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Cited by 76Dementia and Cognitive Impairment ResearchGeriatric Care and Nursing HomesPharmaceutical Practices and Patient Outcomes

When less is more, but still not enough: why focusing on limiting antipsychotics in people with dementia is the wrong policy imperative

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Kales, Helen C., Gitlin, Laura N., Lyketsos, Constantine G.·2019·Journal of the American Medical Directors Association
DOI 10.1016/j.jamda.2019.05.022
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Abstract

Antipsychotic reductions have been the primary focus of efforts to improve dementia care in nursing homes by the Centers for Medicare & Medicaid Services National Partnership. Although significant antipsychotic reductions have been achieved, this policy focus is myopic in 2 ways; there is no evidence for any increases in use of nonpharmacologic interventions, and there are indications for compensatory increases in the use of other (unmeasured) sedating psychotropics. This increased use of other sedating psychotropics is more concerning than the antipsychotics that they replaced, as there is even less support of efficacy for behavioral and psychological symptoms of dementia (BPSD) and ample proof of harms, including mortality. The current paradigm of "assessment" and "treatment" for BPSD is largely cursory and reflexive, with little effort put forth to understand possible underlying causes. This contrasts with the methodical, evidence-based way the field handles other symptoms considered "medical" (eg, shortness of breath). To move beyond this nonmedical approach to BPSD, we suggest a conceptual model that includes putative causal contributors. Although at their core BPSD are caused by brain circuitry disruptions, such disruptions are theorized to increase the person with dementia's vulnerability to 3 categories of triggers: those related to the (1) patient (eg, pain, hunger, and infection), (2) caregivers (eg, competing priorities, unrealistic expectations, and negative communications), and (3) environment (eg, overstimulation and limited light exposure). Assessing modifiable triggers is inherently person-centered as it enables clinicians to select specific nonpharmacologic strategies to mitigate identified triggers. Assessing triggers and selecting strategies, however, is time-intensive and reflects a paradigm shift necessitating a reorganization of dementia care including compensation for time spent elucidating and addressing modifiable triggers, vs unintendedly incentivizing the use of potentially harmful psychotropics. This paradigm shift should also include the measurement and restriction of any sedating medications for BPSD, particularly without assessment of underlying causes.

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  • Despite national policies such as the UK National Dementia Strategy having some effect on antipsychotic prescribing, prescribing of other psychotropics is still relatively common in dementia and other older people.

    “Despite national policies such as the UK National Dementia Strategy having some effect on antipsychotic prescribing, prescribing of other psychotropics is still relatively common in dementia and other older people [39, 40].”

    From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [40]

    The paper reports that US efforts reduced antipsychotic use in long-term care, while other psychotropics remained common among residents with dementia (Abstract; “Maust et al 25” section). It does not address the effect of the UK National Dementia Strategy or establish how common such prescribing is among older people without dementia. (LLM, conf=0.87)

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Research works printed but not linked: 3

  1. Choosing wisely: Five things physicians and patients should question. 2012. Available at: http://www.choosingwisely.org/choosing-wisely-five-things- physicians-and-patients-should-question-press-release-april-4-2012/. Accessed February 11, 2019.
  2. Savundranayagam MY, Ryan EB, Anas AP, Orange J. Communication and de- mentia: Staff perceptions of conversational strategies. Clin Gerontol 2007;31: 47e63.
  3. NIMH/NIA Workshop: Novel Approaches to Understanding the Mechanisms of the Neuropsychiatric Symptoms in Alzheimer's and Advancing Therapy Development; May 8-9, 2017; Bethesda, MD.

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Authors
Kales, H. C., Gitlin, L. N., & Lyketsos, C. G.
Affiliations
  • University of Michigan (US)
  • Drexel University (US)
  • Johns Hopkins University (US)
Corresponding author
Kales, Helen C.
ORCID
Venue
Journal of the American Medical Directors Association
Publisher
Elsevier BV
Published
2019-09
Volume
20
Issue
9
Pages
1074-1079
ISSN
1525-8610 (ISSN-L)
DOI
10.1016/j.jamda.2019.05.022
OpenAlex
W2965313826
Cited by
76
References
32
Citations by year
2026: 6 · 2025: 3 · 2024: 14 · 2023: 11 · 2022: 13 · 2021: 17 · 2020: 11 · 2019: 1
FWCI
8.35
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of the American Medical Directors Association (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
Funders
  • Genentech
  • National Institute on Aging
  • Servier
  • Novartis
  • Harry and Jeanette Weinberg Foundation
  • BrightFocus Foundation
  • Bristol-Myers Squibb
  • Health Services Research and Development (IIR 15-330)
  • Pfizer
  • Novartis Pharmaceuticals Corporation
  • Astellas Pharma US
  • National Institute of Mental Health
  • Elan
  • U.S. Department of Defense (W81XWH-16-1-0551)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
  • Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
Keywords
dementia, antipsychotic reduction, behavioral and psychological symptoms of dementia, nursing homes, non-pharmacological treatment, person-centred care, caregiver stress, light exposure, drug policy
MeSH terms
Dementia, Health Policy, Humans, Long-Term Care, Nursing Homes, Psychotropic Drugs, Antipsychotic Agents, United States

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