Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review

BMC Geriatrics, Jan 2017

Background The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. Methods We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic. Results Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality. Conclusions Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement.

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

http://www.biomedcentral.com/content/pdf/s12877-017-0428-1.pdf

Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review

Cioltan et al. BMC Geriatrics Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review Hannah Cioltan 0 1 2 Samah Alshehri 2 3 Carol Howe 2 5 Jeannie Lee 0 2 3 Mindy Fain 0 2 4 Howard Eng 1 2 3 Kenneth Schachter 1 2 Jane Mohler 0 1 2 3 4 0 Arizona Center on Aging, College of Medicine, University of Arizona , Tucson, Arizona , USA 1 College of Public Health, University of Arizona , Tucson, Arizona , USA 2 University of Arizona, University of Washington, Healthy Brain Research University of Pennsylvania, University of South Network Carolina, Oregon Health and Science University, Collaborating Centers and University of Illinois at Chicago 3 College of Pharmacy, University of Arizona , Tucson, Arizona , USA 4 Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona , Tucson, Arizona , USA 5 University of Arizona Health Sciences Library , Tucson , USA Background: The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use. Methods: We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic. Results: Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality. Conclusions: Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement. Antipsychotics; Nursing homes; Dementia; Behavioral symptoms - Background The 1987 Omnibus Budget Reconciliation Act’s Nursing Home Reform Law, was enacted to improve patientcentered nursing home care quality, and included standards regarding freedom from unnecessary drugging; freedom from chemical restraints; and rights to be informed about, participate in, and refuse treatment [1].In 2005, the Food and Drug Administration (FDA) placed a black box warning on antipsychotic medications (APMs) use in elderly patients because of the dangerous health outcomes associated with use including mortality [2]. In a 2011 report from the Office of Inspector General, it was determined 83% of Medicare claims for APMs in nursing home residents were associated with off-label conditions [3]. Following this, in March 2012, the Centers for Medicare and Medicaid Services (CMS) launched an education and training, and oversight and provider accountability initiative targeted to provide appropriate, resident-centered dementia care to decrease the use of APMs in nursing homes nationwide by 15%. CMS added two quality measures on the Nursing Home Compare website related to APMs including the percent of long-stay residents who received an APM [4]. Despite these gains, APM use in elderly nursing home patients has continued, with 1 in 5 nursing home residents treated with APMs [5]. This problem will only grow in magnitude if not addressed. By 2050 the population of older adults aged 65 and older is projected to reach 83.7 million, almost doubling the estimated 2012 elder population of 43.1 million [6]. In 2012 15,700 nursing homes served 1.4 million residents; the number of elders residing in nursing homes will only increase with our increasing older population [7]. APMs are approved by the FDA for the treatment of schizophreni (...truncated)


This is a preview of a remote PDF: http://www.biomedcentral.com/content/pdf/s12877-017-0428-1.pdf

Hannah Cioltan, Samah Alshehri, Carol Howe, Jeannie Lee, Mindy Fain, Howard Eng, Kenneth Schachter, Jane Mohler. Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review, BMC Geriatrics, 2017, pp. 32, 17, DOI: 10.1186/s12877-017-0428-1