The use of antipsychotic and other psychotropic medications to address behavior and mood among older adults residing in long-term care settings has become a national concern. In 2011, 24% of nursing home residents received antipsychotic medications, despite strong black box warnings issued by the federal Food and Drug Administration of their risk of life-threatening adverse effects, as well as the availability f effective non-pharmacological alternatives. In response, in 2012 the Centers for Medicare & Medicaid Services launched a national initiative that to date has reduced antipsychotic use in nursing homes by 17 percent. Emerging evidence suggests grave cause for concern in assisted living residences (ALRs) as well, which provide care for almost 750,000 older adults. Seventy percent of assisted living residents have cognitive impairment, 38% have behavioral symptoms, and 25% have symptoms of depression. New data indicate that 69% of ALRs regularly administer medication to control behavior, and 57% of residents with behavioral symptoms are prescribed a medication - including 42% who have no cognitive impairment and 46% who have only mild cognitive impairment. Further, unlicensed staff administer medications in more than 20% of ALRs, and these same individuals determine when an as needed (pro re nata; PRN) medication should be administered. It is no surprise, then, that concern about antipsychotic prescribing in assisted living has become a focus of attention for numerous organizations. Despite notable concern and national attention, there is insufficient information about the actual use of antipsychotic and other psychotropic drugs in ALRs, and virtually no information regarding the settings in which they are most likely to be used and the feasibility of implementing evidence-based alternatives to care. Consequently, it is not possible to develop policies and benchmarks to promote better care as is now occurring in nursing homes. In response, this project, conducted by clinical and health services experts in assisted living research - with close involvement of an advisory board composed of national and state leaders in ALR policy, regulation, practice, education, and advocacy - will obtain and disseminate information to help stakeholders understand the scope of the problem and promote change. Specifically, in a stratified random sample of 280 ALRs across seven states in two regions of the country noted to have the highest and lowest prescribing rates, the proposed study will ascertain (1) the scope and patterns of antipsychotic and other psychotropic medication use; (2) organizational and person-level characteristics related to medication use and potentially inappropriate prescribing; and (3) alternate strategies in use or feasible to address resident distress. It also will (4) disseminate the results to practice, policy, and advocacy stakeholders. t is hypothesized that antipsychotic and other psychotropic medication use, as well as the capacity to implement evidence-based, non-pharmacological practices, will relate to modifiable organizational characteristics that have implications for policy and practice.

Public Health Relevance

This project will describe the range of antipsychotic and other psychotropic medication prescribing in assisted living, as well as how prescribing varies by characteristics of the assisted living organization, information about potentially inappropriate prescribing, and the feasibility of implementing non-pharmacological alternatives to care. The advisory board will help disseminate the related findings to inform practice and policy.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
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Study Section
Health Services Organization and Delivery Study Section (HSOD)
Program Officer
Fazio, Elena
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University of North Carolina Chapel Hill
Schools of Social Welfare/Work
Chapel Hill
United States
Zip Code
Scales, Kezia; Zimmerman, Sheryl; Miller, Stephanie J (2018) Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia. Gerontologist 58:S88-S102
Prizer, Lindsay P; Zimmerman, Sheryl (2018) Progressive Support for Activities of Daily Living for Persons Living With Dementia. Gerontologist 58:S74-S87