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Researchers receive $3.4 million grant to study inappropriate and excessive use of antipsychotic medications

National Institute on Aging study targets use of medications in assisted living communities

Researchers in aging at the University of North Carolina at Chapel Hill have been awarded a nearly $3.4 million federal grant to examine the inappropriate and excessive use of antipsychotic medications in assisted living communities.

Funded by the National Institute on Aging, the five-year study focuses on older adults with dementia who are prescribed off-label medications to manage and control behavior—a growing and dangerous trend that was first observed in nursing homes several years ago. The study will explore the reasons behind the inappropriate and excessive use of drugs and potential alternate practices.

Researchers say similar prescribing practices also occur within the nation’s assisted living residences, which provide care to an estimated 733,000 older adults. Although these communities generally attract individuals eager to live out their retirement years as independently as possible, assisted living residences have become a primary provider for an aging population in need of additional assistance and care.

A first-ever National Survey of Residential Care Facilities recently found that as many as seven out of 10 adults in assisted living have some form of cognitive impairment, such as dementia, as well as other limitations that affect their ability to eat, dress, bath and take medications. Perhaps more troubling, almost 70 percent of these communities regularly dispense antipsychotic and other drugs to control residents’ behaviors, said UNC-Chapel Hill study principal investigator Sheryl Zimmerman, a Kenan Distinguished Professor in Carolina’s School of Social Work.

“Many of these drugs have serious side effects, and there’s little evidence that they help people with dementia,” said Zimmerman, who is also the co-director of the Program on Aging, Disability, and Long-Term Care at the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill.

Zimmerman is collaborating on the study with Philip Sloane, a Sheps Center program co-director and distinguished professor at UNC Family Medicine; Daniel Kaufer, a neurologist and director of the UNC-Chapel Hill Memory Disorders Program and co-director of the Carolina Alzheimer’s Network; and John Preisser, a biostatistics research professor at Carolina’s Gillings School of Global Public Health.

Because assisted living communities are not federally regulated, requirements related to dementia care generally vary from state to state. While federal oversight is not necessarily needed, additional training is, according to Zimmerman, particularly for staff members who dispense antipsychotics, many of which carry black box warnings from the Food and Drug Administration.

“These warnings are used to convey the FDA’s strongest caution—that these drugs carry a significant risk of serious or life-threatening adverse effects, including risk of a heart attack or stroke,” Zimmerman said. “In fact, the only step more stringent than a black box warning is to remove the medication from distribution altogether. It’s imperative that these communities not only better understand what they’re prescribing, but that they also consider other alternatives before prescribing antipsychotics.”

The UNC-Chapel Hill study, which aims to address some of this education, will target 280 assisted living communities, housing nearly 12,000 residents, across seven states: Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania and Texas. As part of the investigation, Zimmerman and her colleagues hope to learn more about non-pharmacological solutions that study communities have tried and why others might be quick to prescribe medications to manage behaviors.

“In the same way that a crying infant communicates a need to a parent, people with dementia are also generally telling us something with their behavior,” Zimmerman explained. “Maybe they’re in pain. Maybe they’re in an environment that’s too noisy or where there’s too much stimulation. The fact is, you don’t consider drugs as a first choice for stopping a child’s crying without investigating what else may be going on. We need staff in assisted living communities to be just as sensitive to residents with dementia and to be aware of alternative practices.”

Four years ago, following national reports that as many as 24 percent of nursing home residents with dementia were being prescribed antipsychotics, the Centers for Medicare and Medicaid Services launched a campaign to reduce the overuse of such medications, Zimmerman said. By the end of 2015, that percentage had decreased to 17 percent.

UNC researchers are optimistic their study will motivate similar conversations in assisted living residences, largely because they will be working closely with leaders from across the country from numerous organizations involved in aging care and oversight. Such partnerships are critical for improving policies and practices that enhance the safety of residents in assisted living communities.

“All of the things that we used to talk about in nursing homes are the things that we should be talking about in assisted living today,” Zimmerman said. “Ultimately, older adults, especially older adults with dementia, deserve the best care, and our hope is that over the next five years, our work will lead to changes that improve their chances of having the best quality of life.”