GAO Calls For Expanded Efforts to Reduce Antipsychotic Use in Older Dementia Patients

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The Department of Health & Human Services should do more to curb antipsychotic use in older adults with dementia, according to a recent report by the Government Accountability Office.

Antipsychotics are often prescribed off label to treat behavioral symptoms of dementia such as delusions, agitation, aggression, and personality changes. But the medications carry an increased risk of death and other adverse effects in older adults and should be used only when other options have been exhausted, said Sen. Ron Johnson (R-WIs.) and Sen. Susan M. Collins (R-Maine), who requested the report.

“Clinical guidelines consistently suggest the use of antipsychotic drugs for the treatment of the behavioral symptoms of dementia only when other, non-pharmacological attempts to ameliorate the behaviors have failed, and the individuals pose a threat to themselves or to others,” they said.

In 2012, Medicare Part D plans paid about $363 million for antipsychotics used by dementia patients aged 66 years and older.

About 33% of older adults with dementia who resided in a nursing home and were enrolled in Medicare Part D plans were prescribed antipsychotics, the authors said. Among those who did not reside in a nursing home, 14% were prescribed antipsychotics.

The investigation also found that 23% of short-stay [100 days or fewer] nursing home residents were prescribed antipsychotics, compared with 33% of long-stay residents. Sixty-six percent of the antipsychotic prescriptions for Medicare Part D patients were prescribed by internists and family medicine physicians, and 16% were written by psychiatrists or neurologists, the report said. Meanwhile 5% of the antipsychotics for these patients were prescribed by nurse practitioners and physician assistants, and the rest were prescribed by many specialties.

Although several HHS programs exist that aim to reduce antipsychotic use in aging populations, these efforts are limited to adults in nursing homes, who likely have greater disease severity, Sen. Johnson and Sen. Collins wrote.

“Similar efforts have not been directed toward caregivers of older adults living outside of nursing homes, such as those in assisted living facilities and private residences,” the authors said. “Targeting this segment of the population is equally important given that over 1.2 million Medicare Part D enrollees living outside of nursing homes were diagnosed with dementia in 2012 and Medicare Part D pays for antipsychotic drugs prescribed to these individuals,” they added.

By expanding its outreach and educational efforts, HHS might be able to reduce the unnecessary reliance on antipsychotics for treating the “behavioral symptoms of dementia for all older adults regardless of their residential setting,” the author wrote. HHS concurred with the report’s conclusions.

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