title: Variation in use of antipsychotic medications in nursing homes in the United States: A systematic review.
abstract: The use of antipsychotic medications (APMs) in nursing home residents in the U.S. is an increasingly prominent issue and has been associated with increased risk of hospitalization, cardiovascular events, hip fractures, and mortality, among other adverse health events. The Food and Drug Administration has placed a black box warning on these drugs, specifying that they are not meant for residents with dementia, and has asked providers to review their treatment plans. The purpose of this systematic PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)-based review was to summarize original research studies on facility level characteristics contributing to the use of antipsychotics in nursing homes across the United States, in order to investigate the variation of use.
  
  
  
  We searched Ovid Medline, Embase, Cochrane Library, Web of Science, CINAHL, PsycInfo, and Sociological Abstracts. Articles were selected according to the following criteria: (1) Population of interest: older adults (≥60 years of age) residing in nursing homes (not home-based or inpatient hospital settings) in the U.S. (2) Receiving APMs, typical and/or atypical. Specifically excluded were studies of psychotropic medications such as antidepressants, benzodiazepines, anxiolytics, hypnotics, mood stabilizers, and stimulants. All study designs were considered, though reviews, editorials, letters to the editor and opinion pieces were excluded. An expert consultant panel was consulted to categorize facility characteristics into domains and determine possible etiologies of APM use based upon each characteristic.
  
  
  
  Nineteen observational studies, both quantitative and qualitative, published from 2000 to 2015, met full inclusion criteria and were included in this review. APM use varied based on multiple facility characteristics across several domains: 1) physical, 2) staffing, 3) occupancy, 4) market, and 5) quality.
  
  
  
  Variation in use of APMs in U.S. nursing homes based upon facility characteristics exemplifies the need for a more systematic protocol guiding the use of these medications, along with heightened regulatory policies and enforcement.
authors.affiliation: College of Public Health, University of Arizona, Tucson, Arizona, USA. hstocker@aging.arizona.edu.|Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA. hstocker@aging.arizona.edu.
authors.forename: Hannah
authors.identifier: 0000-0003-4775-4304
authors.initials: H
authors.lastname: Cioltan
authors.affiliation: College of Pharmacy, University of Arizona, Tucson, Arizona, USA.
authors.forename: Samah
authors.initials: S
authors.lastname: Alshehri
authors.affiliation: University of Arizona Health Sciences Library, Tucson, USA.
authors.forename: Carol
authors.initials: C
authors.lastname: Howe
authors.affiliation: Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA.|College of Pharmacy, University of Arizona, Tucson, Arizona, USA.
authors.forename: Jeannie
authors.initials: J
authors.lastname: Lee
authors.affiliation: Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA.|Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA.
authors.forename: Mindy
authors.initials: M
authors.lastname: Fain
authors.affiliation: College of Public Health, University of Arizona, Tucson, Arizona, USA.|College of Pharmacy, University of Arizona, Tucson, Arizona, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Eng
authors.affiliation: College of Public Health, University of Arizona, Tucson, Arizona, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Schachter
authors.affiliation: College of Public Health, University of Arizona, Tucson, Arizona, USA.|Arizona Center on Aging, College of Medicine, University of Arizona, Tucson, Arizona, USA.|College of Pharmacy, University of Arizona, Tucson, Arizona, USA.|Division of Geriatrics, General Internal Medicine and Palliative Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA.
authors.forename: Jane
authors.initials: J
authors.lastname: Mohler
mesh_terms: D000368:Aged; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D003704:Dementia / Q000188:drug therapy / Q000453:epidemiology; D006707:Homes for the Aged / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D054539:Medication Therapy Management / Q000592:standards; D009735:Nursing Homes / Q000592:standards / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians'; D014481:United States / Q000453:epidemiology
chemical_list: D014150:Antipsychotic Agents
keywords: Antipsychotics; Behavioral symptoms; Dementia; Nursing homes