The Antipsychotic Problem in Elderly Care

Antipsychotic medications prescribed to elderly patients — particularly those with dementia — carry serious risks including increased mortality. CMS specifically tracks this metric, and our risk model incorporates it.

Why CMS Tracks This

The FDA issued a black box warning in 2005 for atypical antipsychotics used in elderly dementia patients, citing a 1.6-1.7x increase in mortality. In 2008, this was extended to conventional antipsychotics. Despite these warnings, antipsychotic use in nursing homes and elderly care settings remained stubbornly high.

CMS now tracks antipsychotic prescribing to patients aged 65 and older as a quality measure for nursing homes. High rates may indicate chemical restraint use rather than medically necessary treatment.

What the Data Shows

The Medicare Part D dataset includes a field specifically for antipsychotic claims prescribed to beneficiaries aged 65+. Providers with elevated rates in this field appear in our risk scoring model.

Legitimate vs Concerning Use

Antipsychotics have legitimate uses in elderly patients:

• Schizophrenia and bipolar disorder — These don't disappear at 65
• Severe agitation with psychosis — When non-pharmacological interventions fail
• Delirium — Short-term use in acute settings

But they are concerning when used as:

• Chemical restraints — Sedating patients for staff convenience
• First-line dementia management — Before behavioral interventions
• Chronic prescriptions without review — Indefinite use without reassessment

Our Approach

We assign risk points to providers whose antipsychotic prescribing to patients 65+ exceeds statistical norms. This is one of ten components in our specialty-adjusted risk model. It is not, by itself, an indicator of wrongdoing — but it raises questions worth examining.