(084) Trends in Central Nervous System Medication Use among Assisted Living Residents with Cognitive Impairment: Variation by Presence of Dementia Care and the COVID-19 Pandemic

Background: Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about its capacity to care for this vulnerable population given its lower levels of professional staffing and services. Ensuring appropriate use and oversight of central nervous system medications, including antipsychotics, represents a particular quality concern.

Objectives: To examine the associations between COVID-19 pandemic waves 1-4 (relative to historical comparisons) and prevalent antipsychotic, antidepressant, anti-dementia, benzodiazepine, and gabapentinoid drug use among AL residents with dementia/cognitive impairment, and variation by setting (dementia care vs other AL type).

Methods: We conducted a population-based, repeated cross-sectional study using linked clinical and health administrative databases for eligible residents of all publicly subsidized AL homes in Alberta, Canada, examined between January 2018 - December 2021. Setting specific quarterly cohorts of residents were derived for pandemic (starting March 1, 2020) and comparable historical (2018/2019 combined) periods. The quarterly proportion of residents dispensed a study medication was examined for each setting and period. Log-binomial GEE models estimated prevalence ratios (PR) for period (pandemic vs historical quarterly periods), setting (dementia care vs other AL) and period-setting interactions, adjusting for AL resident (age, sex) and home (COVID-19 cases, health region, ownership) characteristics.

Results: On March 1, 2020, there were 2,779 dementia care and 3,013 other AL residents (mean age 83, 69% female, both settings). Antipsychotic use increased during waves 2-4 for residents of both settings, but this increase was significantly greater for dementia care than other AL residents during waves 3 and 4 (e.g., wave 3, adjusted [adj]PR 1.20, 95% CI 1.14-1.27 vs adjPR 1.09, 95% CI 1.02-1.17, interaction p=0.023). Both settings showed a statistically significant but modest increase in antidepressant use and decrease in benzodiazepine use during several pandemic waves. For dementia care AL residents only, there was a statistically significant increase in gabapentinoid use during waves 1, 3 and 4 (e.g., wave 3 adjPR 1.32, 95% CI 1.10-1.59). Other than a modest decrease in prevalent anti-dementia drug use for both settings in wave 2, no other significant pandemic effects were observed.

Conclusions: The persistence of the pandemic-associated increase in antipsychotic and antidepressant use in AL residents, and greater increase in antipsychotic and gabapentinoid use for dementia care settings, raises concerns about the attendant risks for residents with cognitive impairment.