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Bipolar Disorder in Nursing Homes: Impact on Antipsychotic Use, Diagnosis Patterns, and New Diagnoses in People with Dementia
Journal article   Open access   Peer reviewed

Bipolar Disorder in Nursing Homes: Impact on Antipsychotic Use, Diagnosis Patterns, and New Diagnoses in People with Dementia

Ryan M Carnahan and Elena M Letuchy
The American journal of geriatric psychiatry, Vol.26(1), pp.2-10
01/2018
DOI: 10.1016/j.jagp.2017.09.007
PMCID: PMC6946118
PMID: 29031571

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Abstract

•Including people with bipolar disorder when calculating the antipsychotic use quality measure for long-stay nursing home residents negatively impacts the measure.•The most negatively impacted nursing homes have larger proportions of residents with bipolar disorder, but may not provide more mental health-specific care than other homes.•Minimum Data Set indicators for bipolar disorder did not agree very well with diagnoses from Medicare claims, particularly when non-specific diagnoses were excluded.•Over two-thirds of long-stay residents with bipolar disorder diagnoses had dementia, and over half of this group had dementia before bipolar disorder per Medicare records.•People diagnosed with dementia before bipolar disorder often received only non-specific bipolar disorder diagnoses, which may represent symptoms of dementia. Nursing home quality measures include the proportion of residents who receive antipsychotics. Residents with bipolar disorder are included even though antipsychotics are FDA-approved for this indication. We evaluated how including residents with bipolar disorder impacted the antipsychotic use quality measure for long-stay residents. We evaluated the agreement of minimum data set (MDS) bipolar disorder diagnoses with Medicare data, whether dementia was diagnosed before bipolar disorder, and how less-specific bipolar disorder diagnoses impacted findings. Cross-sectional study. Nursing homes in Iowa. 21,955 long-stay nursing home residents in the first quarter of 2014. We identified antipsychotic use and bipolar disorder using MDS data. We compared MDS bipolar disorder diagnoses with Chronic Conditions Warehouse (CCW) “ever” bipolar disorder indicators, and prior year claims. We compared CCW condition onset dates to identify bipolar disorder diagnosed after dementia. The mean (SD) proportion receiving antipsychotics was 19.6% (11.1%) with bipolar disorder and 18.3% (10.8%) without. The positive predictive value (PPV) of MDS bipolar disorder diagnoses was 80.2% versus CCW lifetime indicators, and 74.6% versus claims. PPV decreased by 27.1% when “bipolar disorder, unspecified” and “other bipolar disorders” diagnoses were excluded. Nearly three-quarters of residents with bipolar disorder had dementia. Over half of those with dementia had dementia first per CCW records. This proportion was lower among those with more specific bipolar disorder diagnoses or MDS bipolar disorder indicators. Bipolar disorder in nursing home residents is often first diagnosed after dementia using nonspecific diagnoses. This practice deserves further evaluation.
 antipsychotics Bipolar disorder dementia late onset bipolar disorder quality measures nursing homes

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