Did the COVID-19 Pandemic Affect the Use of Antipsychotics Among Nursing Home Residents With ADRD?

Objective: To examine whether and how the COVID-19 pandemic affected the use of antipsychotics among residents with Alzheimer's disease and related dementias in nursing homes.

Design: Observational study based on the Minimum Data Set and Medicare claims.

Setting: Medicare- and/or Medicaid-certified nursing homes.

Participants: Nursing home residents diagnosed with Alzheimer's disease and related dementias between 2017 and 2020.

Measurements: The main outcome variable was any antipsychotic use during a quarter. The secondary outcome was certified nursing assistants' staffing hours per bed per day in a quarter. We categorized nursing homes into quartiles based on the distribution of nursing home racial and/or ethnic composition. To explore the relationship between the COVID-19 pandemic and the frequency of antipsychotic use, we estimated a linear probability model with robust standard errors, individual and facility random effects. We used a similar model for certified nursing assistant hours.

Results: About 23.7% of residents with ADRD had antipsychotic uses during the study period. The frequency of antipsychotic use declined from 23.7%-23.1% between the first quarter of 2017 (2017Q1) and the first quarter of 2020 (2020Q1) but increased to 24.8% by the last quarter of 2020 (2020Q4). Residents in all four racial and/or ethnic groups experienced an increase in antipsychotic use during the COVID-19 pandemic, but the extent of the increase varied by race and/or ethnicity. For example, while residents in the very-high minority nursing homes experienced a greater increase in antipsychotic use than did the residents of other nursing homes at the beginning of the pandemic, the increasing trend during the pandemic was smaller in the very-high minority nursing homes compared to the low-minority nursing homes (0.2 percentage points less, p<0.001, based on heteroskedasticity-robust t statistics, t = 3.67, df = 8,155,219). On average, the certified nursing assistant hours decreased from 1.8-1.7 hours per bed per day between 2017Q1 and 2020Q1, and further decreased to 1.5 hours per bed per day by 2020Q4. There was also a decreasing trend in staffing hours across all racial and/or ethnic groups during the pandemic.

Conclusions And Relevance: The COVID-19 pandemic was associated with an increase in the use of antipsychotics among nursing home residents with Alzheimer's disease and related dementias and decreased staffing of certified nursing assistants, especially among nursing homes with a high minority penetration. Future research is needed to explore means for reducing antipsychotic use, particularly in homes with a high penetration of minority residents.