All US antipsychotic labels include boxed warnings of mortality risk in older patients with dementia-related psychosis. We compared mortality risk in patients with Parkinson’s disease psychosis (PDP) after initiating pimavanserin or other atypical antipsychotics in an overall PDP cohort and a subcohort in long-term care or skilled nursing facilities (LTC/SNF). Patients aged ≥65 years with PDP initiating pimavanserin or a comparator atypical antipsychotic in US Medicare claims (2016-2021) were identified. Cox proportional hazards models were used to estimate hazard ratios (HRs) comparing all-cause mortality in propensity score–matched treatment groups. Cumulative incidence curves, time period–specific relative risk, and risk difference estimates evaluated risk over time. After propensity score matching, the overall PDP cohort included 4,381 patients per treatment group, the LTC/SNF subcohort included 905 patients per treatment group, and all baseline characteristics were well-balanced. Matched HR for mortality (pimavanserin versus comparator) was 0.76 (95% CI, 0.68-0.85) in the overall PDP cohort and 0.90 (95% CI, 0.74-1.10) in the LTC/SNF subcohort. Time period–specific relative risks and risk differences indicated that pimavanserin initiators in the overall PDP cohort had a lower mortality risk during the first year after follow-up. Overall, the mortality risk in older patients with PDP treated with pimavanserin was lower than in patients treated with other atypical antipsychotics through at least the first year of treatment. No meaningful differences in mortality risk were observed between groups in the LTC/SNF subcohort. Regardless of treatment, mortality was higher in the LTC/SNF subcohort than in the overall PDP cohort.
