Prescriptions of antipsychotics dispensed in long-term care facilities during the COVID-19 pandemic

Residents of long-term care facilities (LTCFs), including nursing homes and assisted living facilities, were disproportionately affected by the COVID-19 pandemic. Since the start of the pandemic, 5% of total cases and 31% of total deaths have occurred in LTCFs, representing more than 186,000 deaths of residents and staff [1]. The high COVID-19 related mortality in LTCFs reflects not only the challenges posed by the pandemic in congregate care settings, but also longstanding deficiencies in the quality of care in these facilities. Recent studies have reported on the increasing use of antipsychotics in LTCFs to help manage challenging behaviors of residents, a concerning trend even before the pandemic [2,3]. However, little is known about trends in antipsychotic prescribing in LTCFs during the pandemic, especially after the first three quarters of 2020 [3]. We present trends in antipsychotic prescriptions dispensed in LTCFs between 2019 and 2021, including new prescriptions and refills.

Prescription data were drawn from IQVIA's National Prescription Audit (NPA) database. NPA includes over 3 billion prescriptions per year, representing more than 92% of prescriptions dispensed at retail pharmacies (chain, independent, and food store pharmacies), 72% of mail-order medications, and 78% of medications used in LTCFs. Long-term care data in IQVIA tracks prescriptions dispensed through pharmacies that service residential care facilities, institutional providers, and nursing home pharmacies. IQVIA's data include prescriptions dispensed to nursing homes and assisted living providers nationwide. Quarterly data on prescriptions for antipsychotics dispensed in LTCFs were analyzed to estimate how the number of antipsychotic prescriptions dispensed differed between 2020 and 2021 compared to 2019. Antipsychotic drugs were identified through IQVIA's Uniform System of Classifications.

More antipsychotic prescriptions were dispensed in LTCFs during the first quarter of 2020 (7.41%) and 2021 (5.43%) compared to 2019 (Fig. 1 ). There was a 0.92% increase in antipsychotics dispensing in the second quarter of 2020 and a 2.68% increase during the second quarter of 2021, compared to 2019. Antipsychotic prescriptions declined during the third quarter of 2020, but reached 2019 levels by the end of year, and remained higher than 2019 levels in the third and fourth quarter of 2021. Refill prescriptions were higher throughout 2020 and 2021 compared to 2019, with the largest increases occurring during the first and second quarters. New prescriptions for antipsychotics increased only during the first quarter of 2020 and then experienced a decline compared to 2019. New prescriptions were higher throughout 2021 compared to 2019, with the largest increase taking place in the first and second quarter.

Fig. 1.

Trends in Total, New and Refill Antipsychotic Prescribing and Percent Difference in Long Term Care Facilities: January 2019 – December 2021.

Antipsychotic use among patients in LTCFs is recommended only after the patient's physical and mental health conditions have been thoroughly evaluated, and when the benefit outweighs the risks. Inappropriate off-label use and over-prescribing of these drugs to reduce behavioral and psychological symptoms of people living in LTCFs, many of whom are older, frail, and have dementia, has been a concern for years, long before COVID-19 [4,5]. Given the decline in nursing home resident census – and likely decline in overall LTCF census – during 2020 and 2021 [4], the increase in antipsychotic prescriptions per resident may be even larger.

Discerning the reasons for this increasing trend in antipsychotic use in LTCFs from our data is difficult, but this increase maybe a reflection of facilities struggling to manage care of residents and/or clinical need of LTCF patients during the pandemic. It is possible that during the first quarters of the pandemic, LTCFs could have lacked staffing and training to implement robust infection control programs, and this could have resulted in LTCFs turning more towards antipsychotics to manage patients [6]. It is also possible that patients felt more anxious and distressed during the pandemic, and also COVID-19 infection might have resulted in agitation, prompting LTCFs to prescribe more antipsychotics [6]. Side effects from antipsychotics vary from mild sedation to more severe adverse reactions, including blood clots, fall risk, and severe nervous system problems [7]. The Centers for Medicare and Medicaid Services (CMS) tracks the use of antipsychotic medications as one of many statistics used to assess the quality of care in LTCFs (specially nursing homes) and seeks to discourage over-utilization of these drugs. On November 12, 2021, CMS released State Survey Guidance stating that inappropriate use of antipsychotic medications continues to be an area of concern related to quality of care, directing oversight efforts on identifying inappropriate use and emphasizing non-pharmacologic practices [8].

Disclaimer

The views expressed here are those of the authors and do not necessarily reflect the views of the Office of the Assistant Secretary for Planning & Evaluation, or US Department of Health & Human Services.

Data availability

The authors do not have permission to share data.