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Quality of Care:

Steer Clear of Shortfalls in Managing Antipsychotic Therapy

Published on Wed Mar 28, 2012

Heed pointers from 2 MDs.

Louis Mudannayake, MD, CMD, tells MDS Alert that the facility where he's medical director has a program that "involves the interdisciplinary team gathering data useful in defining the risk versus benefit of using antipsychotic medications."

Mudannayake discussed the facility's program in a session, "Less is More: An Interdisciplinary Team (IDT) Approach to Reduction and Monitoring of Antipsychotics in the Skilled Nursing Facility Setting," at the March 2011 annual American Medical Directors Association meeting.

Mudannayake's session handout notes: "There is not an anti-aggressional or anti-adverse behavior drug that is not off-label or investigational. 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," his handout states.

Also: "You have to distinguish a harmful delusion from a harmless one," Mudannayake says. "I always talk about that when I give my presentation on antipsychotics at annual AMDA meetings."

Example: Mudannayake recounts admitting one patient in a straitjacket to the SNF 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 says. "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."

The facility educates staff about the program about every six months, Mudannayake says. "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," he adds. "You need staff buy-in...," he emphasizes. And "you have to do the monitoring, including biochemical monitoring." (See page 27 of this issue.) "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 cautions.

Outcomes: Mudannayake relays that the 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 adds. "At my SNF, we haven't had any increase in psychiatric hospitalizations or costs of staffing due to using less antipsychotics," Mudannayake says.

Trade Group Quality Initiative Includes Antipsychotics

The American Health Care Association/National Center for Assisted Living's new Quality Initiative has a goal to "reduce the off-label use of antipsychotic drugs by 15 percent" by Dec. 31, 2012, according to a press release from the trade group.

"We picked this goal because there is a significant number of individuals with dementia in nursing homes who are on antipsychotic medications for behaviors that are normal and predictable for those with dementia," David Gifford, MD, MPH, senior VP of quality and regulatory affairs for AHCA/NCAL, tells MDS Alert.

AHCA/NCAL sees the goal as "fitting in" with the Quality Initiative's other goals "for [improving] staffing stability, customer satisfaction, and reducing hospitalization," Gifford says. "The medications can be associated with worse outcomes and hospitalizations," he adds. "One of our strategies for addressing the goal [for antipsychotics] is to get more stable staff and consistent assignments," Gifford relays. "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 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," Gifford explains. "If someone is hallucinating, they may need antipsychotics," he says. But "what is a person who isn't familiar with where they are or what's going on -- and sees a strange nursing aid approach them to help them get dressed likely to do? Scream and hit the person. And those two things probably get you a medication." Gifford points out that "this isn't unique to the nursing home. We also see it in the home healthcare and a number of other settings," he adds.

"Some of it 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," Gifford says. "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," says Gifford. "A lot of it is subconscious behavior that we all learn by being around someone," he adds. "The individual with dementia also probably develops some sense of familiarity" with the CNAs.

Watch out: "CMS has indicated that they intend to increase focus on reviewing use of antipsychotic drugs in nursing facilities to identify whether that use is appropriate," states AHCA in a summary of its antipsychotic goal measurement. "You can expect that in the coming year and beyond, this will be an area you will see emphasized in survey and enforcement activity," the summary cautions.

Update: At press time, CMS had posted an online notice that "on March 29," the agency "will launch a new initiative aimed at improving behavioral health and safeguarding nursing home residents from unnecessary antipsychotic drug use. As part of the initiative, CMS is developing a national action plan that will use a multidimensional approach including public reporting, raising public awareness, regulatory oversight, technical assistance/training and research. The action plan will be targeted at enhancing person-centered care for nursing home residents, particularly those with dementia-related behaviors," CMS states.

A "video streaming event" on March 29 "will provide an overview of the national initiative, resources for technical assistance, and plans for upcoming educational offerings on this topic," CMS states. The "program will be available for viewing up to one year following March 29, 2012, at http://surveyortraining.cms.hhs.gov."

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