Drug Substitution as a Potential Unintended Consequence of Antipsychotic Deprescribing in Long‐Term Care: A Retrospective Cohort Study in Ontario, Canada
Bibliographic record
Abstract
Abstract Background The overuse of antipsychotics in persons with dementia in long‐term care (LTC) has been a source of clinical concern, public attention, and policy intervention for over 30 years. Targeted quality improvement, broader awareness of risks, and other initiatives have resulted in substantial reductions in antipsychotic use in LTC settings in North America and elsewhere. Limited evidence suggests that reductions in antipsychotic use may be resulting in unintended consequences, such as substitution with alternate, but similarly harmful, psychotropic medications. Methods We used a retrospective, matched cohort study design using linked population‐based health care databases held at ICES. LTC residents 66 years or older with dementia who were prescribed an inappropriate (i.e., without an indication aligning with the definition of appropriate antipsychotic use in LTC, including schizophrenia, Huntington’s disorder, hallucinations, delusions, or end‐of‐life care) antipsychotic medication with at least 6‐months of continuous use were identified over a 10‐year period (2008‐18). Antipsychotic users who subsequently discontinued an antipsychotic medication were matched 1:1 to persistent users on key variables and followed for up to 1‐year following antipsychotic discontinuation for new prescriptions of one or more psychotropic medications and clinical outcomes. Results Among 26,092 LTC residents with dementia (mean age of 84 years) who were prescribed an inappropriate antipsychotic medication, 5,854 (22%) discontinued during the follow‐up period. After adjusting for key variables, new psychotropic medication prescription was not more common among antipsychotic discontinuers in the 6‐months following antipsychotic discontinuation compared to those who continued an antipsychotic medication (hazard ratio (HR) 0.90; 95% CI, 0.70‐1.15). Mortality was similar between the two groups (HR 1.01; 95% CI 0.90‐1.15) at up to 1‐year following antipsychotic discontinuation. Conclusion Antipsychotic discontinuation in this study was not associated with medication substitution. These results supports other studies indicating that antipsychotic discontinuation in dementia can be safe but has questionable effect on mortality. While medication use trends in LTC have shown increases in other psychotropic medication use alongside antipsychotic reductions, this study suggests that this may be driven by factors other than substitution, such as increasing complexity of LTC residents, including higher prevalence of mental health disorders other than dementia.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.003 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.006 |
| Science and technology studies | 0.004 | 0.001 |
| Scholarly communication | 0.002 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".