Image of different colored pills spilled onto a flat surface

There is wide variation by state in the prescribing of antipsychotics and benzodiazepines to hospice enrollees, according to a new study. The findings highlight the lack of evidence-based guidance for end-of-life prescribing, researchers say.

Investigators identified more than 1.3 million Medicare beneficiaries aged 65 years and older who were prescribed any antipsychotic or benzodiazepine during a day of hospice enrollment in 2017. The most common hospice diagnoses in qualified study participants were cancer, heart disease and dementia. 

The analysis, representing more than 4,200 hospices, resulted in state-level averages of adjusted prescribing rates. Using that data, large prescribing variations by state were found for each drug class. For antipsychotics, prescribing rates ranged from 62% for hospice beneficiaries in Oregon to 15% in Oklahoma. Benzodiazepine prescribing rates varied from 77% in Oregon to 42% in New York. 

Benzodiazepine prescription fills were higher than antipsychotics in all states. And for each class of drug, five states topped the prescriptions list: Oregon, New Mexico, Washington, New Hampshire and Florida.

Hospice drug standards lacking

Antipsychotics and benzodiazepines are routinely used to treat distressing end-of-life symptoms. Yet guidance and consensus on best prescribing practices is limited, according to lead author Donovan Maust, MD. 

The drugs also are tied to adverse side effects such as sedation and falls in older adults, and appropriate use will vary, he and his colleagues wrote. 

For example, “for those patients who are not imminently dying, patients and their care partners may prefer avoiding such medications in order to maintain function and minimize sedation,” the authors wrote.

Without clear evidence and guidance for hospice, use of these drugs may remain varied and inconsistent, they wrote in the Journal of the American Geriatrics Society.

Understanding variation in practice patterns may help in efforts to develop “appropriate prescribing in hospice and to clarify the current standard of care,” they concluded. 

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