Patient Safety Tip of the Week
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
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review the cases of residents whose antipsychotics are withdrawn to make sure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dementia can be withdrawn from long-term antipsychotics without detrimental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!
References:
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)
http://www.bmj.com/content/349/bmj.g6420
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
http://archinte.jamanetwork.com/article.aspx?articleid=2089230
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
http://www.medpagetoday.com/Geriatrics/Dementia/47781
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.
http://www.cms-handinhandtoolkit.info/
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
http://archinte.jamanetwork.com/article.aspx?articleid=1901117&resultClick=3
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