residents in 16 nursing facilities in Wisconsin published before the implementation of the anti-anxiety guidelines (Svarstad and Mount, 2001a) and in a study of 372 nursing homes in Minnesota (Garrard et al., 1995).

In a 6-year retrospective study in one private, nonprofit nursing home in Georgia conducted in 1994, the rate of anti-anxiety drug use of 22 percent immediately before the implementation of the psychotropic drug regulations (up from 15.5 percent in 1988) decreased significantly to 8.9 percent in 1994, 2 years after the implementation of the anti-anxiety drug regulations (Taylor et al., 2003). A 10-year follow-up study comparing 1984 and 1994 rates of prescription indicated that OBRA implementation coincided with a declined in the prescription of anxiolytic and sedative/ hypnotic medications from 12.1 to 6.4 percent (p <0.01) (Lantz et al., 1996). Comparison of the rates of prescription of benzodiazepines during 1986–1989 and those in 1993–1994 using a stratified random sample of 16 skilled nursing facilities in Wisconsin showed an increase from 18.1 to 22.8 percent, which was not statistically significant (Svarstad et al., 2001).

A comparison conducted of chronic benzodiazepine use by Medicaid residents in nursing homes before 1990 and during 1993–1994 to assess the impact of the OBRA guidelines documented a decline of only 3.9 percent, which was not statistically significant (Svarstad and Mount, 2001a). Only the ratio of licensed nurses to residents was associated with improvement in medication appropriateness. Using publications and national datasets, Kidder (1999) determined that following OBRA, national rates of anti-anxiety drug use increased slightly from 10.62 percent (or 13.1 percent if nonrepresentative data were excluded) to 14.29 percent, and hypnotic medication use decreased from 10.62 to 6.83 percent.

Use of Antidepressants

While the use of antipsychotic medication has decreased, the use of antidepressants has increased since the implementation of OBRA (Lantz et al., 1996; Svarstad et al., 2001; Taylor et al., 2003). This may be attributed to increased education about undertreatment of depression, availability of safer medications, and responsiveness of depression in older adults. Lapane and Hughes (2004) found that depression was more likely to be addressed in larger nursing facilities or facilities staffed with a full-time physician, whereas increased antipsychotic drug use was found in facilities that were government-owned, had more licensed nurses, and had more residents reliant on Medicaid funding. Kidder (1999) also noted that antidepressant use had increased from 12.64 to 24.9 percent during the implementation of OBRA, although he observed that the increase began pre-OBRA as safer agents emerged and probably was not due to substitution for drugs covered by the OBRA regulations.

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