Comparative Safety of Antipsychotic Medications in Nursing Home Residents

Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.57). 02/2012; 60(3):420-9. DOI: 10.1111/j.1532-5415.2011.03853.x
Source: PubMed


To compare the risk of major medical events in nursing home residents newly initiated on conventional or atypical antipsychotic medications (APMs).
Cohort study, using linked Medicaid, Medicare, Minimum Data Set, and Online Survey Certification and Reporting data. Propensity score-adjusted proportional hazards models were used to compare risks for medical events at a class and individual drug level.
Nursing homes in 45 U.S. states.
Eighty-three thousand nine hundred fifty-nine Medicaid-eligible residents aged 65 and older who initiated APM treatment after nursing home admission in 2001 to 2005.
Hospitalization for myocardial infarction, cerebrovascular events, serious bacterial infections, and hip fracture within 180 days of treatment initiation.
Risks of bacterial infections (hazard ratio (HR) = 1.25, 95% confidence interval (CI) = 1.05-1.49) and possibly myocardial infarction (HR = 1.23, 95% CI = 0.81-1.86) and hip fracture (HR = 1.29, 95% CI = 0.95-1.76) were higher, and risks of cerebrovascular events (HR = 0.82, 95% CI = 0.65-1.02) were lower in participants initiating conventional APMs than in those initiating atypical APMs. Little variation existed between individual atypical APMs, except for a somewhat lower risk of cerebrovascular events with olanzapine (HR = 0.91, 95% CI = 0.81-1.02) and quetiapine (HR = 0.89, 95% CI = 0.79-1.02) and a lower risk of bacterial infections (HR = 0.83, 95% CI = 0.73-0.94) and possibly a higher risk of hip fracture (HR = 1.17, 95% CI = 0.96-1.43) with quetiapine than with risperidone. Dose-response relationships were observed for all events (HR = 1.12, 95% CI = 1.05-1.19 for high vs low dose for all events combined).
These associations underscore the importance of carefully selecting the specific APM and dose and monitoring their safety, especially in nursing home residents who have an array of medical illnesses and are undergoing complex medication regimens.

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Available from: Stephen Crystal, Dec 31, 2013
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    ABSTRACT: Background Despite well-documented evidence regarding antipsychotic use in older adults residing in nursing homes (NHs), there is a lack of evidence-based use and quality benchmarks for other psychopharmacological medications (PPMs), including antidepressants, anxiolytics, and sedative-hypnotics. Objective To estimate the prevalence and patterns of use of PPMs and to measure the quality of PPM use. Methods Using a 5% random sample of 2007 Medicare claims data linked to the Minimum Data Set 2.0, this cross-sectional study identified a nationally representative sample of 69,832 NH residents with ≥ 3 months of institutionalization. This study measured 1-year prevalence and quality of PPM use, as assessed by indication, dose, and duration of use defined and operationalized according to the current Centers for Medicare and Medicaid Services Unnecessary Medication Guidance for Surveyors and relevant practice guidelines. Results Over two-thirds of residents (72.1%, n=50,349) used ≥1 PPM in 2007, with the highest prevalence seen in antidepressants (59.4%), and the lowest in anxiolytics (8.9%). Almost two-thirds (61.0%) of PPM users used ≥2 PPM classes. Compared to other PPM therapeutic classes, antipsychotic users had greatest evidence of guideline adequate use by indication (95.8%) and dose (78.7%). In addition, longer duration of adequate treatment was observed among antipsychotic users (mean=208 days, standard deviation [SD] =118) as compared to anxiolytic (mean=159 days, SD=118) and sedative-hypnotic users (mean=183 days, SD=117). Conclusions This study found that PPM use remains highly prevalent among long-stay Medicare NH residents. While antipsychotic use remained high (31.5%), little antipsychotic use was deemed inadequate by indication. However, the 1-year prevalence of use, dose, and duration of use of other PPMs remain high and potentially inadequate. Practitioners and policy-makers should heed both the high use and lower prescribing quality of antidepressants, anxiolytics, and sedative-hypnotics in NH residents.
    Research in Social and Administrative Pharmacy 01/2013; 10(3). DOI:10.1016/j.sapharm.2013.10.003 · 2.35 Impact Factor
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    ABSTRACT: BACKGROUND:Administration of scheduled antipsychotic therapy to mechanically ventilated patients to prevent or treat delirium is common, despite the lack of evidence to support its use. Among long-term acute care hospital (LTACH) patients requiring prolonged mechanical ventilation (PMV), the frequency of scheduled antipsychotic therapy use, and the factors and outcomes associated with it, have not been described.OBJECTIVE:To identify scheduled antipsychotic therapy prescribing practices, and the factors and outcomes associated with the use of antipsychotics, among LTACH patients requiring PMV.METHODS:Consecutive patients without major psychiatric disorders or dementia who were admitted to an LTACH for PMV over 1 year were categorized as those receiving scheduled antipsychotic therapy (≥24 hours of use) and those not receiving scheduled antipsychotic therapy. Presence of delirium, use of psychiatric evaluation, nonscheduled antipsychotic therapy, and scheduled antipsychotic therapy-related adverse effects were extracted and compared between the 2 groups and when significant (p ≤ 0.05), were entered into a regression analysis using generalized estimating equation techniques.RESULTS:Among 80 patients included, 39% (31) received scheduled antipsychotic therapy and 61% (49) did not. Baseline characteristics, including age, sex, illness severity, and medical history, were similar between the 2 groups. Scheduled antipsychotic therapy was administered on 52% of LTACH days for a median (interquartile range [IQR]) of 25 (6-38) days and, in the antipsychotic group, was initiated at an outside hospital (45%) or on day 2 (1-6; median [IQR]} of the LTACH stay (55%). Quetiapine was the most frequently administered scheduled antipsychotic (77%; median dose 50 [37-72] mg/day). Use of scheduled antipsychotic therapy was associated with a greater incidence of psychiatric evaluation (OR 5.7; p = 0.01), delirium (OR 2.4; p = 0.05), as-needed antipsychotic use (OR 4.1; p = 0.005) and 1:1 sitter use (OR 7.3; p = 0.001), but not benzodiazepine use (p = 0.19).CONCLUSIONS:Among LTACH patients requiring PMV, scheduled antipsychotic therapy is used frequently and is associated with a greater incidence of psychiatric evaluation, delirium, as-needed psychotic use, and sitter use. Although scheduled antipsychotic therapy-related adverse effects are uncommon, these effects are infrequently monitored.
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