By Mary Beth Nierengarten
March 16, 2023
Article In Brief
Behavioral and psychological symptoms of dementia as well as access to care for those with the condition may have worsened after COVID-19 restrictions went in place in 2020, with evidence that more patients were given antipsychotics. The trend was troubling, experts said, given the adverse events associated with these drugs.
Antipsychotic drug prescriptions for people with dementia increased during the initial months of the COVID-19 pandemic and continued through 2021, according to a large multinational network cohort study published Jan. 25 in JAMA Psychiatry.
The finding suggests a worsening of behavioral and psychological symptoms of dementia during the pandemic as well as a reduction in the access to care following implementation of COVID-19 restrictions, according to study coauthor Kenneth K.C. Man, PhD, lecturer in pharmacoepidemiology and medication safety in the research department of practice and policy at UCL School of Pharmacy in London.
“The implementation of unprecedented public health measures due to the COVID-19 pandemic disrupted the daily routines and social support for people with dementia, which could have made their behavioral and psychological symptoms worse,” said Dr. Man.
He called those findings worrying given the ineffectiveness of the drugs for most people with dementia and their negative side effects of nausea and dizziness, which can worsen the frailty dementia already causes. Despite current clinical guidelines that advise against using antipsychotics in people with dementia except as a last resort, he said clinicians still frequently use these agents to treat behavioral and psychological symptoms in those patients.
“Antipsychotics should be offered only when psychological options, such as therapy or changing environment, haven't worked and the patient is suffering delusions, hallucinations, or severe agitation,” he said.
Using population-based electronic health records and claims data from six countries—France, Germany, Italy, South Korea, the United Kingdom, and the United States—on people 65 years and older from January 2016 through November 2021, researchers looked at yearly and monthly incidence of dementia diagnosis and prevalence of antipsychotic drug prescriptions for dementia in each country's dataset.
Researchers used the data to examine the trends in antipsychotic prescriptions before and during the height of COVID-19, using April 1, 2020, as the “exposure” date—or the date that countries initiated containment and health policies in response to COVID-19.
A total of 857,238 people were diagnosed with dementia in 2016, 58 percent of whom were female. During the early phase of the pandemic (April to June 2020), the study found a rapid decreased incidence of dementia in all databases, except those from Germany, with the highest reduction seen in the United States. After this acute pandemic phase, the incidence of dementia gradually increased to pre-pandemic levels for all countries except for the United Kingdom and United States, where the incidence in the later months of 2021 remained lower than the three-year mean.
The study also found that antipsychotics prescriptions initially fell during the early phase of the pandemic in most countries but increased markedly in most countries as the pandemic progressed. For example, the rate of antipsychotic prescribing increased from 5.85 percent in February 2020 to 14.5 percent in May 2020 in the United Kingdom and remained higher than pre-pandemic prescribing rates until November 2020 (the end of the study). When comparing rates of antipsychotic prescribing from 2019 to 2020, the United Kingdom had the second-most pronounced increase in prescribing after South Korea. For all countries except Germany, the increases in antipsychotic prescribing persisted into 2021.
Given the remaining rise in antipsychotic prescribing, Dr. Man and colleagues offered a number of suggestions to improve the quality of care for people living with dementia, including medication reviews, antipsychotic drug deprescribing campaigns, and using different technology and online platforms to deliver non-pharmacologic interventions.
Dr. Man said the most straightforward intervention is to encourage medication reviews and to devise strategies to encourage antipsychotic drug deprescribing campaigns. He also referred to current research assessing the delivery of psychological interventions virtually to avoid disruptions to treatment when access to in-person treatment is difficult, such as during the pandemic lockdowns.
Experts Weigh In
Eran D. Metzger, MD, was not surprised by the increased use of antipsychotic prescribing during the pandemic given the reduction of non-pharmaceutical interventions necessitated by strict infection controls that drastically reduced or eliminated dementia care interventions, such as expressive arts therapy, milieu therapy, and recreational/physical fitness activities.
“The increased utilization of these therapies had contributed to gratifying reductions in antipsychotic prescriptions in the US in the years leading up to the outbreak of the pandemic,” said Dr. Metzger, director of psychiatry at Hebrew SeniorLife, a Harvard Medical School affiliate in Boston.
He posited that one reason antipsychotic prescribing has not decreased to pre-pandemic levels, as found in the study, is that once a patient is prescribed an antipsychotic medication, they run the risk of staying on it unnecessarily. Implementing a process to periodically reassess the need for a patient to continue on an antipsychotic is necessary, he said, underscoring the study authors' recommendation to implement medication reviews as a key intervention to improve the quality of dementia care.
Along with the other interventions the study authors listed, Dr. Metzger also emphasized the need for supporting the dementia care workforce who implement these interventions.
“The pandemic significantly reduced a dementia care workforce that was already understaffed and over-taxed pre-pandemic,” he said. “Now that we have an idea of what good dementia care looks like, and what the consequences are when it's interrupted, we need to prioritize supporting it.”
“My concern is that these prescribing practices may continue for far longer than what we would like given the slow post-pandemic recovery. This can result in poor outcomes among individuals with dementia, including increased sedation, falls, cerebrovascular events, and even death.”—DR. RAJESH R. TAMPI
Rajesh R. Tampi, MD, professor and chair of the department of psychiatry at Creighton University School of Medicine and adjunct professor of psychiatry at Yale School of Medicine, also is not surprised by the increased use of antipsychotics for dementia during the pandemic given the lack of caregiver/staff time and other pandemic-related stressors that relegated nonpharmacologic treatments to the back burner as the standard of care for neuropsychiatric symptoms.
“My concern is that these prescribing practices may continue for far longer than what we would like given the slow post-pandemic recovery,” said Dr. Tampi, a past-president of the American Association for Geriatric Psychiatry. “This can result in poor outcomes among individuals with dementia, including increased sedation, falls, cerebrovascular events, and even death.”