PRP194: Virginia nursing homes with high antipsychotic use: unanticipated initial qualitative data

J. Kerns, MD; Jonathan Winter, MD


Context: CMS grades US nursing homes on unsafe antipsychotic use for behavioral symptoms of dementia. While Virginia nursing homes have markedly decreased antipsychotic prescribing, reported use per facility varies from 0 to nearly 40%. Higher antipsychotic use in Virginia nursing home patients with dementia has been shown to be associated with African American males, rural locations, lower social determinants of health, and not for profit status. Additional resources for those facilities for non-drug therapies and increased psychiatric support are touted as ways of decreasing antipsychotic use.
Objectives: Compare facility admission criteria and dementia behavioral symptom management between Virginia nursing homes which differ in antipsychotic use, racial composition, and locale, emphasizing successful/unsuccessful strategies.
Sample/Setting: Administrative and clinical dementia management personnel in 16 Virginia nursing homes chosen for high and low reported use of antipsychotics, as well as maximal variation in ethnicity and location.
Design: Semi-structured interviews of multiple key informants regarding admissions and dementia management, initial analysis by immersion and crystallization.
Early Results: COVID 19 halted recruitment. Initially 6 facilities, zip code matched but differing in antipsychotic use, were fervently recruited. All 3 with low antipsychotic use declined. Most informative of 14 interviews were obtained from the 3 in the highest antipsychotic use quintile. 2/3 were urban, 2/3 were not for profit. All 3 were >95% Caucasian, top quintile for social determinants of health, selective regarding admissions, had enhanced staffing including psychiatrists, yet reported >20% antipsychotic use. Non-pharmacologic management of behaviors was individualized and supported. Psychiatrist directed medications were used for quality of life and safety in patients with dementia: often quetiapine, sometimes benzodiazepines and trazodone, valproate becoming first line in 1 facility.
Preliminary Conclusions: By their exceptional patient-focused care, some Virginia nursing homes in the highest antipsychotic use quintile defy ingrained assumptions about how to improve care. Further efforts are necessary to define best practices, and which facilities thus need the limited available resources to advance dementia care.

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