The Quality of Antipsychotic Drug Prescribing in Nursing Homes

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Abstract
Antipsychotic drug prescribing in nursing homes (NHs) has been rising again after a period of marked decreases.1 In 1999, 19.4% of NH residents received antipsychotics compared with 16.0% in 1995.2 Antipsychotics have also become the most costly drug class for Medicaid programs, the main payer of medications prescribed in NHs.3 In 2001, Medicaid spent over $3.0 billion for antipsychotic drugs compared with $2.7 billion for antimicrobial agents, $2.4 billion for cardiovascular agents, and $1.8 billion for antidepressants.3 The reversal in NH prescribing patterns and high Medicaid drug expenditures can be attributed to the availability of second-generation antipsychotic agents, first introduced with clozapine and followed by risperidone, olanzapine, quetiapine fumarate, ziprasidone, and lastly, aripiprazole in 2002. These “atypical” agents have transformed the therapeutic applications of antipsychotics by replacing the older conventional agents and expanding the clinical prerogative to prescribe for indications outside those approved by the Food and Drug Administration (FDA).4 The influence of the atypicals in NHs is especially remarkable because antipsychotic use must adhere to prescribing guidelines of appropriateness that limit off-label use.

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