MDS Alert

Make sure you're covering 4 bases for residents taking these meds.

If you still have physicians routinely ordering hypnotics or other sleep aids for residents, beware. The facility could end up with an F329 citation for unnecessary medications, or face questions about negative outcomes tied to inappropriate use of these meds.

The clinical reality: "Any medication used to induce sleep will inherently have side effects such as excessive drowsiness and other central nervous system effects," cautions Carla Saxton McSpadden, RPh, CGP, with the American Society of Consultant Pharmacists. As a result, sleep aids have the potential to cause or contribute to falls and confusion, especially in people with pre-existing cognitive impairment.

Solution: Consider these four clinical and survey management best practices:

1. Don't jump the gun. Prescribing hypnotics is generally only appropriate after the staff has tried non-pharmacological interven-tions for insomnia, says McSpadden.
"And at that point, the [medications] should generally only be used short-term or sparingly," she adds. (For advice on how to use the MDS to do a sleep assessment that gets to the root of a resident's insomnia, see last month's MDS Alert.)

Also keep in mind: "Everyone experiences insomnia on occasion, especially when in a different environment or when their sleep cycle is disrupted," McSpadden notes.

2. Review F329 requirements. To comply with F329, the resident should have an "adequate indication" for use of a sleep medication and a "detailed rationale" for its use, McSpadden counsels.

The team should also be monitoring the medication's effectiveness and any adverse consequences. Also make sure the resident gets the right dose and takes the medication for an appropriate period of time. All of this should be specific to the individual resident, she adds.

"F329 also outlines recommendations for quarterly tapering of hypnotics used routinely and beyond the manufacturer's recommendations for duration of use," adds McSpadden, noting that "the last two stipulations are the key."

Although the definition of "routine" use is a "little gray," any scheduled hypnotic given nightly would certainly fall in that category, McSpadden advises. "PRN hypnotic orders get a little trickier." But definitely look at any PRN given more than 50 percent of the time, she suggests. And review scenarios where a resident begins to receive a PRN med more frequently within a short period of time.

3. Consider these prescribing principles. If providers are going to administer sleep medications, they should follow some general guidelines, according to Tom Lynch, PharmD, in a presentation at the March 2008 annual American Medical Directors Association meeting. These include:

• Before prescribing, address environmental, medical, psychiatric, and medication causes of insomnia.

• Give the lowest effective dose (usually half the adult dose);

• Give for less than four weeks duration;

• Use intermittent dosing (every two to three nights);

• To discontinue, gradually taper the dose if the person has received prolonged or high doses.

4. Don't underestimate risks of OTC sleep aids. Many times, over-the-counter sleep aids can be more problematic and prone to adverse effects than prescription hypnotics, McSpadden says.

Key example: "Diphen- hydramine (Benadryl), which is the active ingredient in many OTC sleep aids and Tylenol PM, has anticholinergic side effects," paving the way for falls, confusion, delirium, constipation, and urinary retention, McSpadden cautions.

Also: Tolerance to the OTC medications containing antihistamines can develop after four days of continuous use, warned Lynch in his AMDA presentation.

MDS coding tip: The newer sleep medications like Ambien and Lunesta are coded as hypnotics at O4, says Christine Twombly, RN, a consultant with Reingruber & Company in St. Petersburg, Fla.

"You look for the drug's classification as a hypnotic to code it -- not its intended therapeutic use." Thus, "you wouldn't code an antihistamine given for sleep, for example."