Antipsychotic Prescribing for Dementia Spurred by Pandemic

The American Geriatrics Society Beers Criteria state that antipsychotics should be avoided for behavioral problems of dementia or delirium unless nonpharmacological options have not worked or are not possible and the patient is threatening to harm themselves or others. Yet a study in JAMA Psychiatry has found that prescription rates of antipsychotics for people with dementia rose in the first few months of the COVID-19 pandemic and did not decrease to prepandemic levels after the acute phase of the pandemic had ended.

Hao Luo, Ph.D., an assistant professor in the Department of Social Work and Social Administration at the University of Hong Kong, and colleagues examined data from 857,238 people with dementia aged 65 years or older collected between January 1, 2016, and November 30, 2021. The researchers also compared prescribing of antipsychotics among the study population in April, May, and June 2020 with the same months in 2019. The data were drawn from eight databases in six countries: France, Germany, Italy, South Korea, the United Kingdom, and the United States, including two databases each from South Korea and the United States.

The researchers found that although there were reductions in the incidence of dementia in seven of the databases in April, May, and June 2020, antipsychotic prescribing rates for people with dementia increased in six of the databases, which represented all of the countries in the study. The greatest increase occurred in South Korea, where people with dementia had more than twice the risk of receiving an antipsychotic prescription in May 2020 compared with May 2019. The second greatest increase occurred in the United Kingdom, where people with dementia had slightly less than twice the risk of receiving an antipsychotic prescription in June 2020 compared with June 2019. Patients with dementia in the U.S. Medicare database had a 43% greater risk of receiving a prescription for an antipsychotic in the early months of the pandemic compared with corresponding months in 2019.

“Although specific causes for the increase in the rates of antipsychotic drug prescribing may vary and cannot be identified by the current data, the increase may in part be associated with both a deterioration in behavioral and psychological symptoms of dementia and reduced access to care following the introduction of COVID-19 restrictions,” Luo and colleagues wrote.

Antipsychotic prescribing rates for people with dementia in the latest available months of 2021 were still among the highest compared with previous years. For example, among patients with dementia in the U.S. Open Claims database, 17.58% had been prescribed an antipsychotic in 2019, 18.26% had been prescribed an antipsychotic in 2020, and as of November 30, 2021, 19.12% had been prescribed an antipsychotic.

That antipsychotic prescribing for people with dementia had not returned to prepandemic levels concerns study researcher Kenneth K.C. Man, Ph.D., a lecturer in pharmacoepidemiology and medication safety in the Research Department of Practice and Policy at the University College of London School of Pharmacy.

“We didn’t look into the causes of why the prescribing continued, but we speculate that in addition to the likely continuation of restricted health care access that might have still been present in 2021, patients may not be routinely or frequently assessed to stop their prescription,” Man told Psychiatric News. “Therefore, in addition to the promotion of nonpharmacological strategies, health systems may benefit from considering strategies to encourage medication reviews and antipsychotic deprescribing campaigns.”

Man added that psychiatrists should be “fully aware” of the limited efficacy of antipsychotics in people living with dementia and be prepared to draw on nonpharmacological strategies, potentially in collaboration with other health professionals such as nurses, counselors, and social workers to treat these patients.

In an accompanying editorial in JAMA Psychiatry, Helen C. Kales, M.D., chair of the Department of Psychiatry and Behavioral Sciences at the University of California, Davis, and colleagues wrote that “clinicians still clearly view antipsychotics as the hammer to reach for when confronted with BPSD [behavioral and psychological symptoms of dementia].” They added that when the pandemic took hold, it was possible that health care professionals resorted to prescribing antipsychotics as the most effective pharmacological treatments in an “emergency” situation that included increases in symptoms and decreases in access to care.

Kales told Psychiatric News that physicians face a challenge in promoting nonpharmacologic ways of addressing behavioral and psychological symptoms of dementia.

“We sort of look at this as a physician problem with them prescribing the drugs, but one thing physicians say is that they receive relentless requests for [antipsychotics], whether the requests come from a nurse in a care facility or a caregiver in an Alzheimer’s support group. People hear somewhere that [antipsychotics] work and want to know why [their patients or loved ones] can’t have them,” Kales explained.

“It’s a systems issue, and we need to look at it as such,” Kales added. “If we can empower caregivers with training on how to manage the behaviors, they can think about ways they can calm the person [with dementia] down, and there will be fewer requests.”

This study was supported by the Research Grants Council of Hong Kong. ■