Antipsychotic medications are often used for treating agitation and aggressive behavior in patients with dementia. Use of antipsychotics in patients with dementia has long under fire because of limited efficacy and occurrence of serious adverse effects, such as an increase in stroke and mortality (Corbett 2014). They may also cause sedation, extrapyramidal signs, and some may produce orthostatic hypotension. The latter may all contribute to falls and fractures, as reported recently in patients 65 years and older who were started on an atypical antipsychotic medication as an outpatient (Fraser 2015). That study found that antipsychotic use increased the risk of serious falls by 52% and the risk or nonvertebral osteoporotic fracture by 50% compared to a matched control group, regardless of the specific agent used.
Despite guidelines and warnings against their use, antipsychotics continue to be used often in nursing homes and long-term care settings. In 2012 CMS challenged LTC and SNF facilities to reduce use of antipsychotics by 15% and between the end of 2011 and the end of 2013, the national prevalence of antipsychotic use in long-stay nursing home residents was reduced by 15.1 percent.
So now CMS has announced that the National Partnership to Improve Dementia Care, a public-private coalition of CMS and several other partners, has established a new national goal of reducing the use of antipsychotic medications in long-stay nursing home residents by a further 25 percent by the end of 2015, and 30 percent by the end of 2016 (CMS 2014).
To make sure the initiative does not produce unintended consequence, CMS will review prescriptions of anxiolytics and sedative/hypnotics to make sure nursing homes do not just replace antipsychotics with other drugs. In addition, CMS will review the cases of residents whose antipsychotics are withdrawn to make sure they don’t suffer an unnecessary decline in functional or cognitive status as a nursing home tries to reduce its usage. Note that a previous Cochrane Review (Declercq 2013) showed the evidence suggests that older nursing home residents or outpatients with dementia can be withdrawn from long-term antipsychotics without detrimental effects on their behavior. Caution is required in older nursing home residents with more severe neuropsychiatric symptoms, as two studies suggest these peoples' symptoms might be worse if their antipsychotic medication is withdrawn. Moreover, one study suggested that older people with dementia and psychosis or agitation and a good response to their antipsychotic treatment for several months could relapse after discontinuation of their antipsychotic medication. They recommended that programs that aim to withdraw older nursing home residents from long-term antipsychotics should be incorporated into routine clinical practice, especially if the neuropsychiatric symptoms are not severe.
The Partnership’s larger mission is “to enhance the use of non-pharmacologic approaches and person-centered dementia care practices”.
In a commentary on the new goals Leonard Gellman, MD, a participant in the Partnership announced by CMS, points out that most antipsychotic medications are not actually prescribed by the nursing homes (Frieden 2014). Rather they are often started when the patient is in a hospital and continued upon discharge or they may have been started by the patient’s primary care physician. Once they have been started, facilities and patients’ families are reluctant to discontinue or reduce them.
So how do you go about reducing such inappropriate usage? An excellent article was recently published on using the FOCUS PDSA process to improve antipsychotic medication management in a long-term care facility (Hampton 2014). They started by putting together a performance improvement team with representation of all key stakeholders and asking appropriate questions about what they wanted to improve and how they would know they were improving before they implemented interventions. They identified a list of 16 antipsychotic medications from the Primaris Changing Antipsychotic Thinking (CAT) program and implemented a screening process for all new admissions who are taking one of the medications. The admitting nurse initiates the screen and forwards a form to the advanced practice RN for review and recommendations about medication management. The team reviewed the medications on each of their 6 patient divisions on a regular basis over several PDSA cycles. They explored whether non-pharmacological interventions had been tried and the committee would decide whether to continue the medication, attempt a gradual dose reduction, or discontinue the medication. Recommendations were forwarded to the patient’s healthcare provider, who could agree or disagree with the recommended action. A log book was kept and the committee’s recommendation was put in a form that became part of the patient’s medical record.
Of the four antipsychotics used most frequently, they were able to reduce the amount of Abilify by 34%, Risperdal by 33%, Seroquel by 54%, and Zyprexa by 27%.
A key barrier identified by Hampton and colleagues was staff concern that undesirable behaviors would emerge in patients as the dose of antipsychotics was reduced. The team therefore looked to CMS’s Hand in Hand program. That is a program that helps nursing homes understand that behaviors are really a form of communication and helps staff learn how to communicate differently with patients and use alternative non-pharmacologic means of dealing with behaviors.
It should be noted that the high placebo response rates (40-50%) seen in clinical trials indicate that other factors (good general care, clinical review, treatment of comorbidities, improved social interaction, etc.) have an impact on the behavioral manifestations of dementia (Corbett 2014).
Beyond the non-pharmacological (behavioral) interventions that should be tried as a first line of management of agitation or aggression in patients with dementia, one must always be alert for other underlying medical problems. Appearance of agitation or other change in behavior in patients with dementia should always prompt a search for possible triggers, such as pain or conditions such as constipation or UTI.
In addition to the beneficial effect on patient safety, such reductions in antipsychotic use should also produce considerable financial savings. In 2011, Medicare Part D spending on antipsychotic drugs totaled $7.6 billion, which was the second highest class of drugs, accounting for 8.4 percent of Part D spending (CMS 2014).
Antipsychotics, of course, are not the only medication commonly misused in dementia patients in nursing homes. Sedatives and hypnotics and antianxiety agents are also commonly misused and will be monitored in the CMS/Partnership initiative as well. And in advanced dementia several other medications of questionable benefit are often continued. A recent study of nursing home patients with advanced dementia found that 53.9% of such patients were prescribed at least one medication of questionable value (Tjia 2014). Cholinesterase inhibitors (36.4%), memantine (25.2%), and lipid lowering agents (22.4%) were most commonly prescribed. High facility use of feeding tubes increased the likelihood of patients receiving such medications. The mean 90-day expenditure for such medications was $816. So we anticipate that as SNF and LTC facilities successfully implement programs to reduce inappropriate use of antipsychotics, sedatives, hypnotics and antianxiety agents, they may look at adding more comprehensive medication management reviews to their activities.
It’s great when we can implement programs that improve patient outcomes and patient safety and reduce costs at the same time!
Corbett A, Burns A, Ballard C. Don’t use antipsychotics routinely to treat agitation and aggression in people with dementia. BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g6420 (Published 03 November 2014)
Fraser L-A, Liu K, Naylor KL, et al. Falls and Fractures With Atypical Antipsychotic Medication Use: A Population-Based Cohort Study. Research Letter. JAMA Intern Med 2015; Published online January 12, 2015
CMS. National Partnership to Improve Dementia Care exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal. CMS Press Release September 19, 2014
Declercq T, Petrovic M, Azermai M, et al. Withdrawal versus continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev 2013; 3: CD007726
Frieden J. Antipsychotics for Dementia: CMS Says Use Less. Medpagetoday 2014; September 22, 2014
Hampton JK; Reiter T, Hogarth J, et al. Using FOCUS PDSA to Improve Antipsychotic Medication Management. Journal of Nursing Care Quality 2014; 29(4): 295-302
Primaris. Resources. Changing Antipsychotic Thinking (CAT).
CMS. Hand in Hand: A Training Series for Nursing Homes.
Tjia J, Briesacher BA, Peterson D, et al. Use of Medications of Questionable Benefit in Advanced Dementia. JAMA Intern Med 2014; 174(11): 1763-1771
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