Experts also noted that additional research is needed to  develop effective interventions. Approximately 33 Percent of Older Adult Medicare Part D Enrollees with Dementia Who Resided in a Nursing Home, and 14 Percent Outside of a Nursing Home, Were Prescribed Antipsychotic Drugs in 2012

About one-third of older adult Medicare Part D enrollees with dementia  who spent over 100 days in a nursing home were prescribed an  antipsychotic drug in 2012. 1.) 2.) Experts and Research Commonly Cited Certain Patient and Setting-Specific Factors Contributing to the Prescribing of Antipsychotic Drugs to Older Adults

Experts we spoke with and research we reviewed commonly identified  certain factors that are specific to the patient that contribute to  antipsychotic prescribing, such as patient agitation or delusions. These experts agreed that antipsychotic  drugs are often initiated in hospital settings and carried over to nursing  home settings. HHS Agencies’ Actions Focused on Reducing Antipsychotic Drug Use by Older Adults with Dementia Target Nursing Home Residents, Not Those in Other Settings

HHS agencies, including CMS, AHRQ, and NIH, have taken actions to  address antipsychotic drug use by older adults with dementia in nursing  homes. However, HHS has done little to address antipsychotic drug use  among older adults with dementia living in settings outside of the nursing  home. To reach this goal, HHS outlined several  actions, including monitoring, reporting, and reducing the use of  antipsychotics drugs by older adults in nursing homes. HHS Has Taken Little Action to Educate and Provide Outreach to Reduce Antipsychotic Drug Use among Older Adults Residing Outside of Nursing Homes

While the National Alzheimer’s Plan was established to improve care for  all individuals with dementia regardless of the setting where they reside,  HHS efforts related to reducing antipsychotic drug use among older  adults have primarily focused on those living in nursing homes with less  activity geared toward those living outside of nursing homes. Stakeholder groups we spoke to indicated that educational efforts similar  to those provided under the National Partnership should be extended to  those providing care to older adults in other settings, such as hospitals  and assisted living facilities. Extending  educational efforts to caregivers and providers outside of the nursing  home could help lower the use of antipsychotics among older adults with  dementia living both inside and outside of nursing homes. Recommendation for Executive Action

We recommend that the Secretary of HHS expand its outreach and  educational efforts aimed at reducing antipsychotic drug use among older  adults with dementia to include those residing outside of nursing homes  by updating the National Alzheimer’s Plan. At that time, we will send copies to the Secretary of Health and  Human Services. Analyses of Antipsychotic Drug Prescribing for Older Adults with Dementia

We used two primary data sources to examine antipsychotic drug  prescribing for older adults with dementia: the Medicare Part D  Prescription Drug Event (PDE) data to identify antipsychotic drug  prescribing for Medicare Part D enrollees in and outside of the nursing  home, and the Long Term Care Minimum Data Set (MDS) to identify  antipsychotic drug prescribing for all nursing home residents, regardless  of Medicare Part D enrollment. 3.
Why GAO Did This Study

Dementia affects millions of older adults, causing behavioral symptoms such as mood changes, loss of communication, and agitation. Concerns have been raised about the use of antipsychotic drugs to address the behavioral symptoms of the disease, primarily due to the FDA's boxed warning that these drugs may cause an increased risk of death when used by older adults with dementia and the drugs are not approved for this use.
GAO was asked to examine psychotropic drug prescribing for older adult nursing home residents. In this report, GAO examined (1) to what extent antipsychotic drugs are prescribed for older adults with dementia living inside and outside nursing homes, (2) what is known from selected experts and published research about factors contributing to the such prescribing, and (3) to what extent HHS has taken action to reduce the use of antipsychotic drugs by older adults with dementia. GAO analyzed multiple data sources including 2012 Medicare Part D drug event claims and nursing home assessment data; reviewed research and relevant federal guidance and regulations; and interviewed experts and HHS officials.

What GAO Found

Antipsychotic drugs are frequently prescribed to older adults with dementia. GAO's analysis found that about one-third of older adults with dementia who spent more than 100 days in a nursing home in 2012 were prescribed an antipsychotic, according to data from Medicare's prescription drug program, also known as Medicare Part D. Among Medicare Part D enrollees with dementia living outside of a nursing home that same year, about 14 percent were prescribed an antipsychotic. (See figure.)
Experts and research identified patient agitation or delusions, as well as certain setting-specific characteristics, as factors contributing to the prescribing of antipsychotics to older adults. For example, experts GAO spoke with noted that antipsychotic drugs are often initiated in hospital settings and carried over when older adults are admitted to a nursing home. In addition, experts and research have reported that nursing home staff levels, particularly low staff levels, lead to higher antipsychotic drug use.
Agencies within the Department of Health and Human Services (HHS) have taken several actions to address antipsychotic drug use by older adults in nursing homes, as described in HHS's National Alzheimer's Plan; however, none have been directed to settings outside of nursing homes, such as assisted living facilities or individuals' homes. While the National Alzheimer's Plan has a goal to improve dementia care for all individuals regardless of residence, HHS officials said that efforts to reduce antipsychotic use have not focused on care settings outside nursing homes, though HHS has done work to support family caregivers in general. Stakeholders GAO spoke to indicated that educational efforts similar to those provided for nursing homes should be extended to other settings. Extending educational efforts to caregivers and providers outside of the nursing home could help lower the use of antipsychotics among older adults with dementia living both inside and outside of nursing homes.

What GAO Recommends

GAO recommends that HHS expand its outreach and educational efforts aimed at reducing antipsychotic drug use among older adults with dementia to include those residing outside of nursing homes by updating the National Alzheimer's Plan. HHS concurred with this recommendation.