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Antiepileptic Prescribing for Nursing Home Residents Living With Dementia

Valproic acid and gabapentin are being used in “clinically distinct ways” in nursing home residents with Alzheimer’s disease and related dementias (ADRD), a study shows, with valproic acid for disruptive behaviors and gabapentin for pain. “Antiepileptic prescribing among nursing home residents with ADRD is increasing, while antipsychotic and opioid prescribing is declining,” the authors conclude. “Antiepileptic prescribing of questionable risk-benefit for dementia care warrants further scrutiny.”

The investigators constructed annual cohorts of residents with ADRD with long-term stays in nursing homes from 2015 to 2019 using Minimum Data Set and Medicare data, including Part D pharmacy claims. The study looked at the proportion of residents with ADRD in nursing homes nationwide with at least 1 antiepileptic prescription; trends in valproic acid, gabapentin, antipsychotic, and opioid prescribing; and how prescribing rates differed based on whether residents with ADRD had disruptive behaviors or reported pain.

“Our study sample includes 973,074 persons living with ADRD who had a long-term stay in a nursing home, which was defined as at least 3 months,” write the authors. “The proportion of residents with ADRD with at least one antiepileptic prescription increased from 29.5% in 2015 to 31.3% in 2019, which was driven by increases in the rate of valproic acid and gabapentin prescribing. Conversely, antipsychotic prescribing rates declined from 32.1% to 27.9% and opioid prescribing rates declined from 39.8% to 31.7%. The risk of valproic acid prescribing was 10.9 percentage points higher among residents with ADRD with disruptive behaviors, while the risk of being prescribed gabapentin was 13.9 percentage points higher among residents with ADRD reporting pain.”

Editorial: “If the intent of tracking anticonvulsant use moves from a quality improvement and assessment framework to a quality monitoring framework, it is worth pausing to consider the challenges and potential harms of implementing additional quality measures related to management of conditions that lack menus of clearly safe and effective pharmacologic options, and how such a measure might keep up with evolving evidence about off-label use,” editorialists write. “The data from [this study] suggest that policy interventions to reduce use of one type of medication may result in increased use of other medications, which in some cases may be worse choices than the original targets of those interventions. It is difficult to predict which drug may pop up next in a game of whack-a-mole to try to prevent unnecessary use of medications for [behavioral and psychological symptoms of dementia]. This study … serves as a reminder that as we hammer away at the variety of often futile and sometimes harmful attempts to manage complex clinical and quality-of-life challenges in the absence of resources and robust evidence, we must ensure that facilities have the staffing, resources, and evidence needed to ensure optimal, person-centered care and symptom management.”

Source: Journal of the American Geriatrics Society