Hazard in a Medication Bottle: Older Patients in Peril

It is now widely agreed by health care experts—clinicians and quality advocates—antipsychotic medications are wrong for most older patients with dementia. Every indication is that the drugs harm more than they help. They boost the likelihood of a fall that can result in a broken bone. They increase hospitalizations. They increase the risk of death.

Even so, a new report from the Government Accountability Office (GAO) says the message is not reaching the people who write prescriptions. The report also notes there are several initiatives targeting the overuse of these drugs within nursing homes. But, it adds, efforts to curb their use by patients who do not live in a nursing home are woefully insufficient.

Why do doctors prescribe these drugs? Antipsychotics are often prescribed to modify behavior. As dementia progresses, patients may become agitated or aggressive, which can be challenging for families and health care staff. Antipsychotics treat these symptoms. They do not treat the actual dementia. They may, in fact, accelerate a decline in health.

When the American Geriatric Society updated its list of drugs with potential for inappropriate use—commonly known as the Beers List—it discouraged the use of antipsychotics unless a patient is at risk of self-harm and if all other non-medication options have failed. The panel that formed the list wrote that antipsychotics present “increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.” The FDA also issued a “black box” warning for antipsychotics. That warning is reserved for drugs that are likely to pose a serious hazard.

There is a bright spot in this cloudy report, however: We are collecting data on the use of these drugs and the populations using them. More information can impact efforts to trim their use.

How does NCQA address this issue? By doing what we do best: measuring quality and outcomes. A growing consensus among public payers that there is a need to integrate physical and behavioral health has produced diverse pilot and demonstration projects to do just that in Medicare and Medicaid. What’s more, the number of behavioral health measures we track is growing rapidly.

In 2014, NCQA added antipsychotics and benzodiazepines to the list of harmful drug interactions we check for elderly patients with dementia. When we added those drugs, the percentage of harmful drugs prescribed to the elderly with dementia jumped from 24 percent to 50 percent.

“We don’t know which medication contributes to the high rate on this measure,” explains Erin Giovannetti, NCQA Research Scientist. “But given the significant change in rates when we added the new medications, we can guess that it is antipsychotics and benzodiazepines.”

Although not stated overtly, the report confirms something we have known at NCQA for a long time: Collecting data, measuring a wide array of outcomes, producing reports like this one—all are pivotal to improving care—both physical and behavioral—inside and outside of formal care facilities. The more we know about these issues and who they affect, the more we can do to help.

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