MDS Alert

Follow 7 steps to comply with tightening antipsychotic guidelines for dementia patients.

You know you have to tread carefully when administering antipsychotic medications to your residents. And the Centers for Medicare & Medicaid Services (CMS) is arming surveyors with increasingly stringent standards for your use of antipsychotics in residents with dementia.

In a recent CMS surveyor training webcast, the agency reinforced its ongoing focus on reducing the use of antipsychotic medications in dementia patients when they’re not clinically indicated. CMS also formed the Partnership for Improving Dementia Care.

Based on careful review, the American Geriatrics Society 2012 Beers Criteria Update Expert Panel "recommends against the use of antipsychotic agents for behavioral expressions of distress in dementia, unless non-pharmacologic options have failed and behavior threatens the safety of the person or others," Dr. Shari Ling, Deputy Chief Medical Officer at CMS, relates in the webcast.

Heed 7 Recommendations for Avoiding Antipsychotics

"Although certain behaviors such as agitation and aggression may appear in nursing home residents with dementia, such behavior may also be an early manifestation of physical illness or the effect of medications used to treat a medical illness," Ling cautioned. Therefore, antipsychotics should not be your go-to solution to resolve distress in your residents with dementia.

Further, Ling offered the following steps to stay compliant and avoid antipsychotic use in dementia patients:

1. Get details about the resident’s behavior, including the nature, frequency, severity and duration of symptoms, and then get details on the risks of those behaviors;

2. Discuss the potential underlying causes with the care team and the family;

3. Exclude potentially remediable causes of behaviors, and determine if symptoms are severe, distressing or risky enough to adversely affect the safety of residents;

4. Try environmental and other interventions that attempt to understand and address behavior as a form of communication in dementia, and modify the environment and daily routines to meet the person’s needs;

5. Assess the effects of any intervention (pharmacologic or non-pharmacologic), identify the benefits and complications in a timely fashion, and adjust treatment accordingly;

6. For those residents for whom antipsychotic and other medications are warranted, use the lowest effective dose for the shortest possible duration, based on findings in the specific individual; and

7. Try tapering the medication when symptoms have been stable or adjusting doses to obtain benefits with the lowest possible risk.

What to Do When Antipsychotics Are Necessary

Even if you can justify that your dementia patient truly needs an antipsychotic medication, you still need to keep a close eye on the ongoing use of that medication. According to Ling, after starting a resident on an antipsychotic medication, the care team should:

Determine if treatment results in improved behavior;

Observe the resident for any unintended or adverse effects associated with treatment; and

Adjust the care plan to best suit the resident’s individual needs.

Crucial: Further, you must have supporting information in the care plan for continued use of antipsychotic medication, Ling stressed.

Always Beware of the Risks

Evidence highlighted in the Cochrane report of 2012, as well as in others, shows that use of antipsychotic agents can result in accelerated debility, immobility and deterioration in function, cardiovascular complications, and death, Ling warned. The U.S. Food and Drug Administration (FDA) issued "black box" warnings for both typical and atypical antipsychotic medications, stating that there is an increased risk of death in elderly persons with dementia.» »

"Given these risks, regulations require an attempt at gradual dose reduction when behaviors and circumstances no longer require use of the antipsychotic agent," Ling noted.

Bottom line: Don’t think that only antipsychotics will get you into trouble — plenty of other types of medications will catch a surveyor’s attention if used improperly. Despite the increased focus on antipsychotic agents, "many other classes of medications may be harmful to nursing home residents and should be evaluated as well," instructs Alice Bonner, CMS Division of Nursing Homes director in the Survey & Certification Group.