Push to Reduce Antipsychotic Drugs in Nursing Homes May Have Boosted Costly Hospitalizations

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.