Frequency and appropriateness of antipsychotic medication use in older people in long-term care
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Many studies have reported excessive use of antipsychotic medications in long stay institutions in Britain and America.
We examined the frequency and appropriateness of antipsychotic prescribing in a variety of extended care settings in the west of Ireland.
Clinical details of 345 residents (211 public and 134 private) were obtained from medication sheets and medical notes and by interviewing nursing staff. American prescribing guidelines were applied for those residents taking antipsychotic medications.
Of the 345 residents, 80 (23%) were prescribed regular antipsychotic medications of whom 41 (51%) were deemed to be receiving these agents inappropriately. There was no difference in the use of antipsychotic drugs (21.3% vs. 26.1%, Chi-sq = 1.1, p = 0.3) between residents of public and private units. However, inappropriate antipsychotic use was more common among those in private care (23/35 (66%) vs. 18/45 (40%); Chi-sq = 5.2, p = 0.02). Prominent inappropriate indications for antipsychotic use were: restlessness (26/41 (63%) patients); history of very intermittent aggression (23 (56%) patients); and wandering (19 (46%) patients).
Inappropriate use of antipsychotic medications, as judged by American legislative guidelines, is common in long-stay units in the west of Ireland.
KeywordsAntipsychotic medications Dementia Elderly Long-term care
There has long been concern about overuse of antipsychotic medications in nursing homes . Antipsychotic medications are often prescribed without appropriate diagnosis or monitoring for side effects and in excessive doses . Withdrawal of antipsychotic medications in nursing home residents has been associated with improvement in alertness and in cognitive function without any increase in problem behaviour .
While the quality of care in long-stay units in Ireland has recently been the subject of public concern, the specific issue of antipsychotic medication use in this setting has received little attention. A study from two public long-term care units found that 20 (26.3%) of 76 residents were receiving antipsychotic drugs, which is consistent with reports from other countries . However, the appropriateness of antipsychotic use in Irish long-stay units has not been examined.
In the United States, strict regulations to reduce unnecessary drug use, including antipsychotic medications, in nursing homes were introduced in 1987 as part of the omnibus budget reconciliation act (OBRA) . Using these guidelines, we investigated use and appropriateness of antipsychotic use in public and private long-stay units in the west of Ireland.
We sought permission from the directors of nursing from three public and six private long-stay units in Galway city and county to examine antipsychotic prescribing in their unit. Agreement was obtained for all of the public and for four of the private units.
We visited each of the participating units, and examined the medicine dispensing sheets of all long-stay residents; short-term and respite patients were excluded. We identified those taking antipsychotic medications regularly and collected information on the drugs and dosages prescribed. A senior member of nursing staff was interviewed using a standardised questionnaire and the medical notes examined to determine demographic data for patients receiving antipsychotic drugs, the main reason for use of the medication and details of medical conditions, including dementia.
The health care financing administration (HCFA), an agency responsible for regulating nursing homes participating in the medicare and medicaid programs, developed interpretive guidelines for fulfilling OBRA requirements . We applied the 1999 HCFA guidelines to decide whether the drug was being used appropriately. In brief, the guidelines state that an antipsychotic medication may be appropriate for (a) psychotic disorders and (b) organic mental syndromes associated with specific psychotic and non-psychotic behaviours that present a danger to the resident or others or that interfere with the ability of families or staff to provide care for the resident . However, antipsychotic treatment is not appropriate for wandering, poor self care, restlessness, impaired memory, anxiety, unsociability, indifference to surroundings, fidgeting, nervousness, depression without psychosis, insomnia, uncooperativeness or for agitation that is not dangerous.
As is conventional, antipsychotic medication doses were converted to chlorpromazine equivalents. The estimates provided by Woods were used; for example, 2 mg haloperidol, 2 mg risperidone, 5 mg olanzapine and 75 mg quetiapine are all equivalent to 100 mg chlorpromazine .
Non-parametric statistics were used to compare the characteristics of those receiving or not receiving antipsychotic drugs and of those in public and in private institutions.
