For many individuals with serious mental illness, antipsychotic medications play an important role in helping them to maintain and improve their mental health, It has been become increasingly clear, however, that antipsychotics are overprescribed, especially to individuals in nursing homes, to manage undesirable behaviors. These prescribing patterns come with real risks, especially for individuals with dementia, that we must all be aware of.
Individuals with schizophrenia, psychosis, or bipolar disorder are often prescribed one or more antipsychotic medications. Antipsychotics belong to two basic classes -- typical and atypical. Developed in the 1950s, typical antipsychotics include drugs such as Haldol (haloperidol) and Thorazine (chlorpromazine). Atypical antipsychotics, developed in the 1980s, include drugs such as Seroquel (quetiapine) and Risperdal (risperidone). For many individuals identified by PASRR as having a serious mental illness, these drugs are essential components of their therapy. But too often they are being prescribed to individuals who don't have an appropriate diagnosis, often as a way to manage difficult behaviors.
In January, the Federal Government Accountability Office (GAO) released a sobering report on the overuse of antipsychotics, both among nursing home residents and among the general population -- especially among individuals with dementia. ("Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use among Older Adults in Nursing Homes, but Should Expand Efforts to Other Settings." Highlights here.)
Using three primary data sources -- the Medicare Master Beneficiary Summary File (MBSF), the Medicare Part D prescription drug plan, and the nursing home Minimum Data Set (MDS) -- GAO identified the following trends:
- Among individuals who were enrolled in Part D and who remained in a nursing home for at least 100 days, 33 percent were prescribed an antipsychotic in 2012.
- According to data from the MDS, about 30 percent of all older adult nursing home residents with a diagnosis of dementia were prescribed an antipsychotic.
- Residents with a diagnosis of dementia were more likely to receive antipsychotics if they had been in the nursing home at least 100 days.
- Among older adults enrolled in Part D, the rate of antipsychotic drug prescribing was lower for those living in the community than for those in nursing homes.
Experts interviewed by GAO for the report indicated that antipsychotics were often prescribed to help manage behavioral symptoms, such as agitation or aggression. Experts also identified low staffing levels as a key driver of antipsychotic prescribing patterns.
As GAO notes, these drugs are not approved for managing behavior. More importantly, antipsychotics are seriously contraindicated for individuals with dementia, as they can cause death. In 2005, the Food and Drug Administration (FDA) required that antipsychotics carry a boxed warning for this very reason.
For individuals without dementia, the GAO report emphasizes the importance of trying non-pharmacological interventions first, including on a focus on emotions, sensory stimulation, behavior management, and other psychosocial factors. In the words of the report:
Clinical guidelines consistently suggest the use of antipsychotic drugs for the treatment of behavioral symptoms of dementia only when other, non-pharmacological attempts to ameliorate the behaviors have failed, and the individuals pose a threat to themselves or others….nursing homes must ensure that antipsychotics are prescribed only when necessary to treat a specific condition diagnosed and documented in the patient's record, and that residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated. (GAO Report 15-211)
In a footnote on page 10 of the report, GAO mentions PASRR specifically, stating:
If PASRR recommends that a nursing home is the appropriate setting, necessary treatment, such as antipsychotic drugs, should be specifically listed in the recommendations. If an individual does not have a PASRR recommendation for antipsychotic drugs, additional scrutiny may be triggered if an antipsychotic is prescribed. (GAO Report 15-211)
Various agencies within Health and Human Services, including the Centers for Medicare and Medicaid Services (CMS), have undertaken efforts to reduce the inappropriate use of antipsychotics. Most notably, CMS's Five-Star Quality Rating System for nursing homes will now be based in part on the extent to which nursing homes use antipsychotic drugs. In February, Kaiser Health News published an excellent piece on the consequences of this change, and others ("Government to Grade Nursing Homes on Tougher Scale"; see also the New York Times piece, "Medicare Revises Nursing Home Rating System").
As we think about how states administer PASRR programs, the GAO report suggests several action items:
- Consider collecting information about antipsychotics on the Level I screen, and using it as part of an algorithm that might trigger a Level II.
- If individuals who take antipsychotic medications also have a PASRR disability, the Level II recommendations should explicitly mention the need for an antipsychotic.
- A new antipsychotic prescription for someone without a known PASRR disability should perhaps trigger a Resident Review.
As the results of the GAO report become more widely known, and as the changes to CMS's Five-Star Rating System take effect, we will no doubt hear more about the (over)use of antipsychotics both in and out of nursing homes, among individuals with with and without dementia. At PTAC, we'll continue to monitor these developments and return to this topic when there are new developments. Stay tuned.