population decreased more than 50%. It's not clear if that drop was "enough," or if the drugs are still being overprescribed, says Dorsey.

"Whether or not 19% is an appropriate decrease or not is uncertain," he says. "We can say that atypical antipsychotics are commonly prescribed, they have no indication for this use and there is limited evidence for their efficacy," he addsd.

The second study found that almost one third of residents in nursing homes were prescribed antipsychotics and that one third of that number did not have dementia or psychosis.

Newly arrived residents were more likely to receive this type of drug if they were in a nursing home that routinely prescribed such drugs, suggesting that organizational culture and not patients are driving the trend.

"If you enter a nursing home that has a higher proportion of people on antipsychotics, you are also likely to be put on antipsychotics," Briesacher says.

— Source: Brigham and Women's Hospital