Non-Pharmacologic Approaches Being Tested, More Data Gathered
By Annette M. Boyle
PITTSBURGH – Antidepressants and antipsychotic medications are being overused or prescribed inappropriately for residents of VA Community Living Centers (CLCs), according to recent research.
That problem is especially significant because so many CLC patients suffer from these conditions: One in three have been diagnosed with depression, while one-third have dementia. Furthermore, the issue is expected to become more complex as a large influx of aging baby boomers with even higher rates of dementia and substance-abuse disorders enter the VA’s long-term care and mental-health systems.
VA is both gathering evidence on how long-term care patients are currently being treated for dementia and depression and testing some nonpharmacologic solutions to the situation.
An analysis of records for 3,692 long-stay patients over the age of 65 admitted to 133 VA CLCs in 2004 and 2005 revealed that nearly 25% of these older patients had a diagnosis of depression. The study, published in the Journal of the American Geriatric Society, found almost twice as many patients received antidepressants, however, suggesting substantial overuse of the drugs.1
On the other hand, the study found that a quarter of patients with depression received no antidepressants. In addition, among depressed patients who received antidepressants, more than 40% had potential prescribing problems such as drug-drug and drug-disease interactions that could increase the potential for falls and cognitive impairment.
Treating depression appropriately is a growing concern for CLCs, as its prevalence has risen sharply among patients. A comparison of CLC residents admitted in 1998 and 2006 found that depression prevalence rose across all age groups and cohorts, from 27% to 37% overall. And, the prevalence is expected to continue to increase.
“The data suggest that those 55 to 64 years old, who make up the ﬁrst cohort of baby boomers, have higher rates of depression, anxiety, and substance abuse compared with those now 65 to 74 years old,” noted Michele Karel, PhD, mental health program coordinator, Home-Based Primary Care at the VA Office of Mental Health Services, and colleagues in American Psychologist.2
As the leading edge of the “silver tsunami,” this group provides an indication of the challenges facing the VA as the number of Americans over the age of 65 rises from 40 million in 2010 to more than 72 million in 2030.
The powerful drugs may be prescribed because clinicians have had few other choices or because the risks were not fully understood.
“Unfortunately, there are limited nonpharmacologic treatments and limited expertise with these treatments, although some are effective, and the ones that exist can be resource intensive,” Gellad said.
“In some cases, the benefits may actually outweigh the risks of treatment, but it’s clear that many clinicians in the past were underestimating the actual risks and perhaps overestimating the benefits,” he added.
A number of studies have shown that antipsychotics are not efficacious in alleviating behavioral issues in patients with dementia. At the same time, they are associated with an increased risk of mortality. In 2005, the Food and Drug Administration (FDA) issued a warning for atypical antipsychotics that stressed the risk of increased morality associated with their use in the elderly with dementia. In 2008, the FDA extended the warning to include all antipsychotics.
Gellad noted that study data “was collected prior to these warnings, so we cannot draw conclusions about whether they make a difference in current practices.”
Prior to the study period, however, “reports had already appeared in print about the risks of these drugs,” he said.
More recently, however, the VA has tested a patient-centered, nonpharmacological approach to management of dementia-related behaviors. In 2010/2011, the VA introduced Staff Training in Assisted Living Residences (STAR-VA) to 17 CLCs. The program adapts an interdisciplinary approach developed by Linda Teri, PhD, and colleagues at the University of Washington.
In the STAR-VA intervention, a doctoral level mental-healthcare provider (usually a psychologist) serves as a behavioral coordinator working closely with other interdisciplinary staff in the development and implementation of an individualized behavioral intervention plan.
According to Karel, who also is with the Harvard Medical School Department of Psychiatry, the program trains interdisciplinary teams to provide effective care for veterans with challenging dementia-related behaviors and improve clinical outcomes for participating veterans.
So far, the nonpharmocologic interventions appear to be working.
“Program evaluation data from the STAR-VA pilot revealed that veterans enrolled in STAR-VA demonstrated significant reductions in the frequency and severity of challenging dementia-related behaviors. In addition, these veterans exhibited decreases in symptoms of depression and anxiety,” Karel told U.S. Medicine.
The benefit extends to the CLC staff as well, she added.
“CLC mental-health providers participating in the pilot reported, overall, that STAR-VA helped them and their teams to better manage challenging behaviors, including agitation, disruptive vocalization, physical aggression and resistance to care,” Karel said.
1. Hanlon JT, Wang X, Castle NG, Stone RA, Handler SM, et al. Potential underuse, overuse and inappropriate use of antidepressants in older veteran nursing home patients. J Am Geriatr Soc. 2011 August; 59(8): 1412–1420.
2. Karel, M. J., Gatz, M., & Smyer, M. A. Aging and Mental Health in the Decade Ahead: What Psychologists Need to Know. American Psychologist. 2011 Sept 26. Advance online publication. doi: 10.1037/a0025393
3. Gellad WF, Aspinall Sl, Handler SM, Stone RA, Castle N, et al. Use of antipsychotics among older residents in VA nursing homes. Med Care. 2012 Nov;50(11):954-960.Antipsychotics Overprescribed
Treatment of dementia showed a similar pattern of high demand and inappropriate use of medications. According to the authors of a recent study published in Medical Care, “veterans with dementia but no documented psychosis were as likely as those with an evidence-based indication to receive an antipsychotic.”
The authors of the dementia treatment analysis used the same set of records as the researchers in the American Geriatric Society study and found that 26% were prescribed an antipsychotic, although fewer than 60% had an evidence-based indication for use. Antipsychotic prescriptions were most common among residents with aggressive behavior, who were three times more likely to be prescribed the medications than non-aggressive patients. Residents in Alzheimer or dementia care units were 66% more likely to receive antipsychotics.3
Lead researcher Walid Gellad, MD, staff physician and researcher at the Pittsburgh VA Medical Center and VA Center for Health Equity Research and Promotion (CHERP), told U.S. Medicine “there is a long history of prescribing antipsychotics in dementia patients. In some cases, the behavioral problems can be very troublesome to the patient or to the family, and physicians and other clinicians want to do something to try and help, but there are limited options.”
Patients with dementia exhibit a wide range of symptoms and behaviors that clinicians or families might want to address, said Gellad, who also is an assistant professor of medicine and health policy at the University of Pittsburgh.
“Dementia patients in nursing homes get symptoms like depression, apathy, agitation, aggression, psychosis, hallucinations, delusions, sleep problems and also have behaviors like wandering,” he said.
In some cases, use of antipsychotics may be appropriate, even if an official diagnosis of psychosis was missing.
“In our analysis, we classified those patients with psychotic symptoms in dementia (like hallucinations) actually as potentially appropriate, based on Centers for Medicare and Medicaid Services’ guidance to long-term care facilities,” said Gellad. But, he noted, “whether an antipsychotic is truly ‘inappropriate’ or not really depends on the clinical situation, which we measured as best as we could with the data we had. There’s not one behavior or another for which antipsychotics might be prescribed inappropriately — they could be inappropriate in any behavior.”
Legislation that would streamline VA’s community care programs into one program and expand VA’s caregiver program to veterans of all eras was signed into law earlier this month..
The good news from a recent consultant study is that, overall, the VA healthcare system is generally equal or better than others when inpatient and outpatient quality is measured.