Long-Term Care Survey Alert

Follow these suggestions to cut down on unnecessary use.

Get ready for CMS to be very closely monitoring the use of antipsychotic drugs in your facilities in upcoming surveys. On May 30, CMS officially unveiled its quality initiative to ensure appropriate care and use of antipsychotic medications for nursing home residents and short-stay patients.

Called the Partnership to Improve Dementia Care, this new program is spurred by widespread concerns that providers are inappropriately using antipsychotic drugs in the care of their dementia patients. "A CMS nursing home resident report found that almost 40 percent of nursing home patients with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis," notes Patrick Conway, MD, MSc, CMS' chief medical officer and director of clinical standards and quality.

In addition, CMS data indicates that in 2010 more than 17 percent of nursing home residents had daily doses exceeding recommended levels. "Managing dementia without relying on medication can help improve the quality of life for these residents," Conway emphasizes, "and the Partnership to Improve Dementia Care will equip residents, caregivers, and providers with the best tools to make the right decision."

Alarming: One in three residents in skilled nursing centers receive antipsychotic drugs, mainly to manage behaviors associated with dementia, according to the American Health Care Association (AHCA), "We've learned over time that many of these medications can actually cause people to fall, be re-hospitalized and have a worse outcome," notes David Gifford, MD, MPh, AHCA's senior vice president of regulatory affairs.

"And so," adds Dave Kyllo, executive director of the National Center for Assisted Living (NCAL), "it's important that we look for alternatives, that we come up with better ways to care for the behaviors that frequently come with residents who suffer from dementia." Safely reducing the off-label use of antipsychotics by 15 percent by December 2012 is one of the goals of the AHCA/NCAL quality initiative. (More information on this initiative is available at www.ahcancal.org/quality_improvement/qualityinitiative/Pages/default.aspx).

"One of our strategies for addressing the goal [for antipsychotics] is to get more stable staff and consistent assignments," Giffords noted. "When you have consistent assignments and have individuals who aren't having disruptive behaviors, the families are also going to be more satisfied overall. We see it as a package deal . . ."

"Another big strategy, " Giffords continued, "is to focus on the manner in which staff interact with individuals so the interaction doesn't lead to behaviors that lead to antipsychotic medications. If someone is hallucinating, they may need antipsychotics," he noted, but "what is a person who isn't familiar with where they are or what's going on -- and sees a strange nursing aide approach them to help them get dressed -- likely to do? Scream and hit the person. And those two things probably get you medication."

"Some of it," Gifford added, "is that many individuals get started on an antipsychotic for an acute episode as I described, but they don't need to be on it forever. Some patients come into the facility on these medications and we should be able to taper them off fairly quickly."

With consistent assignments, "the CNAs learn how to approach someone -- for example, the person gets anxious if you approach them from the left side, so you approach them from the right side," said Gifford. "A lot of it is subconscious behavior that we all learn by being around someone," he added. "The individual with dementia also probably develops some sense of familiarity" with the CNAs.

"You have to distinguish a harmful delusion from a harmless one," Louis Mudannayake, MD, CMD, medical director of Cobble Hill Health Center in Brooklyn, New York, advised. He recounts admitting one patient to the facility from a psychiatric hospital. "She was on 200 mg BID of Seroquel and in a straitjacket, because she had a delusion . . . that she was still back working," he said. "So we took her off the medication and gave her simple things to do like filing, so she's still back at work as far as she's concerned."

Ease off: "Sometimes the key to reducing hostility and aggression is simply to take a step back and to return to the care task at a later juncture," he added. The program employed at Mudannayake's facility involves the interdisciplinary team gathering data useful in defining the risk versus benefit of using antipsychotic medications. The facility educates staff about the program every six months or so, he noted.

"The education has to go from the psychiatrists down to the CNAs, and you have to have administrative backing. A 2010 evidence-based study in the International Journal of Geriatric Psychiatry showed that prescription of antipsychotics in nursing homes is a culture and not a science," Mudannayake said. "You need staff buy-in . . . ," he emphasized. And "you have to do the monitoring, including biochemical monitoring." (See the box on "Know the 'Adverse Consequences of Antipsychotics' Listed in the CAA Resource" on pg. 55.)

"Here we do EKGs to identify prolonged QT intervals, which the federal guidelines don't require, but if you don't do the EKGs, the patient could have a fatal cardiac arrhythmia before you identify the problem," he cautioned.

Proven results: Mudannayake reported that his nursing facility "went down from nearly 30 percent of patients being on antipsychotics to about 8 percent now. It fluctuates between about 7 percent to the highest peak, which has been 16 percent, in the five years since we started the program. The national figures are [that] about one-fourth to one-third of nursing home residents are on antipsychotics," he added. "At my SNF, we haven't had any increase in psychiatric hospitalizations or costs of staffing due to using less antipsychotics," he noted.