Of the 345 residents, 80 (23%) were prescribed regular antipsychotic medications. Of these residents, 68 (85%) were receiving an atypical antipsychotic (olanzapine, respiridone and quetiapine in order of frequency); median (range) dose in chlorpromazine equivalents was 150 mg (50–870 mg) per day. There was no significant difference in age between those receiving (median 82 (range 61–92) years) and those not receiving antipsychotics (77 (56–99) years); 32/80 (40%) of those receiving antipsychotics were male, as were 82/265 (31%) of those not receiving these drugs (chi-square = 2.3, p = 0.13).
Appropriate and inappropriate antipsychotic use in 80 residents
Appropriate use (N = 39)a
Persistent aggressive behaviour
Depression (prescribed by psychiatrist)
Bipolar disorder (prescribed by psychiatrist)
Anxiety (prescribed by psychiatrist)
Inappropriate use (N = 41)a
Intermittent or distant aggressive behaviour
Distant psychosis, no review
Anxiety (not prescribed by psychiatrist)
There was no difference in the frequency of dementia (58.2% vs. 56.7%, chi-square = 0.1, p = 0.8) or in the use of antipsychotic drugs (21.3% vs. 26.1%, chi-square = 1.1, p = 0.3) between residents of public and private units. However, inappropriate antipsychotic use was more common among those in private care (23/35 (66%) vs. 18/45 (40%); chi-square = 5.2, p = 0.02). Of those residents taking regular antipsychotic drugs, 18/45 (60%) residents in public and 7/35 (20%) residents (chi-square = 3.7, p = 0.06) had been seen by a consultant geriatrician or psychiatrist with regard to their problem behaviour; 17/45 (38%) and 5/35 (14%) respectively (chi-square = 5.5, p = 0.02) were under ongoing supervision by a consultant. If patients in the public unit directly run by a consultant geriatrician are excluded, the results become 13/40 (32.5%) versus 7/35 (20%) (chi-square = 1.5, p = 0.2) and 12/40 (28.2%) versus 5/35 (14%) (chi-square = 2.6, p = 0.1) respectively.
Our finding that 23% of residents of long term care units in the west of Ireland were receiving regular antipsychotics is consistent with reported prevalences of 17–30% in the United States before the OBRA legislation was introduced . More importantly, our study suggests that inappropriate use of antipsychotic medications, as judged by American legislative guidelines, is common among Irish long stay residents. Our results are similar to those reported by a study of 330 residents in nursing homes in Manchester where 30% of residents were receiving regular antipsychotics and the percentage of inappropriate antipsychotic prescribing was 54% .
The efficacy of antipsychotic medications for most problem behaviours in this population is debatable, but the side effects are often substantial, especially in older people. In patients with dementia, antipsychotics may increase the rate of cognitive decline, increase mortality, increase the occurrence of stroke and falls and reduce quality of life [3, 9]. These complications have also been reported with the supposedly safer ‘atypical’ antipsychotic agents used by most patients in our study.
We did not interview the prescribing doctors to determine their precise reasons for using antipsychotic medications. Also, this study was based on a small number of long-stay units in a single geographical area. However, the level of antipsychotic use in our study was similar to that in Dublin long stay units in the only other Irish study . The units included in this study agreed to participate. In several cases, staff noted that they were concerned about the level and appropriateness of antipsychotic use but felt that few alternative options were available. We believe it more likely that non-participating units may have higher rather than lower use of antipsychotic medications.
The causes of inappropriate psychotropic medication prescribing are complex and may involve patient, doctor and healthcare setting characteristics. Many challenging behaviours among patients with dementia will respond best to non-pharmacological, psychological measures. However, this approach requires adequate numbers and training of staff and ready access to psychologists, therapists and consultants. The lower rate of inappropriate prescribing of antipsychotic medications in the public long-stay units most likely reflects the higher staffing and better access to consultant staff in such units. Use of psychotropic medications is one of many areas related to long-term care that is not adequately regulated at present. Since legislation regarding antipsychotic prescribing in long-term care was enacted in the United States, overall use of antipsychotic drugs in nursing home residents has declined by nearly a third . A similar approach should prove helpful in Ireland.
- 5.Omnibus Budget Reconciliation Act of 1987: subtitle C, nursing home reform: PL100-203. Washington, D.C.: National Coalition for Nursing Home Reform, 1987Google Scholar
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