Long-Term Care Survey Alert

If you're only doing this for antipsychotics, you're behind the times.

The decision-making tree for whether to taper a resident's meds has become much thornier under the revised F329 for unnecessary medications.

The first step: Review all a resident's psychoactive medications. Consider a gradual dose reduction for the medications if they are being used to manage behaviors or treat psychiatric symptoms, advises Matthew Wayne, MD, CMD, chief medical director of Elias Jennings Senior Care Network in Cleveland.

Don't stop there: Also consider anticonvulsants if they are being used to address behavioral symptoms or mental illness, Wayne adds.

The revised F329 guidelines don't mandate a dosage reduction for the cognitive enhancers, Wayne says, but even so, make sure such meds are appropriate and continue to benefit the resident -- just as you would for any medication.

"The point at which you stop a cognitive enhancer is very personalized and based on the resident/family goals," he continues. "But at some point the benefits of the medication, which can slow cognitive and functional decline or maintain functional status, may no longer be worth the cost and side effects."

Examples: Acetylcholinesterase inhibitors such as donepezil (Aricept) can cause GI effects, including anorexia and weight loss or diarrhea, leg cramps and vivid dreams or even nightmares, Wayne says. Memantine (Namenda), an NMDA receptor antagonist, can cause agitation, confusion, somnolence and dizziness, although usually patients tolerate the drug well, he adds.

Carefully assess and document the effect of tapering an antipsychotic or other psychoactive medication, suggests Chris Puri, JD, in Nashville, TN. "The facility needs good documentation that tapering the medication led to certain outcomes." For example, did the resident's behavioral symptoms worsen in a way that affected his functional status and participation in basic care?

"If a resident has a diagnosed major mental illness, such as schizophrenia, that's been well controlled by antipsychotics, the physician should document that," adds Adam Rosenblatt, MD, a geropsychiatrist at Johns Hopkins.

"Some people don't differentiate between trying to taper or withdraw an antipsychotic for a behavioral symptom, versus reducing or eliminating a medication for a long-standing chronic mental illness."

Good point: "People don't say let's stop a person's Coumadin and see if he has another stroke. The same principle applies to tapering psychoactive medications for a person with a history of a severe mental illness, such as [major depression with psychotic features or schizophrenia]," Rosenblatt says.

Preempt unwarranted F tags: Educate surveyors that tapering patients off antidepressants too soon doesn't follow the standard of care. "Clinically, we provide a nine- to 12-month initial course of antidepressant therapy for the first episode of depression," says William Simonson, PharmD, a consultant in Suffolk, VA.

"After multiple recurrences [of depression], the resident may require life-long therapy," Simonson adds. "Pharmacists should be aware of the proper duration of antidepressant therapy and be prepared to make a case that the patient requires longer therapy [if surveyors suggest otherwise]."

Suppose you try to taper a psychoactive medication, such as an anti-anxiety agent. If all the factors that stimulate anxiety are still present, "you won't be as successful as you would be if you restore the resident's [customary] routine and eliminate some of the potential causes of psychosocial distress," says Barbara Frank, co-founder of B&F Consulting in Warren, RI.

Example: A person with dementia who can't decipher written words well anymore always gets agitated and disoriented when she tries to find her room. You can provide visual cues, such as a picture on her door of her and her husband from a time she remembers, and a quilt from home on her bed, to help her find her room, suggests Frank. Staff who care for a resident on a regular basis can "track what sets the person off and make alterations environmentally" to address behavioral symptoms "in lieu of medication," she adds.

Nurses, be prepared: Consultant Dee Kostolich, RN, with Howard, Wershbale & Co. in Cleveland sees surveyors during med pass ask nurses questions that can lead to F329 citations -- for example, about dosage reductions of psychoactive medications.