key: cord-0875762-97lh1ylr
authors: Stall, N. M.; Zipursky, J. S.; Rangrej, J.; Jones, A.; Costa, A. P.; Hillmer, M. P.; Brown, K. A.
title: Increased Prescribing of Psychotropic Medications to Ontario Nursing Home Residents during the COVID-19 Pandemic
date: 2020-11-30
journal: nan
DOI: 10.1101/2020.11.26.20239525
sha: e77413ce756b6351aa04693cecde9e9306497510
doc_id: 875762
cord_uid: 97lh1ylr

In this population-based study of all Ontario nursing home residents, we found increased prescribing of psychotropic drugs at the onset of the COVID-19 pandemic that persisted through September 2020. Increases in prescribing were out of proportion to expected secular trends, and distinct from observed prescribing changes in other drugs during the pandemic. Our findings underscore the urgency of balancing infection prevention and control measures in nursing homes with the mental wellbeing of residents.

An enduring feature of the COVID-19 pandemic is the sizeable number of outbreaks and deaths in nursing homes. To limit the introduction of virus in these settings, strict and lengthy lockdowns were imposed on nursing homes worldwide. These restrictions have led to concerns about the mental health of nursing home residents, and increases in the use of psychotropic medications, which were frequently overprescribed prior to the pandemic. 1,2

We examined the monthly proportion of nursing home residents in Canada's most populous province of Ontario dispensed psychotropics from January-September 2020. As of March 1, 2020, there were 77,291 residents living in the province's 623 licensed nursing homes receiving personal and nursing care, subsidized accommodation and all prescription medications under a publicly long-term care program. Restrictions on visitation, absences, and most congregate dining and group activities began in all nursing homes on March 14, 2020.

We studied the dispensation of four psychotropic medications: antipsychotics (1 st -and-2 nd generation), antidepressants (SSRIs, SNRIs, bupropion, mirtazapine), benzodiazepines, and trazodone. We also examined the prescribing of two negative tracer drugs (metformin and statins) not expected to change during the pandemic. Data were obtained from the Ontario Drug Benefit database through the Ministry of Health as part of the province's COVID-19 Modeling Consensus Table. We examined the proportion of residents receiving a prescription across the first seven months of the pandemic (March-September 2020). To account for the dynamic number of residents living in nursing homes during the pandemic, we calculated the monthly number of residents filling a prescription for each drug of interest as a proportion of the monthly number of residents filling a prescription for any drug. In unadjusted analyses, we examined absolute changes in the proportion of residents receiving a prescription compared to the most recent pre-pandemic months (January-February 2020). In adjusted analyses, we examined absolute changes compared to anticipated absolute prescribing trends based on the linear secular trend of prescribing rates . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.26.20239525 doi: medRxiv preprint from April 2019 to February 2020. All analyses were based on logistic regression. The study was approved by the University of Toronto's research ethics board.

Comparing January-February 2020 with September 2020 (Table 1) 

In this population-based study of all Ontario nursing home residents, we found increased prescribing of psychotropic drugs at the onset of the COVID-19 pandemic that persisted through September 2020. Increases in prescribing were out of proportion to expected secular trends, and distinct from observed prescribing changes in other drugs during the pandemic.

Our results align with findings of increased prescribing of antipsychotics during the pandemic to people living with dementia in the United Kingdom. 3 We offer additional insights by studying prescribing of multiple classes of psychotropic drugs, as well as those unexpected to change during the pandemic. Our study is limited by lack of data on prescribing indications; while some of the observed increases in psychotropics may be for palliative management of residents dying of COVID-19, increases were more likely related to the effects of prolonged social isolation during lockdowns. 4, 5 Due to diminished resources, clinicians may have been less likely to prioritize more favorable non-pharmacological management for common issues like responsive . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted November 30, 2020. ; https://doi.org/10.1101/2020.11.26.20239525 doi: medRxiv preprint Table 1 : Unadjusted and adjusted absolute changes in psychotropic drug prescribing to nursing home residents in Ontario, Canada (January-September, 2020) 1 The monthly number of residents filling a prescription of interest as a proportion of the monthly number of residents filling a prescription for any drug. As of March 1, 2020 there were 77,291 residents living in Ontario's 623 licensed nursing homes. 2 Unadjusted absolute difference with 95% Confidence Interval (CI) compared to January-February, 2020. 3 Adjusted absolute difference with 95% Confidence Interval (CI) compared to prescribing rates expected based on a linear secular trend in the April 2019 to February 2020 period.

Mar-Sep, 2020 Sept, 2020 Mean monthly proportion 1 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review) 

Social Isolation-the Other COVID-19 Threat in Nursing Homes

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Antipsychotic prescribing to people with dementia during COVID-19

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Behavioral and Psychological Effects of Coronavirus Disease-19 Quarantine in Patients With Dementia

Recommendations for Welcoming Back