Zullo Andrew R, Riester Melissa R, Varma Hiren, Daiello Lori A, Gerlach Lauren B, Coe Antoinette B, Thomas Kali S, Joshi Richa, Zhang Tingting, Shireman Theresa I, Bynum Julie P W
Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.
Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
J Am Med Dir Assoc. 2025 Mar;26(3):105439. doi: 10.1016/j.jamda.2024.105439. Epub 2025 Jan 10.
Little information exists on whether nationwide efforts to reduce antipsychotic use among nursing home (NH) residents with Alzheimer's disease and related dementias improved mortality and hospitalization outcomes for residents. Our objective was to examine the effect of NH decreases in antipsychotic use on outcomes for residents with Alzheimer's disease and related dementias.
Observational nationwide study that emulated a series of cluster randomized trials.
Long-stay NH residents with Alzheimer's disease and related dementias in US NHs.
The study used data from Medicare claims to emulate cluster randomized trials in which NHs were assigned to either decrease or maintain/increase antipsychotic use. Outcome ascertainment for the first trial began on April 1, 2012 (ie, following the announcement of the National Partnership to Improve Dementia Care in NHs). The last day of follow-up was December 31, 2017. Outcomes measured included 12-month all-cause mortality, all-cause hospitalization, and hospitalization for stroke, myocardial infarction, fracture, and psychiatric conditions. Use of other psychotropic medications was also evaluated. Inverse-probability-of-treatment-weighted pooled Poisson regression models estimated covariate-adjusted risk ratios (RRs).
The adjusted risks of death (RR, 1.01; 95% CLs, 1.00, 1.01), all-cause hospitalization (RR, 1.00; 95% CLs, 1.00, 1.01), and hospitalization for specific causes were similar between resident-trials in NHs that decreased vs maintained/increased antipsychotic use. Use of antidepressants, anxiolytic/sedative-hypnotics, anticonvulsant/mood stabilizers, and antidementia medications was slightly higher among resident-trials in NHs that decreased antipsychotic use.
Decreases in NH antipsychotic use do not appear to improve resident outcomes. Intensive initiatives focused predominantly on achieving a decrease in antipsychotic use may not be effective at improving mortality and hospitalization outcomes for residents with Alzheimer's disease and related dementias. These findings suggest the need for better strategies that incorporate safe and effective nonpharmacological or pharmacological alternatives for managing neuropsychiatric symptoms of dementia.
关于全国范围内为减少患有阿尔茨海默病及相关痴呆症的养老院（NH）居民抗精神病药物使用所做的努力是否改善了居民的死亡率和住院结局，目前所知信息甚少。我们的目的是研究养老院抗精神病药物使用量的减少对患有阿尔茨海默病及相关痴呆症居民结局的影响。
一项模拟一系列整群随机试验的全国性观察性研究。
美国养老院中患有阿尔茨海默病及相关痴呆症的长期居住居民。
该研究使用医疗保险索赔数据来模拟整群随机试验，其中养老院被分配到减少或维持/增加抗精神病药物使用组。第一次试验的结局确定于2012年4月1日开始（即全国改善养老院痴呆症护理伙伴关系宣布之后）。随访的最后一天是2017年12月31日。测量的结局包括12个月全因死亡率、全因住院率以及中风、心肌梗死、骨折和精神疾病的住院率。还评估了其他精神药物的使用情况。逆概率治疗加权合并泊松回归模型估计了协变量调整后的风险比（RRs）。
在抗精神病药物使用减少的养老院居民试验与维持/增加使用的居民试验之间，调整后的死亡风险（RR，1.01；95%置信区间，1.00，1.01）、全因住院风险（RR，1.00；95%置信区间，1.00，1.01）以及特定原因住院风险相似。在抗精神病药物使用减少的养老院居民试验中，抗抑郁药、抗焦虑/镇静催眠药、抗惊厥/情绪稳定剂和抗痴呆药物的使用略高。
养老院抗精神病药物使用量的减少似乎并未改善居民结局。主要专注于实现抗精神病药物使用量减少的强化举措可能无法有效改善患有阿尔茨海默病及相关痴呆症居民的死亡率和住院结局。这些发现表明需要更好的策略，纳入安全有效的非药物或药物替代方法来管理痴呆症的神经精神症状。
