More Antipsychotics Given for Dementia During Pandemic

Antipsychotic drug prescribing rates among people with dementia increased markedly during the early months of the COVID-19 pandemic, a multinational database study showed.

Notably, those rates did not return to prepandemic levels after the acute phase of the pandemic had ended, Kenneth K.C. Man, PhD, of University College London School of Pharmacy, and colleagues reported in JAMA Psychiatry.

In U.S. Medicare data, the likelihood of dementia patients getting prescribed antipsychotics after the introduction of COVID-19 restrictions rose 43% (95% CI 1.20-1.71) compared with the same period in 2019.

Across the six countries studied, the biggest shifts occurred in May 2020 in South Korea and June in the U.K., roughly doubling prescribing compared with the same period in 2019 (rate ratio [RR] 2.11, 95% CI 1.47-3.02, and RR 1.96, 95% CI 1.24-3.09, respectively).

At the same time, dementia diagnoses dropped in all the countries except Germany during the early phase of the pandemic (April-June 2020) compared with the corresponding months in 2019. The biggest drop occurred in the U.S. data, with an RR of 0.30 (95% CI 0.27-0.32) in April 2020 in the IBM MarketScan Medicare Supplemental and Coordination of Benefits Database and 0.40 (95% CI 0.37-0.43) in May 2020 in the U.S. IQVIA Open Claims database.

While new diagnoses returned to normal in most of the databases, incidence in the latter months of 2021 remained below the prior 3-year mean in the U.S. data.

The researchers suggested that disruptions in dementia diagnosis services and increased mortality among those who were or would have been diagnosed with dementia were likely behind the changes.

“These findings suggest that the pandemic disrupted the care of people living with dementia and that the development of intervention strategies is needed to ensure the quality of care,” the researchers noted.

In an accompanying editorial, Helen C. Kales, MD, of the University of California Davis, and colleagues acknowledged that “the pandemic created conditions for the worsening of BPSD [behavioral and psychological symptoms of dementia] and, consequently, compensatory increases in psychotropic use.”

Antipsychotics do not typically address the behavioral and psychological symptoms of dementia that families report as most challenging, such as the rejection of needed care or repetitive vocalizations, they observed.

Antipsychotic use peaked in the early 2000s, when 24% to 32% of nursing home residents received these medications, then declined after international regulatory agencies warned of antipsychotics’ adverse effects in this population.

The study included 857,238 people ages 65 or older with dementia (58% women) in France, Germany, Italy, South Korea, the U.K., and the U.S. Health records and claims data came from one database in each country and two additional databases from South Korea and the U.S. between Jan. 1, 2016, and Nov. 30, 2021.

The exposure period began April 1, 2020, a few weeks after all countries in this study introduced stringent lockdown policies. Patients had 365 days of observation before the index dementia diagnosis.

Study authors noted a significant association between the level of strictness of lockdown-style policies (per COVID-19 Stringency Index score) and an increased rate of antipsychotic drug prescribing in all databases except for the one from France and one from South Korea.

“Perhaps the true need is to incentivize and educate clinicians to broaden their toolbox and draw on nonpharmacological strategies [recommended by multiple international expert bodies] that have been shown to effectively manage BPSD in trials,” suggested Kale and colleagues.

“Caregiver problem-solving training has a greater effect size than either antipsychotics for BPSD or cholinesterase inhibitors for cognition,” they noted, pointing to a tailored activity program (TAP) and the DICE approach developed to help tackle modifiable underlying problems, rather than relying solely on sedating medication.

Study authors echoed this sentiment, calling for a variety of nonpharmacological interventions, care support programs, medication review protocols, and antipsychotic drug deprescribing measures.

They noted limitations including limited intercountry generalizability and possible overestimation of the number of unique patients observed in a database.