Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD

Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership.

We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions.

There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007).

Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.