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Fewer residents with dementia now receive off-label antipsychotic drugs in Veterans Health Administration nursing facilities. But overreliance on other behavior-modifying medications has spiked, a new study finds.

Antipsychotics use in VA nursing homes steadily declined — from one third of residents to one quarter — during a decade of federal incentivizing, the researchers reported. Yet as such prescriptions fell, clinicians began switching to potentially inappropriate antiepileptics, antidepressants and opioids, said Lauren Gerlach, D.O., M.S., of Michigan Medicine.

The increase in alternative drug use was largely driven by the epilepsy drug gabapentin, investigators said. Prescriptions for the drug doubled during the study period, from 2009 to 2018. Gabapentin is often prescribed to address pain, but researchers are unsure of its efficacy in patients with dementia, they noted.

Overall, prescriptions for antiepileptic or mood stabilizing medication rose by 17 percentage points, with over 40% of veterans receiving these medications by the end of the study period. 

Much as with antipsychotics, there is little evidence that any of these alternative drugs reduce troubling dementia-related behaviors, the authors found. What’s more, they may be just as dangerous as antipsychotics, Gerlach said. Antipsychotics are known to raise the risk of confusion, falls, stroke and respiratory infections in nursing home residents. 

The takeaway? Nursing home clinicians must consider non-drug solutions to help reduce triggers for agitation, anxiety and other behavioral health issues, Gerlach said. Patient, caregiver and environmental interventions require additional staff and family involvement, but there is evidence that these strategies work, she concluded.

Full findings were published in the American Journal of Psychiatry.

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