only, 33.3 percent with psychiatric diagnosis only, and 36 percent with both diagnoses (Semla et al., 1994).

Similar improvements in antipsychotic drug use were found in the medical records of 99 clients in a Wisconsin intermediate care facility for mental retardation, including decreased antipsychotic dosage, decreased number of persons who used antipsychotics, decreased use of as-needed psychotropics, and increased use of other psychotropics (Howland, 1993). These results are significant, since OBRA-87 was initially directed to this population, as well as older institutional residents.

Kidder (1999) used a federal government study from 1974, studies in the literature, and OSCAR data to conclude that antipsychotic drug prescription decreased from a stable level of 33.65 percent pre-OBRA to 16.05 percent post-OBRA (Kidder, 1999). This Health Care Financing Administration (now Centers for Medicare and Medicaid Services [CMS]) official also concluded that fears of deleterious effects from limiting anti-psychotic drug use had not been realized, since MDS data and studies identified no decrement, and possible improvement, in behavior and activities of daily living among nursing home residents during the implementation of OBRA.

Anti-Anxiety Drugs

The impact of OBRA on anti-anxiety drug use is confounded by the staggered implementation of the OBRA guidelines for antipsychotic and anti-anxiety drugs, since many studies were conducted in the interval between implementation of the respective policies. Based on data prior to the passage of OBRA, Beers and colleagues (1988) reported that of those residents of 12 Massachusetts nursing homes receiving benzodiazepines, 30 percent were taking a long-acting agent, a category that had been associated with increased sedation, falls, and other adverse events. The typical dosage was relatively high for older patients, at 7.3 mg diazepam equivalent per day, which is nearly 50 percent higher than the geriatric dosage in the OBRA guidelines (Gurvich and Cunningham, 2000).

Kane and colleagues (1993) cited data from a large California pharmacy consulting company to introduce the concern that compensatory prescribing of benzodiazepines might replace antipsychotic use. The baseline routine prescribing rate prior to the OBRA antipsychotic guidelines increased from 5.25 to 7.6 percent in November 1991. Similar results were found in a study of one VA nursing home where prescription of benzodiazepines increased from 42 to 48 percent of residents coincident with the time of implementation of the OBRA antipsychotic guidelines (Slater and Glaser, 1995). Conversely, no change in benzodiazepine use was associated with the implementation of the OBRA antipsychotic guidelines in a follow-up study of 1,650



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