The regulatory push to reduce antipsychotic drugs in nursing homes may be correlated to a rise in risk factors for avoidable and non-avoidable hospitalization among residents with behavioral health issues, according to a recent study published in JAMDA, the journal for The Society for Post-Acute and Long-Term Care Medicine.
A team of researchers from the University of Rochester determined that residents with behavioral health issues had a 15% higher risk of non-avoidable hospitalizations, and 9% greater risk for potentially avoidable hospitalizations. According to one of the study’s authors, the results suggest that antipsychotics are over-regulated, a problem heightened by the lack of access to psychiatric expertise in nursing homes.
“The increased risk in this population may have resulted in patients with bipolar disorders having their meds stopped or reduced, an unintended consequence of the National Partnership to Improve Dementia Care, which aims to reduce the use of antipsychotic meds,” Helena Temkin-Greener, a researcher from the University of Rochester School of Medicine, told SNN in an e-mail.
In contrast, the researchers determined that residents with Alzheimer’s and related dementias (ADRD) have significantly lower risk of potentially avoidable hospitalizations (PAH), by 16%. ADRD patients also have 10% lower risk of hospitalizations that the nursing home is not likely to prevent or avoid (N-PAH), according to the study.
The Centers for Medicare & Medicaid Services (CMS) generally discourages the administration of antipsychotics to residents except in cases of schizophrenia, Huntington’s disease, and Tourette’s syndrome as part of the National Partnership to Improve Dementia Care in Nursing Home initiative — a program designed to reduce improper use of the drugs as “psychological restraints” to control residents.
CMS requires the withholding of antipsychotics for patients suffering from dementia, but “bipolar disorder was not included in the CMS definition, and was excluded for no reason. Nursing homes are on a mission to reduce these drugs willy nilly to everyone, and to be so proactive…It’s not surprising that this population may have higher hospitalizations,” Temkin-Greener said.
Dr. Adam Simning, a geriatric psychiatrist at the University of Rochester, said that CMS’s antipsychotic regulations can be “quite challenging.”
More specifically, Simning pointed to the fact that bipolar disorder is a chronic disease and patients frequently require longer-term medication to maintain mental health. Many medications commonly used for bipolar disorder may have serious side effects, and older adults with certain complex medical issues could benefit from antipsychotics.
“If a patient is manic, for example, the antipsychotic can bring the patient back down. It can also prevent more symptoms between episodes,” added Simning, who emphasized that it’s essential to remember that some antipsychotics can have significant side effects as well.
In addition to bipolar disorder, “a smaller population with treatment-resistant major depressive disorder can benefit from adding on an antipsychotic medication in addition to the antidepressant,” he said. “But regulations can create resistance in nursing homes, and they are under pressure not to administer these drugs because it will negatively impact quality metrics,” said Simning.
As CMS has actively pushed the reduction of antipsychotics in nursing homes, the use of these drugs has significantly decreased from 2011 to 2018. In the fourth quarter of 2011, 23.9% of long-stay nursing home residents received an antipsychotic medication; seven years later, the national use of these drugs fell at 14.6%, or a decrease of 39%.
Success has varied by state and CMS region, “with some states and regions having seen a reduction of greater than 45%,” according to CMS.
Even with pressure to reduce the use of antipsychotics across the board, CMS states that the agency recognizes certain contexts for using these drugs, and does not expect total usage to cease completely.
Dr. Thomas Caprio, a geriatrics and aging specialist at the University of Rochester Medical Center, also stressed similar challenges in nursing homes across the board — and not just specific to bipolar disorder. There’s been a “push to reduce or discontinue a whole host of psychotropic medications for patients who have a need for long-standing medication therapy and not surprisingly, they may have worsening of symptoms and require hospital transfer in the worst case scenario,” he said.
Nursing homes have administered antipsychotics to people with dementia, which is contraindicated — meaning that these drugs act as psychological restraints for patients with specific dementia symptoms, according to Temkin-Greener. But for patients experiencing dementia and schizophrenia or psychosis concurrently, “it’s acceptable to administer the antipsychotic,” she said.
The researchers identified 439,822 hospitalizations among long-term care residents as part of the study. Findings point to residents with ADRD having a 10% to 12% lower risk of N-PAH as well as 15% lower risk of PAH. Overall, the measure of PAHs was lowest among residents with ADRD at 47.69% compared to those with neither ADRD nor BHD at 51.76%.
Over half of all hospitalizations in the study were considered potentially avoidable. Medical conditions including pneumonia, urinary tract infection, falls and trauma, congestive heart failure, and dehydration were responsible for more than 78% of PAHs.
Researchers acknowledged a grey area around the correlation between improved care quality and a lower risk of hospitalizations; the team observed that residents with increased cognitive problems, a frequent issue among ADRD residents, had a decreased risk of PAH (and N-PAH).
“Typically, lower rates of avoidable hospitalizations are an indicator of better quality, but when both PAH and non-PAH are so substantially lower among patients with dementia than those without, it may be important to ask if the latter is still a reflection of good quality,” Temkin-Greener said.
While national and state initiatives focusing on improving quality have a positive goal, they “may have negative and unintended consequences for individuals with ADRD and BHD,” the authors wrote, concluding that further study is needed to “better understand how such initiatives impact these most vulnerable of residents.”
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