Addressing Antipsychotic Use in Assisted Living Residents with Dementia.

Abstract

The inappropriate and excessive use of antipsychotic medications to manage the behavioral and psychological symptoms of dementia1 is a pressing national concern. These symptoms can be acutely distressing for individuals and those around them, but managing them with off-label use of antipsychotic medications carries a high risk of serious or life-threatening adverse effects, as clearly indicated in “black box” warnings that the U.S. Food and Drug Administration has issued. Such medications can also negatively affect quality of life and functional independence without addressing the underlying causes of the symptoms. The National Partnership to Improve Dementia Care in Nursing Homes reported that, in 2011, as many as 24% of nursing home residents with dementia were prescribed antipsychotics.2 Galvanized by the mounting evidence, the Centers for Medicare and Medicaid Services (CMS) launched a national initiative that reduced antipsychotic medication use in nursing homes more than 20% by December 2014. In contrast, there is a conspicuous absence of visible action regarding antipsychotic use in assisted living, which provides care for almost 750,000 older adults3 (equivalent to half the size of the nursing home population)—an oversight noted in a recent Government Accountability Office (GAO) Report.4 As many as 90% of individuals in assisted living residences (ALRs) have some degree of age-related cognitive impairment, and more than 40% have moderate or severe cognitive impairment, but only a minority have severe mental illness.5, 6 Together, these statistics suggest that the majority of antipsychotic use in ALRs is off-label and therefore as inappropriate and dangerous as it is in nursing homes. Analysis of data from the first-ever national survey on ALRs found that 57% of residents with behavioral symptoms were prescribed a medication for their behaviors—22% of all ALR residents, similar to the proportion in nursing homes; the data also showed that 69% of ALRs regularly administered medications to control resident behaviors.6 In addition to concern regarding the proportion of ALRs in which these medications are routinely administered, the staffing configuration in assisted living complicates administration. ALRs are highly diverse, but in general are designed to provide 24-hour supervision, support with activities of daily living (most notably medication management), and at least two meals per day in a homelike environment that promotes dignity, autonomy, and choice.7 ALRs are not required to provide nursing services, and 46% do not have a registered or licensed practical nurse on staff. Furthermore, 21% of ALRs do not require staff to receive specialized trained before administering medications,6 even though untrained staff are twice as likely to commit medication errors as licensed nurses.8 Thus, in many ALRs, untrained staff are responsible for deciding when to administer “as needed” antipsychotic medications.9 Diversity among ALRs reflects, in part, that, unlike nursing homes, they are state as opposed to nationally regulated. In nursing homes, CMS has collaborated with state departments of health to achieve significant reductions in antipsychotic use through national advocacy and regulatory mechanisms. In ALRs, efforts must instead focus on ensuring that changes are promoted at the state and organizational level, such as through initiatives of the American Health Care Association's National Center for Assisted Living, which promoted efforts to reduce the off-label use of antipsychotics in ALRs by 15% by March 2015.10 There is also need to improve the use of nonpharmacological techniques to manage behavioral symptoms of dementia in ALRs through better staff training, support, management, and accountability. Such interventions—which leading organizations including the National Center for Assisted Living, the Alzheimer's Association, and the American Medical Directors Association's Society for Post-Acute and Long-Term Care Medicine have recommended—include environmental modifications, psychosocial and group activities, sensory interventions, and individualized care approaches.11 There is also a clear need for training (particularly for staff designated to handle medications) on the use and side effects of antipsychotics, not just on their proper administration. As the assisted living sector continues to evolve to meet the needs of the aging population, it is imperative to combat the problem of inappropriate antipsychotic medication use in these settings, informed by the successes achieved in nursing homes. Better evidence is needed regarding current medication practices and use of alternative interventions to inform policy and practice change regarding the treatment of behavioral symptoms of dementia in ALRs and to improve related quality of care and quality of life. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Zimmerman, Scales, Wiggins, Cohen, Sloane. Preparation of manuscript: Zimmerman, Scales, Wiggins, Cohen, Sloane. Sponsor's Role: Not applicable.