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Use of Antipsychotics Among Older Residents in VA Nursing Homes

Gellad, Walid F. MD, MPH*,†,‡,§; Aspinall, Sherrie L. PharmD*,‡,∥,¶; Handler, Steven M. MD, PhD*,‡,#,**,††; Stone, Roslyn A. PhD*,‡‡; Castle, Nicholas PhD‡‡; Semla, Todd P. PharmD∥,§§; Good, Chester B. MD*,†,∥; Fine, Michael J. MD*,†; Dysken, Maurice MD∥∥; Hanlon, Joseph T. PharmD*,‡,**,††,∥∥

doi: 10.1097/MLR.0b013e31825fb21d
Original Articles

Background: Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Affairs (VA) nursing homes [ie, Community Living Centers (CLCs)], we assessed the prevalence and risk factors for antipsychotic use in older residents of VA CLCs.

Methods: This cross-sectional study included 3692 Veterans age 65 or older who were admitted between January 2004 and June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (eg, schizophrenia, dementia with psychosis). We used multivariable logistic regression and generalized estimating equations to identify factors independently associated with antipsychotic receipt.

Results: Overall, 948/3692(25.7%) residents received an antipsychotic, of which 59.3% had an evidence-based indication for use. Residents with aggressive behavior [odds ratio (OR)=2.74, 95% confidence interval (CI), 2.04–3.67] and polypharmacy (9+ drugs; OR=1.84, 95% CI, 1.41–2.40) were more likely to receive antipsychotics, as were users of antidepressants (OR=1.37, 95% CI, 1.14–1.66), anxiolytic/hypnotics (OR=2.30, 95% CI, 1.64–3.23), or drugs for dementia (OR=1.52, 95% CI, 1.21–1.92). Those residing in Alzheimer/dementia special care units were also more likely to receive an antipsychotic (OR=1.66, 95% CI, 1.26–2.21). Veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic (OR=1.10, 95% CI, 0.82–1.47).

Conclusions: Antipsychotic use is common among VA nursing home residents aged 65 and older, including those without a documented evidence-based indication for use. Further quality improvement efforts are needed to reduce potentially inappropriate antipsychotic prescribing.

*Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System

Department of Medicine (General Medicine), University of Pittsburgh

The University of Pittsburgh Geriatric Pharmaceutical and Gero-Informatics Research and Training Program

§RAND Corporation, Pittsburgh, PA

Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, IL

School of Pharmacy

#Department of Biomedical Informatics, University of Pittsburgh

**Pittsburgh VA Geriatric Research, Education, and Clinical Center

††Department of Medicine (Geriatrics)

‡‡Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA

§§Departments of Medicine and Psychiatry and Behavioral Sciences, The Feinberg School of Medicine, Northwestern University, Chicago, IL

∥∥Minneapolis VA Geriatric Research, Education, and Clinical Center, Minneapolis, MN

Supported by a VA Career Development Award (CDA 09-207), National Institute of Aging Grants (P30AG024827, T32 AG021885, K07AG033174, R01AG034056, R56AG027017, 3U01 AG012553), a National Institute of Mental Health Grant (R34 MH082682), a National Institute of Nursing Research grant (R01 NR010135), and Agency for Healthcare Research and Quality Grants (R01 HS017695, R01 HS018721, K12 HS019461).

T.P.S. reports receiving honorarium from the American Geriatrics Society and LexiComp Inc. (publishing) and consulting fees from Omnicare Inc. T.P.S.’s spouse is an employee of Abbott Labs. The other authors declare no conflict of interest.

Portions of this research were presented as a paper at the VA Health Services Research and Development (HSR&D) Annual Meeting in National Harbor, MD, on February 17, 2011 and as a poster at the Society of General Internal Medicine Annual Meeting in Phoenix, AZ, on May 5, 2011.

Reprints: Walid F. Gellad, MD, MPH, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 7180 Highland Drive, Pittsburgh, PA 15206. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.