OBJECTIVES: Antidementia medication (AD-rx) changes occur upon nursing home admission. Little is known about what factors influence changes in AD-rx and who is involved in prescribing decisions.

METHODS: In 2022, we surveyed Directors of Nursing (DoN) of 1,293 homes (response rate: 26.6%, n=340) sampled in strata defined by size (number of beds 30-99, 100+) and quality ratings (1, 2-4, 5), while oversampling homes with dementia units. Analyses were weighted to provide nationally representative results.

RESULTS: Nearly a third of DoN reported that at least half of new admissions had dementia. Few newly admitted residents with dementia had been seen by a neurologist before (most/all residents: 6.3%) or after admission (most/all residents: 11.4%). Although 84.4% reported that the nursing home prescriber has primary responsibility for AD-rx changes, those always/almost always involved in AD-rx decisions included nursing staff (33.2%), family (23.4%), pharmacist (21.2%), resident (13.8%), primary care provider (12.1%), and neurologist (5.8%). AD-rx were much more likely to be initiated if: residents (55.8%) and family members (53.2%) wanted AD-rx, a neurologist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). If insurance did not cover AD-rx, 28.1% reported that AD-rx were much less likely to be initiated. AD-rx were much more likely to be discontinued with neurologist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), < 6 months prognosis (28.5%), insurance not covering AD-rx (29.8%), emergence of aggressive behaviors (25.2%) or resisting care (19.0%). AD-rx were much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue.

CONCLUSIONS: This study provides nationally representative estimates for shared decision making when changing AD-rx for nursing home residents at admission. Findings from this study will inform the design of interventions to improve the management of dementia in nursing homes.