Antipsychotic reduction in nursing home residents with Alzheimer's disease: Impact on state, facility, and resident psychopharmacological medication use and outcomes

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In 2012, the National Partnership to Improve Dementia Care launched an initiative to reduce antipsychotic use among nursing home residents with Alzheimer’s Disease and Related Dementias (ADRD). Within 5 years, antipsychotic use decreased by 34.1% in all nursing home residents to a national prevalence of 15.7%. There remain important unanswered questions surrounding outcomes of the antipsychotic reduction program (ARP), including: which residents experienced reduced antipsychotic use; were residents who experienced antipsychotic reductions switched to other psychopharmacological medications (PPM); and did medication changes influence their health outcomes? The primary goal of this project is to conduct a series of analyses using national administrative claims data linked to resident and nursing home survey data to assess the impact of the ARP on state-, nursing home-, and individual- level antipsychotic and PPM (sedative-hypnotics, opioids, antidepressants, anxiolytics, and anticonvulsants) utilization and health outcomes in the nursing home population with ADRD. Our central hypothesis is that antipsychotic reductions resulted in unintended consequences that exposed vulnerable nursing home residents to potentially harmful PPMs, leading to downstream adverse health consequences. The proposed study utilizes a nationally-representative, 100% sample of Medicare beneficiaries residing in long-stay nursing facilities from 2010–2016 that links prescription and healthcare utilization claims data to nursing home- and nursing resident- level survey data. We will accomplish the following specific aims: 1) To predict the impact of the ARP on antipsychotic and PPM use patterns in nursing home residents, by state- and population- level characteristics; 2) To identify the impact of the ARP on antipsychotic and PPM use patterns in nursing home residents, by facility-level characteristics; and 3) To test the prediction that ARP implementation affected critical individual-level public health outcomes (e.g., mortality, transitions in care settings, and falls/fractures) and patient-centered health outcomes (e.g., physical restraint use, behavioral symptom emergence, functional status, pain) in nursing home residents with ADRD. Using advanced methodological approaches, our multidisciplinary research team will assess state-, facility-, and individual- level characteristics that may have mediated the impact of a sweeping policy that affected over 1.4 million nursing home residents. Our findings have the potential to guide health policy and program refinement, and will add to our understanding of psychopharmacological medication use and their contribution to health consequences in older adults with ADRD. Results will inform future studies that allow granular examination of medication policies on other vulnerable nursing home subpopulations, such as racial minorities and those with serious mental illness, chronic pain, and/or neurologic conditions. Findings will provide a foundation to achieve our ultimate goal: to provide guidance to providers and policy-makers on how to optimize prescribing decisions and policies that support nursing-home patients’ health and quality of life.