Brown Study Challenges Common Perceptions of Antipsychotic Use in Nursing Homes

Their findings show that exclusionary diagnoses increased only slightly following CMS National Partnership regulations from a baseline of 2.2% to a peak of 2.9%, thus allaying some fears and challenging the current popular consensus. 

Shireman suggests the modest increase is largely due to the awareness among prescribers about the risks associated with these drugs among people with dementia, especially because of their Black Box Warning—the strongest FDA warning for medicines and medical devices on the market. 

“Prescribers know that these medications should not be used in people with dementia,” she said. “So, they are generally adhering to this guidance and avoiding inappropriate use. Nursing homes are also well aware of the policies and the risks tied to these drugs. They understand the importance of providing high-quality care and avoiding practices that could put them at risk of regulatory trouble.”

In a nursing home setting, nursing staff are typically first to raise concerns that a resident needs better management, but it’s ultimately the doctor or nurse practitioner who writes the prescription. “There are two layers of professionals—nurses and prescribers—that are both aware that these drugs should be avoided in dementia patients,” Shireman said, “and I think that’s why we didn’t see a greater increase in their use.”

Meanwhile, the study found that CMS regulations influenced for-profit and not-for-profit homes differently, with a higher rate of exclusionary diagnoses in for-profit homes, while not-for-profit homes saw a decrease. But Shireman cautions that these differences were quite moderate, with both for-profit and not-for-profit homes still well below a 4% rate in the occurrence of these conditions.

“Some people argue that for-profit nursing homes are driven by a need to minimize costs, which could lead to less staffing and potentially greater reliance on medication to manage patients,” she said. “The idea is that they might use drugs as a substitute for adequate staffing. However, it’s not entirely clear if this is consistently true across the industry.”

Shireman acknowledges that not-for-profits may focus more on broader goals of care and therapy, although they still need to maintain a margin to stay in business. “This has been a longstanding debate in the nursing home industry—whether for-profit versus not-for-profit status really makes a significant difference in quality of care,” she said. “There are excellent for-profit and less-than-ideal not-for-profit nursing homes, so it’s hard to make an absolute distinction.”

Shireman stresses that this issue just isn’t about medications, but about how we provide the best care for nursing home residents. “Much like childcare, we need to ensure quality care while balancing economic pressures,” she said. “We need to step away from purely economic-driven decisions and prioritize humanity and dignity.”

Shireman believes that the criticism of nursing homes is overly simplistic and doesn’t tell the full story. She is encouraged to see that, by and large, nursing homes are doing right by people with dementia. She emphasizes the need for public health professionals to support nursing home staff in making better care decisions while recognizing the hard work they do.

“I believe the National Partnership and its quality measures have already done a good job of reducing potentially inappropriate use of antipsychotics,” she said. “Now it’s important to trust the professionals on the ground to make the best decisions for their patients. We’ve successfully reduced a lot of unnecessary use, but our goal shouldn’t be to eliminate antipsychotic use entirely—just to use it appropriately when truly needed.”