Prescribing trends and associated outcomes of antiepileptic drugs and other psychoactive medications in US nursing homes surrounding the COVID-19 pandemic

自从2012年国家改善痴呆症护理伙伴关系首次亮相以来，其目标是减少阿尔茨海默病和/或阿尔茨海默病相关痴呆（AD/ADRD）患者的抗精神病药物使用，CMS审查了几乎所有相关的长期精神药物处方。虽然长期使用这些监测精神活性药物的人数有所下降，但稳定情绪的抗癫痫药物（aed）的处方却有所增加。与抗精神病药物类似，情绪稳定型aed用于治疗AD/ADRD人群中痴呆（BPSD）的行为和心理症状。与抗精神病药物和其他精神活性药物不同，养老院开的抗癫痫药并不强制向CMS报告。初步研究表明，AED的增加完全集中在AD/ADRD和其他没有癫痫诊断的痴呆患者中，并有意将BPSD作为抗精神病药物的不受监测的替代品。aed未被批准用于治疗AD/ADRD或任何痴呆症状，疗效证据薄弱，且具有严重的风险。伙伴关系的首次亮相越来越像是一个拐点，在这个拐点上，使用不受监测的替代药物治疗AD/ADRD症状的趋势急剧增加。此外，初步研究结果表明，COVID大流行代表了第二个拐点，在这个拐点上，现有的向非优越但未报告的AD/ADRD药物的过渡再次迅速加速。与这种不断演变的处方现象相关的所有结果仍然未知，尽管早期数据警告说，危害可能在增加而没有益处。

Since the National Partnership to Improve Dementia Care debuted in 2012 with the goal to reduce antipsychotic use in individuals with Alzheimer’s disease and/or Alzheimer’s-related dementias (AD/ADRD), CMS has scrutinized almost all associated long-stay psychoactive prescribing. While the long-stay use of these monitored psychoactive drugs has declined, prescriptions of mood-stabilizing antiepileptic drugs (AEDs) have increased. Similar to antipsychotics, mood stabilizing AEDs are used to treat the behavioral and psychological symptoms of dementia (BPSD) in the AD/ADRD population. Unlike antipsychotics and other psychoactive medications, AEDs prescribed in nursing homes are not mandatorily reported to CMS. Pilot studies suggest AED increases are concentrated entirely in AD/ADRD and other dementia patients with no diagnosis of epilepsy and purposefully prescribed for BPSD as an unmonitored alternative to antipsychotics. AEDs are not approved to treat AD/ADRD or any dementia symptoms, have weak efficacy evidence, and convey serious risk. Increasingly, the Partnership’s debut seems an inflection point where the trend toward unmonitored alternative drugs for AD/ADRD symptoms sharply increased. Furthermore, initial findings hint that the COVID pandemic represents a second critical point of inflection where the existing transition toward non-superior but unreported drugs for AD/ADRD is again rapidly accelerating. All outcomes associated with this evolving pre-scribing phenomenon remain unknown, though early data warns that harms may be increasing without benefit. We propose a retrospective analysis detailing long-stay prescribing of all psychoactives, including AEDs, for AD/ADRD and other conditions, how such prescribing is changing under the combined pressures of the pandemic and targeted reduction efforts, and the role of such prescribing in adverse health outcomes. We will accomplish this by creating a detailed dataset of quarterly cohorts of nursing home residents, including those with AD/ADRD, for the years 2009-2021 that draws on elements linked at an individual level from CMS’s Minimum Data Set (MDS), Part D, MedPAR, and Public Use files. The final linked dataset will include health, demographic, cognitive, and diagnostic variables, all psychoactive drug claims, nursing home outcomes, records of hospital and ER adverse events, and long-stay facility details, including staffing resources and COVID statistics. Finally, to help explain and validate findings, a national sampling of nursing home prescribers will be surveyed regarding their knowledge and beliefs surrounding changing approaches to the care of AD/ ADRD and associated outcomes. This study will describe current and evolving AED use in nursing homes for all indications, focusing on AD/ADRD and AD/ADRD outcomes. It will describe racial and gender disparities in the long-stay populations treated or not treated with psychoactives. It will delineate the impact of the COVID pandemic in combination with national policies on ADRD management and outcomes. Results of this study will inform policymakers, improve nursing home care and safety, and introduce new avenues for ongoing research.