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. They may also cause sedation, extrapyramidal signs, and some may produce orthostatic hypotension. The latter may all contribute to falls and fractures. Some also predispose to development of metabolic syndrome or glucose intolerance. And some may be associated with severe reactions, such as the neuroleptic malignant syndrome.
Our February 3, 2015 Patient Safety Tip of the Week “CMS Hopes to Reduce Antipsychotics in Dementia” discussed the National Partnership to Improve Dementia Care, a public-private coalition of CMS and several other partners, which 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). The Partnership’s larger mission is “to enhance the use of non-pharmacologic approaches and person-centered dementia care practices”.
Recently, CMS announced a new national goal, involving a 15 percent reduction of antipsychotic medication use by the end of 2019 for long-stay residents in those homes with currently limited reduction rates (CMS 2018).
So has the CMS initiative been successful? It may depend on who you ask.
Since the start of the CMS National Partnership, there has been a decrease of 27 percent in the prevalence of antipsychotic medication use in long-stay nursing home residents, to a national prevalence of 17.4 percent in 2015 Quarter 3 (CMS 2016). Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 25 percent. A statement emailed to CNN (Ravitz 2018) actually notes that the use of antipsychotic drugs has been reduced by 35% since inception of the program in 2011.
On the other hand, Human Rights Watch (Flamm 2018) recently published a paper with scathing criticism of long-term care facilities for continued inappropriate use of antipsychotics, including the lack of free and informed consent in many such cases. The paper does acknowledge that there has been improvement in recent years but that abuses persist.
Researchers visited 109 facilities in six states between October 2016 and March 2017, though they were allowed to conduct their research in only 92 of these. They interviewed 323 people, including residents, family members, nurses, social workers, pharmacists, patient advocates, long-term care experts, administrators, state and federal officials, and others.
Human Rights Watch noted that there are significant challenges in doing quantitative analyses of inappropriate use of antipsychotics in nursing facilities. It is often not possible to determine from a single publicly available data set the proportion of all individuals with dementia in nursing facilities that take antipsychotic medication without a psychiatric or neurological diagnosis for which an antipsychotic drug is clinically indicated. Also, a significant amount of the data on nursing homes is self-reported by those facilities. And it is difficult to determine what forms of non-pharmacologic interventions were tried prior to use of antipsychotics.
Though the study was not a scientific one, it provides numerous anecdotal examples of patients with side effects of antipsychotic treatment and some examples of dramatic improvements once these drugs were discontinued.
Note that we like to tell our own anecdotal story that is relevant. A nursing home one month experienced a dramatic reduction in reported falls. It turned out there had been a contractual issue with a consulting psychiatrist and, as a result, many psychotropic medications had temporarily not been renewed! This included not only antipsychotics but a variety of psychotropic medications. In our February 3, 2015 Patient Safety Tip of the Week “CMS Hopes to Reduce Antipsychotics in Dementia” we noted that 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. This includes drugs that may have been started for treating mild or moderate Alzheimer’s disease but are no longer indicated for advanced disease.
The Human Rights Watch paper goes on to describe a “culture” of antipsychotic drug use and antipsychotic medication use for the convenience of staff as potential explanations for their widespread use.
The Human Rights Watch paper discusses in detail the issues regarding lack of free and informed consent, noting that many such patients with dementia lack capacity to provide consent and other mechanisms for consent may be inadequate. It goes on to discuss deficiencies in governmental regulation and enforcement. It concludes with multiple recommendations for CMS, Congress, the Department of Justice, state legislatures and other regulatory bodies, and others.
Bottom line: the goals of the CMS National Partnership to Improve Dementia Care in Nursing Homes are laudable but the Human Rights Watch study shows we have a long way to go to optimize care for many long-term care patients with dementia.
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
CMS (Centers for Medicare and Medicaid). National Partnership to Improve Dementia Care in Nursing Homes. CMS 2018
CMS (Centers for Medicare and Medicaid). Update Report on the National Partnership to Improve Dementia Care in Nursing Homes. CMS 2016; June 3, 2016
Ravitz J. Nursing homes sedate residents with dementia by misusing antipsychotic drugs, report finds. CNN 2018; February 5, 2018
Flamm H, McLemore M, Brown B, et al. Human Rights Watch. “They Want Docile”. How Nursing Homes in the United States Overmedicate People with Dementia. Human Rights Watch 2018; February 5, 2018