MDS Alert

Hint: Evaluate target behaviors in Section E4, but don't stop there.

Let the MDS be your guide in deciding whether an antipsychotic is improving a resident's functional status and quality of life.

Start by monitoring the drug's effect on the resident's targeted behavioral symptoms, including those in Section E4.

For example, "look for the frequency of the resident's outbursts and combative episodes or how often he won't cooperate with basic care," advises Adam Rosenblatt, MD, a geropsychiatrist with Johns Hopkins Medical Center in Baltimore.

Also check Section E5 of the MDS, which asks you to determine if the resident's behaviors stayed the same, improved or deteriorated over the last 90 days (or since the last assessment). If the behaviors haven't improved or remain unchanged, has the physician attempted to titrate or change the medication?

"When prescribed for dementia-related behaviors, an antipsychotic medication should produce results within a week or two," says Rosenblatt. "And if you're not seeing any effect within several days, the physician should consider increasing the dose.

"If the drug doesn't work within a couple more weeks (as observed by improvements in the resident's targeted behaviors), then try something else," Rosenblatt adds.

Look at the Bigger Picture

Use these additional MDS Sections to assess the impact of an antipsychotic on the resident's cognitive, ADL and psychosocial status:

Section B (cognition). A resident taking a second-generation antipsychotic may appear to have improved cognition if the drug eliminates paranoid or agitation symptoms that were interfering with his performance on cognitive testing or assessments, says geropsychiatrist Ira Katz, MD, with the Philadelphia VA Medical Center.

Section F. Has the resident shown improvements in Section F1 (sense of initiative/involvement)? Does he appear more at ease relating to others - or accept invitations to group activities? Consider tracking (and documenting) the resident's interactions with others, including their quality, advises Angela Lobreto, RN, PhD, a consultant in Benbrook, TX, "For example are the interactions more aggressive or are they positive?"

Section G. Has the resident shown an improvement in performing his own activities of daily living? If the resident is receiving an antipsychotic medication for resisting essential ADL care, carefully assess and document specific improvements in this section.

Section J (hallucinations and delusions). Has the antipsychotic med eliminated hallucinations or delusions coded in this section? If so, surveyors may expect the facility to attempt a dosage reduction after a period of time to see if the psychotic symptoms return - unless the physician documents why that is contraindicated.

Section N (activity patterns). Has the resident shown an improvement in his participation in activities following the addition of an antipsychotic medication or a change in dosage? Look at N2 (time spent in activities) and also N1 (time awake). N1 can let you know if the resident is more sedated than previously.

Sedation is a definite red flag, but the physician may have a therapeutic rationale for prescribing a sedating dose of a psychoactive medication in rare cases, says Rosenblatt. If so, make sure the physician documents her rationale in the medical record carefully.

Clinical example: "In rare cases, a patient's behavior is so out of control that a sedating dose of antipsychotic medication might be preferable to the person dying or seriously hurting himself or someone else - or being forced to live in a state psychiatric hospital instead of the nursing home where he wants to live," says Rosenblatt. (See part 2 of this story on how to use the MDS to identify antipsychotic-related adverse drug reactions in the February 2005 MDS Alert.)