Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014

OBJECTIVE

The Centers for Medicare and Medicaid Services' National Partnership to Improve Dementia Care in Nursing Homes focuses on but is not limited to long-term care (LTC) residents with dementia; the potential impact on residents with other diagnoses is unclear. We sought to determine whether resident subpopulations experienced changes in antipsychotic and mood stabilizer prescribing.

DESIGN

Repeated cross-sectional analysis of a 20% Medicare sample, 2011-2014.

SETTING AND PARTICIPANT

Fee-for-service Medicare beneficiaries with Part D coverage in LTC (n = 562,485) and a secondary analysis limited to persons with depression or bipolar disorder (n = 139,071).

METHODS

Main outcome was quarterly predicted probability of treatment with an antipsychotic or mood stabilizer.

RESULTS

From 2011 to 2014, the adjusted predicted probability (APP) of antipsychotic treatment fell from 0.120 [95% confidence interval (CI) 0.119-0.121] to 0.100 (95% CI 0.099-0.101; P < .001). Use decreased for all age, sex, and racial/ethnic groups; the decline was larger for persons with dementia (P < .001). The APP of mood stabilizer use grew from 0.140 (95% CI 0.139-0.141) to 0.185 (95% CI 0.184-0.186), growth slightly larger among persons without dementia (P < .001). Among persons with depression or bipolar disorder, the APP of antipsychotic treatment increased from 0.081 (95% CI 0.079-0.082) to 0.087 (95% CI 0.085-0.088; P < .001); APP of mood stabilizer treatment grew more, from 0.193 (95% CI 0.190-0.196) to 0.251 (0.248-0.253; P < .001). Quetiapine was the most commonly prescribed antipsychotic. The most widely prescribed mood stabilizer was gabapentin, prescribed to 70.5% of those who received a mood stabilizer by the end of 2014.

CONCLUSIONS AND IMPLICATIONS

The likelihood of antipsychotic and mood stabilizer treatment did not decline for residents with depression or bipolar disorder, for whom such prescribing may be appropriate but who were not excluded from the Partnership's antipsychotic quality measure. Growth in mood stabilizer use was widespread, and largely driven by growth in gabapentin prescribing.

Valproic acid in dementia: does an optimal dose exist?

Valproic acid is widely used in the treatment of behavioral disturbances in patients with dementia; however, there is uncertainty about its dosing and studies have reported mixed findings. The current article examines published trials of valproic acid in the treatment of patients with dementia to identify whether an optimal dosing strategy exists. Secondarily, valproic acid dosing from published studies is compared with a real-world 5-year sample of valproic acid prescribing. Twenty studies met selection criteria and were included in the review. Based primarily on uncontrolled trials and the current retrospective study, valproic acid serum levels between 40 and 60 mcg/mL and relatively low doses (ie, 7-12 mg/kg per d) are associated with improvements in agitation in some patients with dementia. At the same time, similar valproic acid levels produced no significant behavioral improvements in most placebo-controlled studies and led to substantial side effects in some patients. Considerable trial design differences exist between controlled and uncontrolled trials. Overall, valproic acid appears to have limited efficacy as monotherapy in many patients with dementia. Its optimal role may be in combination with other psychotropics as a treatment of agitation associated with dementia.

Potential Anti-Dementia Agents in Traditional Chinese Medicine

Dementia is becoming one of the biggest threats to human health. However, there is no efficient therapeutic approach so far. Thus, traditional medicines, which have accumulated certain experience in the treatment of dementia, are attracting more and more attention. Indeed, many anti-dementia drugs or drug candidates have been derived from these medicines. In this article, the profile of anti-dementia agents contained in traditional Chinese medicine (TCM) is described. It is indicated that TCM is not only a rich source of acetylcholinesterase inhibitors, but also of great potential to derive other kinds of anti-dementia agents which are either directly associated with ameliorating dementia or have complementary effects. These agents have apparent implications for anti-dementia drug discovery, especially for finding multicomponent anti-dementia drugs.