Exacerbated challenges faced by memory care assisted living communities during the COVID-19 pandemic may have contributed to the increased use of antipsychotics and antidepressants, raising concerns about the ability of those settings to care for residents with dementia, according to a new study.
Canadian researchers used clinical and health databases for all publicly funded assisted living homes in Alberta, Canada, to examine connections between the assisted living setting, COVID-19 pandemic waves, and the prevalent use of antipsychotic, antidepressant, anti-dementia, benzodiazepine and anticonvulsant drug among residents living with dementia or cognitive impairment. Their findings were published in BMC Geriatrics.
Specifically, the investigators focused on the prevalence of the use of those medications in assisted living memory care communities, as well as other assisted living communities, focusing on four pandemic waves: Wave 1, March to May 2020; Wave 2, September 2020 to February 2021; Wave 3, March to May 2021; and Wave 4, September to December 2021.
Of the 2,779 residents in memory care settings and 3,013 assisted living residents with dementia or cognitive impairment in non-memory care settings as of March 1, 2020, the researchers found that antipsychotic use increased during Waves 2 to 4 in both settings. Both settings also showed a modest increase in antidepressant use and a decrease in benzodiazepine use. For memory care assisted living residents only, the use of gabapentinoids increased during several waves.
The increase in antipsychotic use occurred earlier in the pandemic and was significantly more pronounced for residents in dementia care than in other assisted living settings, the study found.
Differences in resident and home characteristics associated with medication use during the pandemic raised additional concerns around pharmacotherapy in specific sub-groups of assisted living residents.
Female residents, for instance, were significantly more likely to use benzodiazepines, antidepressants and anti-dementia therapy, whereas antipsychotic use was significantly more common among male residents. The substantially higher use of anti-dementia therapy among residents aged 85 or more years also was concerning, the researchers said, given guidelines that caution against their use in this age group due to the higher risk for adverse events.
Is assisted living a good setting for residents with dementia?
In Canada, more than half of assisted living residents have dementia, but the setting’s lower staffing and service levels, as well as limited or no access to on-site nursing staff, raised questions about the ability of those settings to care for this population, particularly since the studied medications can elevate adverse event risks for residents who have cognitive impairment, the authors wrote.
“Our findings are somewhat surprising as one might reasonably expect the presence of dementia-specific services and trained staff would help mitigate any increase in the potentially inappropriate use of CNS [central nervous system] medications among this cognitively vulnerable cohort,” the authors wrote.
Although greater reliance on antipsychotics and antidepressants in memory care assisted living residents might reflect higher levels of cognitive and functional impairment, the researchers said that the findings suggest otherwise.
“It is possible that dementia care assisted living faced greater challenges during the pandemic, leading to an increased reliance on pharmacotherapy for responsive behaviors,” the authors wrote, adding that those challenges included implementing infection control measures, staffing shortages, reduced access to non-pharmacologic treatments and loss of family involvement.
The significant increase in antipsychotics, antidepressants and gabapentinoids was evident during the third pandemic wave, after widespread vaccination of the assisted living population and “essentially no COVID-19 cases among residents,” the authors stated
The investigators noted that a comparison study of nursing homes and other residential care settings — including assisted living — found that residents with mild dementia in nursing homes had fewer hospitalizations and more stable health than residents in other settings, which they attributed to higher levels of healthcare and staffing.
“Overall, our findings support a call for further research on the drivers of persistent psychotropic drug use and health consequences for assisted living residents with dementia and their families,” the authors concluded. “Careful consideration of the factors underlying these CNS medications changes is required to guide policy changes and inform dementia care strategies in settings that will inevitably see an increasing proportion of residents with dementia in the coming years.”
