Federal Effort Aims to Trim Antipsychotic Drug Use in Facilities

Abstract

Federal officials are asking physicians to try to reduce the use of antipsychotic medications among nursing home residents by 15% by the end of this year. Physicians at nursing homes should instead consider nonpharmacologic options such as increased exercise and time outdoors, better management of acute and chronic pain, and consistent assignment of the same staff members to care for nursing home residents, according to the Centers for Medicare & Medicaid Services. Dr. Shari Ling, deputy chief medical officer of CMS, said that health officials are particularly concerned about the use of antipsychotic medications by individuals with dementia. Since 2008, the Food and Drug Administration has advised physicians that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients who are treated for dementia-related psychosis. Antipsychotics are not indicated for the treatment of dementia-related psychosis, according to the agency. Despite those warnings, dementia patients are continuing to receive the drugs. In 2010, about 39% of nursing home patients with signs of dementia received antipsychotic drugs at some point, according to a CMS nursing home report. Those patients did not have a diagnosis of psychosis. Also in 2010, more than 17% of nursing home patients received daily doses of antipsychotics that exceeded recommended levels, according to CMS data. AMDA leaders have met with Dr. Alice Bonner, CMS's director of the Division of Nursing Homes, and the association has set up a cross-committee work group on this topic. AMDA President Dr. Matthew Wayne, CMD, sent out a letter to medical directors last month on the topic (www.amda.com/advocacy/antipsychotic_msg.pdf). “We are asking you, as the medical director of your facility, to join with AMDA and CMS, in the nationwide effort to reduce the unnecessary use of antipsychotic agents by refocusing the interdisciplinary team on a better understanding of the root cause of dementia related behaviors,” Dr. Wayne wrote. He added that as part of a facility's Quality Assessment and Assurance Committee, medical directors often ask the following questions. ▸How many residents in the facility with BPSD receive antipsychotic medications and how is the use monitored?▸What is the process in the facility to initiate the use of these medications?▸What is the process for gradual dose reduction and discontinuation of these medications?▸How is the resident/family/or legal representative informed of the risks and benefits of the use of these medications?▸How are these discussions documented? Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association (AHCA), said, “We believe these antipsychotic medications are overprescribed and we must do more to reduce the use of these drugs among people living with dementia.” AHCA has already called on its member facilities to reduce the use of antipsychotic medications by using alternative therapies, such as the ones recommended by the CMS, he said. For instance, they are promoting the use of “consistent assignment,” where the same staff members are taking care of the same residents on a regular basis. This way, the staff becomes familiar with the residents’ behaviors and won't unintentionally trigger outbursts that might lead to the use of these medications, he said. It can be a fine line to determine the appropriate use of antipsychotic drugs, said Dr. Cheryl Phillips, senior vice president for public policy and advocacy at LeadingAge and an AMDA past president. Simply using the drugs off-label doesn't make it an inappropriate use, she said. For instance, there may be cases in which it is appropriate to use antipsychotics on a short-term basis in dementia patients. However, it's essential that the use be closely monitored and that patients be put on the lowest dose possible for the shortest period of time, Dr. Phillips said. The push to decrease antipsychotic drug use in nursing home residents is part of a larger initiative to improve dementia care in long-term care facilities. The Partnership to Improve Dementia Care, which was announced on May 30, includes federal and state health agencies, nursing home facilities, physicians and other providers, and patient advocates. As part of the initiative, CMS officials will train nursing home staff members on person-centered care, abuse prevention, and quality of care improvement. CMS is also conducting research in about 20 nursing homes across the country to better understand the decision making involved in whether to prescribed antipsychotic drugs to residents. Starting in July, CMS will publish data on antipsychotic drug use on the Nursing Home Compare website. Dr. Ling said that CMS officials aim to reduce the use of antipsychotic medications in other care settings as well.