The overall rate of antipsychotic drug prescribing for people living with dementia increased during the pandemic and did not return to prepandemic levels when the acute phase was over, according to a new study. The findings reveal the need for new treatment strategies for behavioral and psychological symptoms (BPSD) of dementia, experts contend.

Investigators used databases from six countries, including two from the United States, to determine the yearly and monthly incidence of dementia diagnoses and the prevalence of antipsychotic drugs prescriptions for dementia.

Prescriptions soared 

In the pandemic’s early months, prescribing rates increased across all six countries, including France, Germany, Italy, South Korea, the UK and the U.S., the researchers found. For example, immediate spikes in antipsychotic use for dementia were seen in the U.S. Medicare database after the introduction of COVID-19 restrictions.

These prescribing rates remained elevated, according to the latest available months of data in 2021 — and were among the highest when compared with previous years, reported Ian C. K. Wong, PhD, of the University College London, UK, and the University of Hong Kong.

This continued overreliance on antipsychotics shows a high burden of unmet needs, and that dementia care did not completely adapt to the ongoing threat of the pandemic, Wong and colleagues said.

Renewed efforts should be made to improve care quality for people living with dementia, the authors contended. This could include nonpharmacological interventions, care support programs, protocols that encourage medication reviews and strategies that encourage antipsychotic drug deprescribing, they wrote.

Worsening behavioral symptoms

In an accompanying editorial, U.S. physicians and researchers said the study highlights how the pandemic created the conditions for worsening BPSD. Clinicians likely compensated for these disruptions by increasing their use of psychotropics, they explained.

“Despite more than a decade of regulatory pressure to limit prescribing, antipsychotics remain the treatment providers turn to for BPSD,” wrote Helen C. Kales, MD, of the University of California, Davis, in Sacramento, CA, and colleagues.

New approach to assessments

The editorial authors recommend using an approach called DICE (describe, investigate, create and evaluate) to assess treatment needs for BPSD. Created in 2014, DICE helps clinicians to identify modifiable underlying problems that contribute to BPSD such as pain, poor communication between caregivers and patient, and environmental complexity. 

These factors can then be addressed using evidence-based behavioral and environmental strategies, rather than relying solely on sedating medication, they wrote. Many older adults are becoming comfortable with technology such as video conferencing, which could help connect them to such interventions, they added. 

“To limit this antipsychotic-prescribing reflex, clinicians need a structured approach to their BPSD differential diagnosis to help select the most appropriate intervention, which will typically not be an antipsychotic,” the editorial concluded.

Long-term care considerations

Prior to the uptick of prescriptions during the pandemic, campaigns to reduce the use of these drugs in older adults had been met with some success. Within four years’ of its launch in 2012, for example, the National Partnership to Improve Dementia Care in Nursing Homes led to a 30% decrease in antipsychotics prescriptions among long-stay nursing home residents with Alzheimer’s disease and related dementias, the Centers for Medicare & Medicaid Services reported at the time. 

That campaign was not as successful in the assisted living population, however, according to a study published in August.  

The current study and editorial were published Wednesday, Jan. 25, in JAMA Psychiatry.

Related articles:

Feds’ antipsychotic drug reduction efforts in assisted living fail to produce success seen in nursing homes

Antipsychotic reduction in LTC leads to drug substitutions, more delusions diagnoses

Antipsychotics use falls when LTC nurse staffing hours rise: study

Nonpharmacologic program for residents with dementia linked to fewer meds, falls