Long-term care facilities commonly prescribe antipsychotic drugs to elderly service users, often to treat behavioral issues associated with dementia. Despite a lack of evidence that these drugs are effective for older adults, and at least one study finding that antipsychotics exacerbate behavioral problems in nursing homes, prescription rates continue to climb.
While efficacy is questionable, the harmful effects associated with antipsychotic drugs in elderly populations is not. Antipsychotic prescriptions in elderly service users are linked to increased risk of pneumonia, stroke, kidney injury, blood clots, falls, bone fracture, heart attack, heart failure, anticholinergic reactions, parkinsonian events, tardive dyskinesia, orthostatic hypotension, cognitive slowing, and death.
A 2021 New York Times investigation revealed that nursing homes routinely fraudulently diagnosed residents with schizophrenia to justify prescribing antipsychotics. This report tied higher rates of antipsychotic use to understaffed facilities using these dangerous drugs to tranquilize residents with behavioral issues. Essentially, long-term care facilities are likely drugging residents instead of hiring enough well-trained staff to implement non-drug approaches to difficult behaviors, thereby harming service users for profit.
A recent study published in BMC Geriatrics adds new evidence to this claim.
The current work finds that having better trained staff and more registered and licensed nurses is linked to less antipsychotic use in long-term care facilities. This research, led by Rabia Bibi from the University of Eastern Piedmont in Italy, additionally finds that for-profit facilities used more antipsychotics compared to non-profits and government run institutions. The authors write:
“Staff-related factors proved to be decisive factors for antipsychotic medication (APM) prescribing practice. Factors such as staff qualifications, skills, hours spent per patient and staffing levels were positively associated with APM prescribing. Patient behavior has always been a challenge for nursing staff to deal with. The sedative effect of APMs is commonly used to manage the agitated and aggressive patients in a short time and relieves the burden on nursing staff. However, this form of behavioural control comes with significant risks such as falls and aspiration in older patients. “
Methodology
The aim of the current research was to explore the connection between several institutional factors, such as staffing, training, and ownership, to the use of antipsychotic drugs in long-term care facilities. The authors decided the best way to do this would be a systematic review of existing research on this topic.
Included studies examined antipsychotic drug use patterns from long-term care facilities all over the world, with most coming from the US and Canada. These studies focused on older adults (65 years or older) with dementia diagnoses living in long term care facilities. Only articles written in English and published between 2013 and 2023 were included in the current work. The analysis excluded residents with diagnoses for which antipsychotics are clinically indicated, such as schizophrenia and bipolar disorder. The authors also excluded opinion letters, studies that did not contain original data, study protocols, and studies that examined antipsychotic use in inpatient and home-based settings. In total, the current analysis included 14 studies.
Results
Antipsychotic drug use in long-term care facilities varied greatly. Nursing homes in Tel Aviv reported the highest rates of antipsychotic use at 37.3% of residents, and Japanese nursing homes the lowest at 4.4%. One study found that the highest rates of antipsychotic prescriptions were written in the worst performing long-term care facilities while another study found higher rates in better performing institutions.
The authors explored four main factors related to antipsychotic use in long-term care facilities: occupancy, staff-related factors (such as staffing levels and qualifications), ownership, and location.
Occupancy
While three out of four studies that examined occupancy did not find a link between occupancy rates and antipsychotic use, one found that facilities with more beds typically had lower antipsychotic prescription rates compared to their smaller counterparts. The authors note that previous research has found a link between low occupancy rates and increased antipsychotic use, likely due to lower funding and less staff qualifications in these smaller institutions which are often located in more deprived neighborhoods.
Staff-Related Factors
Staff related factors were most consistently associated with antipsychotic use in the current research. Higher staffing levels were linked to less antipsychotic prescriptions, but qualifications, training, and the availability of specialized staff was more influential. Two studies found that inadequate staffing was linked to higher prescription rates. Another found an association between higher rates of inappropriate antipsychotic use and high staff workload. Several studies pointed to a lack of qualifications and specialized staff as factors in high rates of antipsychotic prescriptions. Typically, more registered nurses, licensed nurses, and geriatricians were linked to lower antipsychotic prescription rates while more general practitioners was linked to higher rates. Two studies also emphasized the importance of staff training in reducing antipsychotic use in long-term care facilities.
Ownership
Five studies examined long-term care facility ownership as a factor in antipsychotic use. Three studies found that for-profit institutions had higher antipsychotic prescription rates compared to non-profits and government owned facilities. One of these studies additionally found that for-profit facilities had consistently lower staffing levels. One study found that for-profit institutions were over-represented in both the highest and lowest antipsychotic prescribing facilities. The last study found no link between ownership and antipsychotic use. Three studies found that in the US, Medicaid reimbursed facilities had higher rates of antipsychotic use than Medicare facilities. It is worth noting that Medicaid is a program for people with limited financial resources while Medicare is a government run health insurance program for older Americans.
Location
Antipsychotic use varied greatly by location, but there were few patterns in these variations. Southern states in the US were increasing their antipsychotic use. Typically, long-term care facilities located in urban areas used more antipsychotics compared to rural areas. There were also conflicting findings based on location. For example, one study found that antipsychotic use in Texas was increasing, while another found that it was decreasing.
Limitations
The authors acknowledge several limitations to the current work. The included studies did not have a uniform design, setting, or data collection methods, limiting generalizability. Details were missing from some of the included studies, such as occupancy rates. There was much more data available from the US. The data from other countries was sparse, meaning the authors cannot draw strong conclusions about antipsychotic use in long-term care facilities outside the US using the present data. Additionally, this research only examined service users that did not have a schizophrenia diagnosis. With half of nursing homes admitting to misdiagnosing schizophrenia during a Centers for Medicare & Medicaid Services audit, the number of long-term care facility residents inappropriately exposed to antipsychotic drugs is higher than the data here would indicate.
Staffing Shortfalls
In the US, long-term care facilities are often paid by Medicaid. The amount of money received from Medicaid residents is set by government agencies. When owners seek to increase profits, or to maintain them in the face of rising costs, they cannot simply increase prices and have to make cuts elsewhere. This often leads to reduced funding for staffing.
The result has been a “workforce crisis” in long-term care facilities, especially for-profit institutions. The staffing shortfall has also caused many long-term care facilities to rely on staffing agencies to provide workers that are less familiar with the institutions and residents. The reliance on staffing agencies, as well as the increased workloads, have left many long-term care facility employees feeling dissatisfied with their working conditions and negatively affected their physical and psychological health. All this adds up to fewer, disgruntled staff that are less prepared to deal with behavioral issues in long-term care facilities and management that is willing to fraudulently diagnose residents with schizophrenia in order to justify drugging them.
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Bibi, R., Panella, M., Saada, S., Payedimarri, A. B., Conti, A., Russotto, S., Barone-Adesi, F., & Masini, A. (2025). Factors associated with the variation in drug prescription of antipsychotics in long-term care facilities: A systematic review. BMC Geriatrics, 26(1). (Link)