Initiation and Persistence of Antipsychotic Medications at Hospital Discharge Among Community-Dwelling Veterans With Dementia.

Adults with dementia are frequently prescribed antipsychotic medications despite concerns that risks outweigh benefits. Understanding conditions where antipsychotics are initially prescribed, such as hospitalization, may offer insights into reducing inappropriate use. Retrospective cohort study of community-dwelling veterans with dementia aged ≥68 with VA hospitalizations in 2014, using Veterans Health Administration (VA) and Medicare data. The primary outcome was new outpatient antipsychotic prescription at hospital discharge. We used generalized estimating equations to study associations between antipsychotic initiation and patient, hospitalization, and facility characteristics. Among veterans with antipsychotic initiation, we used a cumulative incidence function to evaluate discontinuation in the year following hospitalization, accounting for competing risks. 4,719 community-dwelling veterans with dementia had VA hospitalizations in 2014; 264 (5.6%) filled new antipsychotic prescriptions at discharge. Antipsychotic initiation was associated with discharge unit (surgical vs medical, OR 0.41, 95% CI 0.19-0.87; psychiatric vs medical, OR 6.58, 95% CI 4.48-9.67), length of stay (OR 1.03/day, 95% CI 1.02-1.05), and delirium diagnosis (OR 2.61, 95% CI 1.78-3.83), but not demographic or facility characteristics. Among veterans with antipsychotic initiation, the 1-year cumulative incidence of discontinuation was 18.2% (n = 47); 15.9% (n = 42) of those who were alive and not censored remained on antipsychotics at 1 year. Antipsychotic initiation at hospital discharge was uncommon among community-dwelling veterans with dementia; however, once initiated, antipsychotic persistence at 1 year was common among those who remained community-dwelling. Hospitalization is a contributor to potentially-inappropriate medications in the community, suggesting an opportunity for medication review after hospitalization.

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DISCLOSURES This project was supported by the National Institute on Aging though the Duke Creating ADRD Researchers for the Next Generation - Stimulating Access to Research in Residency (CARiNG-StARR) program (R38AG065762). Dr. Zhang is also a member of the Junior Investigator Intensive Program of the US Deprescribing Research Network, which is funded by the National Institute on Aging (R24AG064025). Dr. Shepherd-Banigan received support from the US Department of Veterans Affairs, Health Services Research & Development (HSR&D) Career Development Award (CDA 17-006). Dr. Thorpe received support from the US Department of Veterans Affairs, HSR&D Merit Award (IIR 19-106). This work was supported by the use of facilities at Durham VA Health Care System in Durham, NC. The authors have no competing interests to declare that are relevant to the content of this article.