Did Dementia Patient Care Go Downhill During the COVID Pandemic?

The massive social disruptions caused by the COVID-19 pandemic hit particularly hard for people living with dementia, causing them to become more isolated and less able to take part in normal activities and routines. How did this affect their care? In the January 25 JAMA Psychiatry, researchers led by Kenneth Man at University College London and Ian Wong at the University of Hong Kong reported that dementia patients in six countries were more likely to be prescribed antipsychotics during the 2020 lockdowns than before. This may indicate that patients had trouble coping, becoming more agitated or depressed, and physicians responded to this by medicating them more heavily. Antipsychotic use among people with Alzheimer’s disease is associated with worse quality of life and higher mortality.

“The study… demonstrates that, despite more than a decade of regulatory pressure to limit prescribing, antipsychotics remain the treatment providers turn to for behavioral and psychological symptoms of dementia,” wrote Helen Kales at the University of California, Davis, Donovan Maust at the University of Michigan, Ann Arbor, and Laura Gitlin at Drexel University, Philadelphia, in an accompanying editorial.

Previous smaller studies had suggested a bump in behavioral symptoms and antipsychotic use during COVID (Gedde et al., 2022; Howard et al., 2020; Harrison et al., 2021). To gather a broader view, first author Hao Luo at the University of Hong Kong plumbed eight large electronic health record databases from six countries—France, Germany, Italy, South Korea, the U.K., and the U.S. Altogether, the authors identified 857,238 people, age 65 or older, who had a diagnosis of dementia between 2016 and 2021.

In six of the eight databases, prescriptions for antipsychotic drugs jumped sharply starting in April 2020, when COVID-19 lockdowns began. The exceptions were Germany, where usage climbed more slowly throughout the pandemic, and the South Korean Ajou University database, where prescriptions fell. The South Korean findings were specific to that database, rather than to that country. The other South Korean dataset, from Kangwon National University, recorded the most dramatic effects in this study, with twice as many prescriptions written during early lockdown as before.

Despite wide variations between databases in the prevalence of antipsychotic use and the exact pattern of change after lockdowns began, the overall picture of increased use was consistent and persistent. In every case except the South Korea Ajou and the U.S. Open Claims databases, a higher percentage of dementia patients were taking antipsychotics in 2021 than before the pandemic, suggesting the negative effects were long-lasting.

“Urgent action is needed to begin to reintroduce the practice measures that have previously been effective internationally in bringing about a 30 to 50 percent reduction in antipsychotic prescribing for people with dementia,” Clive Ballard at the University of Exeter, U.K., wrote to Alzforum.

However, Lon Schneider at the University of Southern California, Los Angeles, noted that higher antipsychotic use could reflect a larger number of dementia patients in end-of-life care due to COVID-related disruptions, rather than doctors using antipsychotics to sedate more active patients. “It is a mistake to rely on antipsychotic prescribing as an index of poor care,” Schneider wrote. The authors agree that more investigation of the factors that led to higher usage, and the consequences of it, are needed.—Madolyn Bowman Rogers

Comments

    • User Profile Image Lon S. Schneider
      University of Southern California Keck School of Medicine
    • Posted:

    I don’t think I see what the authors claim about antipsychotics for dementia. The U.S. data is different from the ex-U.S. The two U.S. databases show decreases in dementia diagnoses in 2020, especially during the spring, followed by compensatory increases in 2021. Not a surprise. You can’t get a dementia diagnosis if you are isolated and can’t see your doctor.

    Second, antipsychotic prescribing rates trended differently in each U.S. database. The prevalence rates of prescriptions were constant in the U.S. open claims database, between 17.58 percent and 17.94 percent in the four years before 2020. It then bumped slightly to 18.26 percent in 2020 and 19.12 percent in 2021. The smaller Medicare supplemental database showed a similar bump from 19.81 percent in 2019 to 20.42 percent in 2020. But then there was a drop to 18.67 percent that was lower than the previous five years. So, it seems rates decreased twice as much as they increased in the claims database.

    Both diagnoses and antipsychotics prescribing look to me like perturbations due to the isolation and deaths of older folk during the first year of the pandemic. The deaths and increased morbidity seem as much due to lack of care as they are to COVID directly, which is part of the tragedy of this epidemic. It’s a mistake, however, to rely on antipsychotic prescribing as an index of poor care. Over the many years of administrative efforts to reduce antipsychotic prescribing to people with dementia, other drugs such as antidepressants (e.g., citalopram), anticonvulsants (e.g., gabapentin), and analgesics including opiates have to a large extent replaced antipsychotics as tools to suppress disruptive behavior. Tracking antipsychotic use for people with dementia doesn’t give us enough of the story.

    References:

    Gerlach LB, Maust DT, Kales HC, Chang M, Kim HM, Wiechers IR, Zivin K. Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes. Am J Psychiatry. 2022 Aug;179(8):544-552. Epub 2022 May 26 PubMed.

    Schneider LS. The Safety of Pimavanserin for Parkinson's Disease and Efforts to Reduce Antipsychotics for People With Dementia. Am J Psychiatry. 2022 Aug;179(8):519-521. PubMed.

    View all comments by Lon S. Schneider

  2. This is a substantial and important study showing sustained increases in antipsychotic prescribing for people with dementia. It also accords with our own nursing home studies showing a 30 percent increase in prescribing of antipsychotics over the same period. It is important to remind ourselves of the associated harms of antipsychotics for people with dementia including major morbidities, mortality and quality of life. Urgent action is needed to begin to reintroduce the practice measures that have previously been effective internationally in bringing about a 30 to 50 percent reduction in antipsychotic prescribing for people with dementia.

    View all comments by Clive Ballard

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References

Paper Citations

  1. Gedde MH, Husebo BS, Vahia IV, Mannseth J, Vislapuu M, Naik M, Berge LI. Impact of COVID-19 restrictions on behavioural and psychological symptoms in home-dwelling people with dementia: a prospective cohort study (PAN.DEM). BMJ Open. 2022 Jan 24;12(1):e050628. PubMed.
  2. Howard R, Burns A, Schneider L. Antipsychotic prescribing to people with dementia during COVID-19. Lancet Neurol. 2020 Nov;19(11):892. PubMed.
  3. Harrison SL, Buckley BJ, Lane DA, Underhill P, Lip GY. Associations between COVID-19 and 30-day thromboembolic events and mortality in people with dementia receiving antipsychotic medications. Pharmacol Res. 2021 May;167:105534. Epub 2021 Mar 4 PubMed.

Further Reading

Primary Papers

  1. Luo H, Lau WC, Chai Y, Torre CO, Howard R, Liu KY, Lin X, Yin C, Fortin S, Kern DM, Lee DY, Park RW, Jang JW, Chui CS, Li J, Reich C, Man KK, Wong IC. Rates of Antipsychotic Drug Prescribing Among People Living With Dementia During the COVID-19 Pandemic. JAMA Psychiatry. 2023 Mar 1;80(3):211-219. PubMed.

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