GAO Report Cites Antipsychotic Overuse in Dementia Patients

Alicia Ault

March 03, 2015

A report by the US Government Accountability Office (GAO) says that a third of Medicare beneficiaries living in nursing homes and 14% of those living in the community are being prescribed antipsychotics, and urges the federal government to find ways to curb inappropriate use.

GAO reported that the Department of Health and Human Services has done a good job in reducing antipsychotic use in nursing homes, but it recommended that the agency "expand its outreach and educational efforts aimed at reducing antipsychotic drug use among older adults with dementia to include those residing outside of nursing homes by updating the National Alzheimer's Plan."

The report was requested by Senators Ron Johnson (R-Wisc), Tom Carper (D-Del), and Susan Collins (R-Maine).

GAO found that in 2012, 313,000 of an estimated one million nursing home residents with dementia were prescribed an antipsychotic. Thirty-three percent of those who had a longer stay (over 100 days) were given a medication, compared with 23% of those with a short stay. Among the 19 million Medicare beneficiaries living outside of nursing homes, 1.2 million had dementia, and 14%, or 170,000, were prescribed an antipsychotic.

Medicare's Part D prescription plans paid $363 million in 2012 for antipsychotics used to treat dementia, with quetiapine fumarate, risperidone, and olanzapine most commonly prescribed. The majority of the prescriptions — 82% — were written by internists, family medicine physicians, psychiatrists, and neurologists. Among nursing home residents, prescriptions were highest for those living in the South.

GAO noted that none of the antipsychotics have been approved by the US Food and Drug Administration (FDA) for the behavioral symptoms of dementia. In addition, the drugs carry an FDA-mandated warning of the increased risk for death in adults with dementia.

Even so, said GAO, in some circumstances, prescribing antipsychotics might be warranted — in particular when patients pose a risk to themselves or others. Consistent with that, GAO said it found that 61% of nursing home residents who had been documented to be a risk to themselves or others had been given an antipsychotic.

Report a Bit Off the Mark?

Indeed, there is appropriate use of antipsychotics, said Constantine G. Lyketsos, MD, director of the Johns Hopkins Memory and Alzheimer's Treatment Center. The extreme behavioral symptoms can be hard to manage, "and the most effective treatment we have for them right now is antipsychotics," Dr Lyketsos told Medscape Medical News.

The medications should not be used in all cases, but "in a small subgroup of people with very severe symptoms the use of antipsychotics is unavoidable." However, he said, "the bottom line is we need better alternatives."

In a just-published review paper in BMJ, Dr Lyketsos and colleagues report that medications are often the go-to therapy because there is a lack of provider training in nonpharmacologic strategies, a lack of reimbursement for those approaches, few clear guidelines on dosing and timing, and a perceived lack of efficacy when compared with drugs.

In patients who don't pose a risk to themselves or others, "current evidence suggests that nonpharmacologic strategies, such as family caregiver interventions, show greater effect than most drug treatments," wrote Dr Lyketsos and colleagues.

Penalizing nursing homes or physicians or patients for using the medications is not the way to get to better treatments, he told Medscape Medical News. "We're not going to get there by passing some kind of fiat or decision."

Reduction Targets Already Set

GAO, however, noted that the Centers for Medicare and Medicaid Services (CMS) has set a goal of reducing the prescribing rate in nursing homes by 25% by the end of this year and by 30% by the end of 2016, essentially cutting the current rate in half to 16%.

Also, CMS's Five-Star Quality Rating System for nursing homes has started basing its rating in part on the extent to which antipsychotic drugs are used.

Finally, GAO stressed what it saw as the need to curb antipsychotic use in community-residing adults with dementia. "Many experts we spoke with said that many nursing home residents come to the nursing home already on an antipsychotic drug," said the agency. "Extending educational efforts to caregivers and providers outside of the nursing home could help lower the use of antipsychotics among older adults with dementia living both inside and outside of nursing homes."

Dr Lyketsos reported that he received grant support (research or continuing medical education) from the National Institute of Mental Health, the National Institute on Aging, The Associated: Jewish Community Federation of Baltimore, the Weinberg Foundation, Forest, GlaxoSmithKline, Eisai, Pfizer, AstraZeneca, Lilly, Ortho-McNeil, Bristol-Myers, Novartis, the National Football League (NFL), Elan, and Functional Neuromodulation. He is a consultant or adviser for AstraZeneca, GlaxoSmithKline, Eisai, Novartis, Forest, Supernus, Adlyfe, Takeda, Wyeth, Lundbeck, Merz, Lilly, Pfizer, Genentech, Elan, the NFL Players Association, NFL Benefits Office, Avanir, and Zinfandel, and he hasreceived honorariums or travel support from Pfizer, Forest, GlaxoSmithKline, and Health Monitor.

BMJ. 2015;350:h369. Abstract

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