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

Objectives: 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. Design, Setting, Participants: Retrospective cohort study of community-dwelling veterans with dementia aged ≥68 with VA hospitalizations in 2014, using Veterans Health Administration (VA) and Medicare data. Measurements: 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. Results: 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. Conclusions: 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.