Off-label antipsychotic drug use common in VA nursing home residents, often without documented rationale

The study, the first to address this topic in VA nursing homes, finds similar rates of antipsychotic use as studies in non-VA nursing homes. The findings will be published in the November issue of the journal Medical Care and currently are available online.

"Our study adds to the growing evidence base that antipsychotics have been overused in nursing homes, and the VA is not immune to this problem," said lead author Walid Gellad, M.D., M.P.H., an assistant professor in Pitt's School of Medicine and the Graduate School of Public Health's Department of Health Policy and Management. "Behavioral symptoms in dementia patients are difficult to treat, and, in most cases, nursing home staff are doing what they can to keep patients comfortable and safe. We have to find better ways to do this, though."

Antipsychotics have limited efficacy in alleviating behavioral problems in dementia patients, and several studies associate their use with an increased risk of mortality.

"The VA already is undertaking several initiatives to address the use of antipsychotics in VA nursing homes, including increasing the availability and integration of psychologist services and piloting behavioral modification programs, such as the Staff Training in Assisted Living Residences in VA (STAR-VA) program," said Dr. Gellad, also a core faculty member with the VA Center for Health Equity Research and Promotion and a primary care physician in the VA Pittsburgh Healthcare System.

Dr. Gellad and his colleagues collected data on all veterans age 65 and older who were admitted for 90 or more days to one of the 133 VA Community Living Centers between January 2004 and June 2005, the most recent years for which data could be collected for this study.

Of the resulting 3,692 veterans, 948 – or 25.7 percent – received an antipsychotic. Among that group, 59.3 percent had an evidenced-based reason for use. The U.S. Food and Drug Administration (FDA) has approved antipsychotics for use in treating psychiatric diagnoses, such as schizophrenia, bipolar disorder and Tourette syndrome.

Veterans residing in Alzheimer's or dementia special care units had 66 percent greater odds of receiving an antipsychotic, and residents with aggressive behavior had nearly three times greater odds of receiving an antipsychotic medication. Among those residents with dementia, veterans with no evidence of psychosis for which an antipsychotic would be appropriate were just as likely to receive an antipsychotic as those with documented psychosis.

"We couldn't determine if clinicians are using antipsychotics in residents with dementia without considering the risks, or whether they are considering the risks but have determined that the behavioral symptoms are sufficiently problematic that the potential benefits outweigh the risks of therapy," Dr. Gellad said. "The VA is supporting efforts for better documentation in patients' medical records of the risk vs. benefit discussions regarding the use of these antipsychotics."

Residents receiving multiple medications of any type, particularly those receiving antidepressants, were more likely to receive antipsychotics.

The FDA issued a warning in 2005 for the atypical antipsychotics, emphasizing their association with increased mortality when used for behavioral disorders in elderly residents with dementia. The warning was extended to all antipsychotics in 2008.

"Our data was collected prior to these warnings, so we cannot draw conclusions about whether they make a difference in current practices," said Dr. Gellad. "However, despite the lack of an FDA warning at the time that the data for our study was collected, reports had already appeared in print about the risks of these drugs."

More information: journals.lww.com/l… in_VA.9.aspx

Journal reference: Medical Care

Provided by University of Pittsburgh Medical Center