The broad majority of antipsychotic prescriptions are initiated in nursing homes, but almost 20% were initiated in hospitals and many were continued from other settings, according to a new study published online this month in the Journal of the American Geriatrics Society.

The results suggest that antipsychotic treatment needs to be assessed after transitions of care from settings other than the nursing home.

“I think when these drugs are started, there needs to be good communication about why they were started and the perception of continued need,” corresponding author Ryan Carnahan of the University of Iowa told Skilled Nursing News.

Of 7,496 residents with new antipsychotic use in nursing homes, 64% had the drugs initiated in the skilled setting. But a notable portion of patients, at 18.6%, appeared to have had the drugs initiated in hospitals, while another 17.5% seemed to have had the antipsychotics first dispensed when they were outpatients.

The study used a linked dataset of Chronic Condition Data Warehouse Medicare claims and Long-Term Care Minimum Data Set (MDS) 3.0 to determine the care settings.

“NHs are in a position to advocate for initiation and discontinuation of antipsychotics, and interventions to reduce unnecessary drug initiation should primarily target NHs if antipsychotics are typically initiated in NHs,” the study authors wrote.

“However, if antipsychotics are more often started before NH entry, such as in hospitals or the outpatient setting, interventions in these settings could be helpful in reducing unnecessary antipsychotic use in NHs.”

Of patients who started antipsychotics during their stay in a nursing home, just 63.2% had evidence of a potentially appropriate indication in the MDS, Carnahan noted in an e-mail. Of all sampled residents, 40.4% were first dispensed the antipsychotics within a week after their admission to a nursing home.

“When they’re coming in on those drugs, when most of them are getting continued or getting started early, there’s not a lot of evidence that people are getting rid of the drugs that patients are coming in with,” he said.

The study highlighted the need for better documentation of patient conditions, as well as the importance of better communication between care providers, Carnahan said. Communication during the transition is particularly crucial, and could be improved by a so-called “warm handoff,” where nurses interact with one another at transitions to provide information about the patients, he added.

Reducing unnecessary antipsychotic drug use has long been a priority for the Centers for Medicare & Medicaid Services (CMS), with the agency last year reporting a decline of 34.1% between 2011 and 2017.

Given how difficult the transition to a nursing home can be for residents, getting as much information as possible is key to making sure patients have the best care possible— and that includes no unnecessary antipsychotics.

“They’re confused, they’re entering a new environment, they don’t know their caregivers and their caregivers don’t know them,” Carnahan said. “So when someone gets started on an antipsychotic that quickly, we don’t know there wasn’t a good reason for it. But it does raise questions: Did they consider what was going on?”

Written by Maggie Flynn