The frequency of schizophrenia diagnoses in U.S. nursing home residents with Alzheimer’s disease and related dementias rose between 2011 and 2017, a report in the American Journal of Geriatric Psychiatry has found. During the study period, Black nursing home residents experienced a greater increase in the likelihood of being diagnosed with schizophrenia than White nursing home residents, even if they received care in the same nursing home.
“Future research is need[ed] to examine the root cause for this increase and to re-examine policies that may incentivize inaccurate diagnosis and exacerbate racial disparities in [nursing home] care,” wrote Shubing Cai, Ph.D., of the University of Rochester School of Medicine and Dentistry and colleagues.
Although antipsychotics can reduce behavioral problems in older adults with dementia, multiple studies have shown that the use of such medications can increase the risk of falls, cognitive worsening, and death. To reduce antipsychotic prescribing to older adults with dementia, the Centers for Medicare and Medicaid Services (CMS) in 2012 began requiring nursing homes to report antipsychotic prescribing to residents. However, as Cai and colleagues noted, nursing homes “are not penalized for using antipsychotics” if a resident is coded as having a schizophrenia diagnosis.
To examine whether diagnoses of schizophrenia among nursing home residents with Alzheimer’s and related dementias varied as a function of race, Cai and colleagues analyzed information collected in two databases: the Minimum Data Set (captures information about diagnoses of psychiatric disorders and other conditions) and the Master Beneficiary Summary File (captures demographic information for residents in Medicare- and/or Medicaid-certified nursing homes). The authors specifically focused on Black and White nursing home residents with Alzheimer’s and related dementias who were 55 years or older and who were long-stay residents (a stay of at least 90 days) between 2011 and 2017. (CMS started to publicly report antipsychotic use on July 1, 2012.)
The sample included over 7.7 million person-years (nearly 3 million individuals) over the 2011-2017 period. Among the long-stay nursing home residents with Alzheimer’s and related dementias, about 14% were Black and 86% were White. The overall frequency of schizophrenia diagnosis codes in this cohort was 10.62% for Blacks and 5.75% for Whites, the authors reported. From 2011 to 2017, the proportion of residents with schizophrenia diagnosis codes increased from 4.98% to 7.21% among Whites, and from 9.16% to 12.78% among Blacks
“[Nursing homes] with a higher proportion of Blacks appeared to have a higher proportion of residents with schizophrenia diagnosis and greater increase over time: from 2.59% to 3.34% in [nursing homes] with the lowest percent of Blacks and from 9.59% to 13.19% in [nursing homes] with the highest percent of Blacks,” the authors wrote. “Additionally, among residents of the same [nursing home], increase in schizophrenia diagnosis was greater over time for Blacks than for their White counterparts.”
The authors concluded, “The increase in the diagnosis of schizophrenia … may result in residents being exposed to treatment with significant risks of adverse effects and poor health outcomes that further exacerbate the long-standing racial disparities in care quality among [nursing home] residents with [Alzheimer’s and related dementias].”
For related information, see the Psychiatric News article “Special Report: Racism and Inequities in Health Care for Black Americans.”
Register Now: First Town Hall on Social Determinants of Mental Health to Be Held November 3
Join APA leaders for two town halls featuring presentations on the importance of the social determinants of mental health (SDoMH) in psychiatry, the efforts of the APA Presidential Task Force on SDoMH, and the opportunity to engage with task force members. The first town hall, scheduled for Wednesday, November 3, will explore SDoMH in the context of clinical practice, research, and education.