# Trends in antipsychotic prescribing among community-dwelling older adults with dementia, 2010-2018

## TL;DR

Antipsychotic prescriptions for older adults with dementia increased after medical recommendations against their use, suggesting a need for stronger interventions to reduce overprescribing.

## Contribution

This study reveals that antipsychotic use in community-dwelling older adults with dementia increased despite medical society recommendations, highlighting a gap in guideline adherence.

## Key findings

- Antipsychotic prescribing increased from 9.4% to 15.8% during the publication period of Choosing Wisely recommendations.
- Prescribing remained high (16.0%) in the post-publication period, showing no decline after recommendations were released.
- Both potentially low-value and potentially indicated antipsychotic prescriptions increased over time.

## Abstract

Due to an FDA “black box” warning for heightened risk of death, Choosing Wisely (CW) recommends avoiding antipsychotic prescription drugs as first-line treatment for dementia-related agitation. Yet, post-CW trends among community-dwelling patients with dementia remain unknown. In this retrospective cohort study, we used nationally representative Health and Retirement Study survey data linked to Medicare fee-for-service claims (January 1, 2010-December 31, 2018) to analyze prescribing trends during the pre-publication (2010-2012), publication (2013-2015), and post-publication (2016-2018) periods of CW recommendations. We included community-dwelling adults aged ≥65 years with dementia. We utilized multivariable mixed regression models to determine the percentage of patients prescribed any, potentially low-value, and potentially indicated antipsychotics. Among an estimated 2.4-2.7 million patients with dementia, any antipsychotic prescribing increased from 9.4% (95% CI, 6.4%-12.3%) during the pre-publication period (2010-2012) to 15.8% (95% CI, 12.8%-18.8%) (P < 0.001) during the publication period (2013-2015). Potentially low-value and potentially indicated prescriptions also increased. Post-publication period (2016-2018) prescribing of 16.0% (95% CI, 13.0%-19.1%) (P < 0.001) remained higher than pre-publication. Among older Americans with dementia, antipsychotic prescriptions increased after the publication of CW recommendations and held steady in the subsequent post-publication period. Stronger interventions, such as electronic clinical decision support tools and financial incentives, are needed to curb low-value antipsychotic prescribing for this vulnerable population.

Antipsychotic drugs have a “black box” warning for a heightened risk of death if used to treat behavioral agitation in patients with dementia. Multiple medical societies recommend against using antipsychotics in this way. Prescriptions among institutionalized older adults with dementia have declined over the past decade, but prescribing trends in community-dwelling patients with dementia in relation to medical society recommendations remain unknown. Our study shows that antipsychotic prescriptions among community-dwelling older Americans with dementia increased during the publication of multiple Choosing Wisely society recommendations and did not decline after their publication. Stronger interventions are needed to curb overprescribing for this vulnerable group.