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Antipsychotic reduction in long-term care facilities likely leads to significant unintended fallout, a new study from Canada shows. Medication substitution and changes in diagnosis and symptom coding are the result, investigators say. 

The findings mirror those of similar studies in the United States, with some notable differences.

The researchers looked at healthcare data for 70,000 nursing home residents in Ontario each quarter between 2010 and 2019, when antipsychotics reduction campaigns were instituted in federally funded facilities. Antipsychotics and benzodiazepine use declined significantly during this time, as antidepressant and anticonvulsant use rose, the researchers found.

Coding changes 

In addition, the coding of delusions, which are a symptom used to help determine antipsychotic appropriateness, was initially stable but then increased from 3.5% to 10% between 2014 and 2019. This increase occurred during a period of increased media attention to the industry’s problem with overprescribing, the researchers found. 

Residents with dementia and aggressive behaviors were more likely to have coding for delusion in their records. Coding for schizophrenia, meanwhile, remained stable during the study period. 

The increases in delusion coding may reflect an increase in prevalence of the condition or a shift toward more accurate reporting of behavioral and psychological symptoms of dementia among residents, the authors theorized. Alternatively, these changes may be used to mask symptom management with inappropriate antipsychotic prescriptions, they added.

U.S. vs. Canada

Investigators found slightly different patterns in medication use over time between Canada and the United States. In the United States, recent studies have found an uptick in the use of mood stabilizers, mainly among residents with dementia, and decreases in antidepressant use. 

“In Ontario, we found different patterns that show greater use of antidepressants, which are not without risk,” the authors wrote. What’s more, the increase in antidepressant use was greater in residents with moderate, severe, and very severe aggressive behaviors when compared to residents with no aggressive behaviors.

They also found that anticonvulsants — likely used to treat chronic pain — may be responsible for observed increases in anticonvulsant prescribing over time.

U.S.-Canadian differences in psychotropic medication patterns are driven by many factors, the researchers said. These likely include the longer use of quality indicators by the Centers for Medicare & Medicaid Services than its Canadian counterpart, as well as prescriber preferences and different public reporting programs, they said.

CMS publicly reports potentially inappropriate use of antipsychotics, anxiolytics and sedative-hypnotics, but not anticonvulsants. Canada’s federal oversight agency historically reports only on potentially inappropriate antipsychotic use for nursing homes, the researchers noted.

The overall takeaway? It may be necessary to monitor changes in diagnosis and/or symptom coding along with potential patterns in medication substitution in order to support public efforts to reduce the use of potentially inappropriate antipsychotics, the authors concluded.

The study was published in JAMDA.