Antipsychotic Medication Use Among Nursing Home Residents with Alzheimer’s Disease and Related Dementias: Ownership Structures

Do nursing home residents with Alzheimer’s disease and related dementias (ADRD) receive antipyschotic medications more often than residents with other severe mental illnesses such as diseases that are excluded from public reporting requirements? What disparities in treatment through antipsychotic medications are present in nursing homes? We explore the relationships between ADRD, exclusionary diagnosis, ownership structure, and payment types.

Abstract:

In this paper, we examine the use of Anti-Psychotic Medications (APM), how they are impacted by nursing home ownership changes, and their association with health outcomes (falls, ED use, hospital use and mortality) in Nursing Homes over the last decade, among all residents, residents with Alzheimer’s and Related Dementia (ADRD), Severe Mental Illness (SMI) or other conditions where APM are indicated or considered potentially medically necessary (psychosis, Parkinson’s, Bipolar and for populations with CMS exemptions).

There is longstanding concern regarding the quality of long-term care for patients with Alzheimer’s Disease and Related Dementia (ADRD), especially if reimbursement adjustments do not adequately account for the extra care burdens placed on Nursing Homes. Studies have found that patients with ADRD appear to be discharged to lower quality Nursing Homes following hospitalization \citep{kosar_risk_2023}, perhaps indicating that higher quality NHs are unable to provide care at the prevailing reimbursements. Nursing homes may also turn to other strategies to lower the cost of providing care to patients with ADRD, including the use of antipsychotic medications. A gap exists between best-practice evidence and actual clinical practice related to pharmacological and non-pharmacological care for persons with dementia and behavioral and psychological symptoms of dementia.

In our research using the Minimum Data Set from 2011-2017, we first explore differences in rates of diagnosis and APM use over time for different ownership structures in the nursing home market (profit-seeking and chain-affiliation status). Then, we demonstrate that these trends differ when both types of ownership structures are taken into account. We also explore these trends by the share of patients with Medicaid as primary payer and other nursing home characteristics, with adjustment for patient characteristics, and by major categories of patients (ADRD status). We explore racial disparities in these relationships, examining those disparities with and without controls for certain individual and NH characteristics, such as age, and ownership structure. Last, we examine how changes that have been spurred by policy are causally related to APM use and health outcomes.

Recommended citation: Bowblis, John, Megdalynn Fisher, Judith Lucas, Kosali Simon. "Antipsychotic Medication Use Among Nursing Home Residents with Alzheimer's Disease and Related Dementias: Ownership Structures and Racial Disparities." work in progress.