Age and Ageing Advance Access originally published online on December 6, 2006
Age and Ageing 2007 36(1):107-108; doi:10.1093/ageing/afl131
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How Well do Psychotropic Medications Match Mental Health Diagnoses? A National View of Potential Off-Label Prescribing in VHA Nursing Homes
Sir—The recent article, "Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland’ suggests the potential of off-label use of antipsychotic medications as chemical restraints [1]. Central nervous system medications, especially psychotropic medications, such as antipsychotics, antidepressants, anxiolytics and hypnotics, are frequently prescribed off-label [2–4]. For instance, antidepressants may also be prescribed off-label for peripheral neuropathies [2–4]. Atypical antipsychotics are prescribed off-label for control of behavioural and psychological symptoms of dementia, depression and bipolar disorder [2]. The use of psychoactive medications as chemical restraints or for other inappropriate uses in nursing homes has been a concern for nearly two decades [3, 4]. Although there may be benefits to off-label prescribing of psychotropic medications, clinicians should exercise caution because of potential medication side effects, particularly in elderly patients.The Veterans Health Administration (VHA) is a vertically and horizontally integrated health care system with 136 nursing home care units with an average daily census of over 12,000. Using the minimum data set (MDS) resident assessment instrument (RAI), we identified 6,601 residents who had an annual assessment in fiscal year 2005. Of the 6,601 long-term nursing home patients, 42.27% (2,790/6,601) were taking antipsychotics, 18.95% (1,251/6,601) anxiolytics, 47.37% (3,127/6,601) antidepressants and 4.21% (278/6,601) hypnotics. Among patients taking antipsychotics, 43.80% (1,222/2,790) had a diagnosis of schizophrenia, 11.51% anxiety disorder, 35.09% depression, 11.86% manic depression and 53.44% Alzheimer's disease (AD) or other dementia. Among patients taking anxiolytics, 24.78% (310/1,251) had a diagnosis of anxiety disorder, 30.78% schizophrenia, 41.41% depression and 38.98% AD or other dementia. Among patients taking antidepressants, 68.08% had a diagnosis of depression. Finally, the predominant (49.64%) diagnosis of patients taking hypnotics was depression (138/278).
Our findings indicate that there are large discrepancies between mental health diagnoses and the use of psychotropic medications in long-term nursing home patients in the VHA. Like the Finland study, our preliminary findings suggest there is little association between mental health diagnoses and the use of antipsychotics. Evaluating potential off-label prescribing of psychotropic medications is difficult in long-term nursing home patients because multiple chronic diseases and polypharmacy frequently occur. Treating one behavioural or psychiatric condition with psychotropic medications may result in adverse psychiatric side effects requiring additional psychotropic medications to off-set the side effects [5]. Additionally, antipsychotic medications may also be used for approved symptom relief unrelated to psychiatric diseases, such as antipsychotics for the relief of nausea, emesis, or hiccoughs not fully captured in the MDS [5]. Since a large percentage of VHA nursing home residents taking antipsychotics had a diagnosis of dementia, depression or bipolar disorder, off-label prescribing may have been for behavioural and psychological problems related to these diagnoses.
The current MDS RAI provides some of the data elements necessary to begin surveillance of off-label prescribing in nursing home residents. The present MDS long-term care quality indicators that measure psychotropic medication usage in nursing homes require additional data and refinements to become a practical tool for proactive medication safety surveillance. Inappropriate prescribing of psychotropic medication in nursing homes has been linked to significant adverse events (e.g. mortality, injuries, adverse drug events, avoidable medical expenses, etc.). Future research will link these health outcomes of interest with off-label, inappropriate psychotropic medication usage.
1 VISN-8 Patient Safety Center of Inquiry, 13000 Bruce B. Downs Blvd. (118 M), James A. Haley Hospital, Tampa, FL 33612, USA
2 University of South Florida, College of Public Health, Tampa, FL, USA
3 James A. Haley Hospital, Tampa, FL, USA
* To whom correspondence should be addressed Email: Dustin.French{at}va.gov; drddfrench{at}yahoo.com
References
- Alanen H, Finne-Soveri H, Noro A, et al. (2006) Use of antipsychotics among nonagenarian residents in long-term institutional care in Finland. Age Ageing 35 508–13.
[Abstract/Free Full Text] - Van Iersel MB, Zuidema SU, Koopmans R, et al. (2005) Antipsychotics for behavioural and psychological problems in elderly people with dementia: a systematic review of adverse events. Drugs Aging 22 845–58.[CrossRef][Web of Science][Medline]
- . Department of Health and Human Services Office of Inspector General. ( 11 2001) Psychotropic Drug Use in Nursing Homes. Report OEI 02-00-00490 Available at: http://oig.hhs.gov/oei/reports/oei-02-00-00490.pdf (Accessed September 5, 2006).
- Mendelson D, Ramchand R, Abramson R, et al.
- Prescription drugs in nursing homes: Managing costs and quality in a complex environment. National Health Policy Forum, George Washington University. NHPF Issue Brief No. 784. November 12 (2002) Available at: http://www.avalerehealth.net/research/docs/IB784_RxDrugsNursHomes_11-12-021.pdf (Accessed September 5, 2006).
- Thomson Micromedex Healthcare Series 1974–2006 Health Series Vol. 127 Available at: http://www.micromedex.com (Accessed May 15, 2006).
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