Primary Care Physician Perspectives About Antipsychotics and Other Medications for Symptoms of Dementia

J. William Kerns, MD; Jonathan D. Winter, MD; Katherine M. Winter, CFNP; Terry Boyd, PhD; Rebecca S. Etz, PhD

Disclosures

J Am Board Fam Med. 2018;31(1):9-21. 

In This Article

Abstract and Introduction

Abstract

Background: Guidelines, policies, and warnings have been applied to reduce the use of medications for behavioral and psychological symptoms of dementia (BPSD). Because of rare dangerous side effects, antipsychotics have been singled out in these efforts. However, antipsychotics are still prescribed "off label" to hundreds of thousands of seniors residing in nursing homes and communities. Our objective was to evaluate how and why primary-care physicians (PCPs) employ nonpharmacologic strategies and drugs for BPSD.

Methods: Semi-structured interviews analyzed via template, immersion and crystallization, and thematic development of 26 PCPs (16 family practice, 10 general internal medicine) in full time primary-care practice for at least 3 years in Northwestern Virginia.

Results: PCPs described 4 major themes regarding BPSD management: (1) nonpharmacologic methods have substantial barriers; (2) medication use is not constrained by those barriers and is perceived as easy, efficacious, reasonably safe, and appropriate; (3) pharmacologic policies decrease the use of targeted medications, including antipsychotics, but also have unintended consequences such as increased use of alternative risky medications; and (4) PCPs need practical evidence-based guidelines for all aspects of BPSD management.

Conclusions: PCPs continue to prescribe medications because they meet patient-oriented goals and because PCPs perceive drugs, including antipsychotics and their alternatives, to be more effective and less dangerous than evidence suggests. To optimally treat BPSD, PCPs need supportive verified prescribing guidelines and access to nonpharmacologic modalities that are as affordable, available, and efficacious as drugs; these require and deserve significant additional research and payer support. Community PCPs should be included in BPSD policy and guideline development.

Introduction

Dementia is diagnosed based on cognitive decline with evidence of memory loss, but noncognitive psychiatric symptoms are seen in dementia of all etiologies and stages.[1,2] Referred to as behavioral and psychological symptoms of dementia (BPSD), these include disordered mood, psychosis, inappropriate behaviors, and motor symptoms.[1,3] These noncognitive neuropsychiatric symptoms are often the most intrusive, debilitating, and detrimental for patients and caregivers in terms of quality of life and health outcomes. Furthermore, BPSD symptoms are frequently critical and direct drivers of institutionalization and the economic cost of dementia.[4,5]

Although evidence proving the effectiveness of nonpharmacologic approaches for BPSD across domains of care is lacking, a growing body of literature demonstrates that these skills, techniques, activities, therapies, and personalized interventions can improve quality of life and help to manage certain symptoms and behaviors.[6–8] While these methods are safer for patients than medications, their individualized nature requires greater investments of time, effort, expertise, and financial resources.[10] Also, reimbursement for these services is often poor. For all these reasons, they are likely underused in all settings including long-stay facilities.[6,7,10–12] These techniques are also more effective for some BPSD than for others.[7] For example, an agitated patient can often be calmed by music, touch, and aromatherapy, especially in combination with other personalized approaches, whereas those who are hallucinating are more likely to need medication as part of the treatment plan.[7,9,13–15] At times even optimally applied nonpharmacologic therapies simply do not work because of numerous factors, including disease variation and progression.[8,16]

Medications used "off label" for BPSD include anxiolytics, antidepressants, cognitive enhancers, antipsychotics, and anticonvulsant mood stabilizers. Benzodiazepines, prescribed for anxiety and agitation, increase risks of sedation, confusion, falls, and fractures.[17,18] Cognitive enhancers (N-methyl-D-aspartate antagonists and cholinesterase inhibitors) have been shown to have small statistically significant effects in ameliorating BPSD, but many patients already take these drugs.[19,20] Serotonergic drugs can improve depression and anxiety but have limited efficacy for BPSD.[21] Although they are generally well tolerated, even these medications convey potential risks; citalopram has been shown to be helpful for certain BPSD, but it blunts cognition and results in worrisome electrocardiographic changes.[22] Anticonvulsant mood stabilizers are used for agitation and aggression in particular, although trials evaluating their efficacy and safety for frail elderly are scant, and results are mixed.[23–37] Some anticonvulsants, such as valproate and carbamazepine, carry US Food and Drug Administration (FDA) boxed warnings because of hepatic and bone marrow toxicities.[38,39]

Antipsychotic medications have the best evidence for improving BPSD, although they work only 25% to 30% of the time.[40,41] While their benefit in BPSD is modest, their risk profile is extensive. In addition to extrapyramidal symptoms and sedation, antipsychotics are associated with confusion, falls, and aspiration events.[42] However, increases in strokes, heart attacks, and mortality associated with the use of typical and atypical antipsychotics earned both FDA boxed warnings.[42–44]

In addition to the FDA warnings, political and regulatory spotlights have focused on medication use for BPSD. Inappropriate antipsychotic prescribing for BPSD has been labeled "chemical restraint" and "elder abuse."[45] Some states have proposed legislation to require written informed consent for their use.[46]

The long-standing agenda of the Centers for Medicare & Medicaid Services (CMS) to curb drugs for BPSD was codified in the 1987 Nursing Home Reform Act, which prohibited the chemical restraint of patients in nursing homes.[47] In March 2012, as part of a concerted effort to check off-label prescribing of antipsychotics for BPSD, CMS launched the National Initiative to Improve Behavioral Health & Reduce the Use of Antipsychotic Medications in Nursing Home Residents,[48] subsequently renamed the National Partnership to Improve Dementia Care in Nursing Homes. The rate of antipsychotic use in long-stay facilities was made a quality measure, published through the Medicare Nursing Home Compare website (https://www.medicare.gov/nursinghomecompare/search.html?), and factored into Medicare's 5-star facility rating. In nursing homes, pharmacists also supervise mandatory periodic reviews of all psychoactive medications to encourage consideration for weaning or reducing doses.[48] Since the initiative's debut, antipsychotic use in nursing homes has decreased steadily. CMS's initial goal of a 15% nationwide reduction was achieved in the final quarter of 2013, and by the fourth quarter of 2016 the national rate was down 33%, from 23.8% to 16%.[49,50]

National and international guidelines for medical management of BPSD all state that antipsychotics should be used only when other measures fail and with appropriate discussion of the risks and benefits. According to the American Geriatric Society and respective national and provincial Canadian groups, only potential harm to self or others justifies their use.[51,52] However, the American Psychiatric Association, the American Alzheimer's Association, and the British National Institute for Health Care and Excellence guidelines liberalize indications to include refractive patient distress.[53–56]

Despite evidence of only modest benefit and proven severe risk, the context of purposeful efforts from the FDA, CMS, and state legislation, and the censure of geriatric societies and patient advocacy groups, physicians continue to prescribe antipsychotics and other medications for BPSD to hundreds of thousands of patients in US nursing homes and communities.[50] The reasons for this apparent conundrum are not well understood, and investigation in this area has been scant. This study sought to explore American primary care physicians' use of nonpharmacologic modalities and drugs to treat these challenging symptoms.

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