Older adults newly admitted to nursing homes with high rates of antipsychotic prescribing in the previous year are more likely to receive antipsychotic agents, according to a report in the January 11 issue of the Archives of Internal Medicine.
Of these treated patients, some had no identified clinical indication for this therapy.

In 2007, almost a third of U.S. nursing home residents received antipsychotic drugs. Safety concerns regarding their use are increasing: In 2005, the FDA issued warnings regarding the risk of death among older adults with dementia taking these agents to control behavioral symptoms. A large clinical trial recently concluded the adverse effects of atypical antipsychotic drugs outweighed the benefits in patients with Alzheimer's disease.

Yong Chen, M.D., M.H.S., of the University of Massachusetts Medical School, and colleagues assessed antipsychotic prescribing among 16,586 residents newly admitted to 1,257 nursing homes in 2006. They computed each facility's antipsychotic prescription rates based on 2005 prescribing patterns and analyzed whether these rates, along with individual characteristics, were associated with the likelihood of new residents receiving antipsychotic prescriptions.

About 30 percent (4,818) of new residents in the study received at least one antipsychotic medication in 2006, of whom 32 percent (1,545) did not have dementia, psychosis or any other clinical indication for this therapy. "Residents newly admitted to nursing homes with the highest prescribing rates were 1.37 times more likely to receive an antipsychotic medication relative to those [people] in the nursing homes with the lowest prescribing rates," the authors write. "The influence of the facility-level prescribing rate was most apparent in residents without psychosis, who have the weakest indication for antipsychotic medication use."

The increase in medication use may reflect the increasing proportion of nursing home residents diagnosed with psychoses, the authors note. "However, residents diagnosed as having schizophrenia, bipolar disorder or aggressive behavioral symptoms of dementia accounted for only a small proportion of antipsychotic medication use," they continue. "In addition, we found that 16.4 percent of residents who had no clinical indication for antipsychotic therapy (no psychoses and no dementia) received antipsychotic medication."

The study suggests that organizational culture at some nursing homes may encourage the prescribing of antipsychotics, the authors note. "Future research is needed to determine why such a prescribing culture exists and whether there are adverse health consequences as a result of our observed facility-level antipsychotic prescribing rate," they conclude. "This study may also inform future policies to target nursing homes with high antipsychotic prescribing rates to improve quality of care for nursing home residents."

This study was supported by the Robert Wood Johnson Foundation. Dr. Briesacher and co-authors Dr. Tija and Dr. Lau are also supported by Research Scientist Development Awards from the National Institute on Aging.

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