AGS Applauds New Measures to Reduce Inappropriate Use of Antipsychotics

Late last month, the Centers for Medicare & Medicaid Services (CMS) announced a major initiative to reduce the inappropriate prescribing of antipsychotic drugs for long-term care residents.¹ The US Food and Drug Administration has warned that antipsychotics may significantly increase risks of death in older adults with dementia,² yet as many as 40% of nursing home residents with symptoms of dementia but no diagnosis of psychosis are treated with these drugs.¹ Many of these residents have one or more noncognitive symptoms of dementia, such as wandering, agitation, or aggression, but these medications are not indicated for such symptoms.³ CMS’ new initiative, the Partnership to Improve Dementia Care, aims to reduce inappropriate prescribing of antipsychotics in long-term care by 15% by the end of 2012, and it will collaborate with federal and state agencies, long-term care facilities, and advocacy organizations to achieve this objective.¹ The American Geriatrics Society (AGS) applauds CMS’ initiative to reduce the inappropriate use of antipsychotics.

Among other things, CMS’ new initiative will promote nonpharmacological treatments for long-term care residents with noncognitive symptoms of dementia. The AGS, which has long been committed to improving psychopharmacological care for older adults, dedicated a session to this subject during its recent annual scientific meeting. The session “Best Practices to Manage Behavioral Manifestations of Dementia: Addressing the Overuse of Antipsychotics” included four expert lectures that focused on alternatives to antipsychotics in the management of dementia-related behavioral symptoms.

Marie-Luz Villa, MD, associate professor of medicine, University of Washington, Seattle, moderated the session and delivered one of the lectures, “How Do I Deal with Calls from Overwhelmed Nursing Staff Demanding Action?” Among other things, Villa described hypothetical cases that illustrated how nursing facility staff can better care for challenging residents with dementia. One case scenario she outlined involved an 89-year-old Hispanic widow who had hypertension and dementia. In the middle of a busy night, this resident called out to staff and appeared to believe that she could see dead people. While harried staffers might simply consider administering resperidone, Villa explained that the appropriate response would be to evaluate the resident for any emerging health problems and adverse drug effects and address any such issues first. As for the resident seeing ghosts, Villa added that staff should not assume this is an indication of psychosis because seeing a dead loved one is within cultural norms in Hispanic and other cultures.

There are a number of helpful approaches healthcare professionals can take with a resident who has behavioral symptoms of dementia, noted Lori A. Daiello, Pharm D, BCCPP, research scientist, Alzheimer’s Disease and Memory Disorders Center, Rhode Island Hospital, in the second lecture, “Alternatives to Antipsychotic Medications for Behaviors Associated with Dementia.” To start, healthcare providers should evaluate the resident’s medication regimen to determine whether it is appropriate, and, if not, to adjust it accordingly. If that doesn’t suffice, then staff might consider medication, she explained. After providing a brief overview of the safety and efficacy of pharmacologic alternatives to antipsychotic drugs, Daiello noted that the approach to treatment must be individualized and informed by the predominant target symptom or symptoms and comorbid medical illness. Simply avoiding medications that may be harmful, however, doesn’t guarantee that residents receive high-quality care, Daiello emphasized. To do that, long-term care facilities may need to enact “systematic culture change” to ensure that residents receive symptom relief without significant side effects.

In the third lecture, “Non-Drug Aids to Symptom and Behavior Problems Using Complementary and Alternative Medicine,” Lisa Meserole, ND, of Seattle, WA, described numerous nonpharmaceutical approaches to addressing behavioral symptoms of dementia that can help effect just such a culture change. Soothing music; calming teas and fragrances, such as lavender and rosemary; sufficient sunlight or full-spectrum light; and exercise can all help ease agitation and anxiety, she explained. Water therapy—consisting of a warm bath, foot bath, or simply running a resident’s hands under warm tap water—can also help ease these symptoms, she added. Just as important as trying such approaches is determining whether what may appear to be symptoms of agitation are, in fact, symptoms of something else, such as fear, isolation, boredom, physical discomfort, or fatigue, which need to be resolved in other ways, noted Meserole.

In the last of the four lectures, “Communication Techniques for Dementia Care Training in Home and Institutional Long-Term Care Settings,” Lené Levy-Storms, PhD, MPH, Luskin School of Public Affairs, Geffen School of Medicine at UCLA, and Borun Center for Gerontological Research, offered insights into and advice for improving communication between long-term care staff and vulnerable residents. Levy-Storms and Susan Kohler, MS, CCC-SLP, have developed an interactive communication training program, “Get Connected,” to improve the quality of communication between nursing aides and vulnerable residents. The interactive program is based on the techniques outlined in Kohler’s book, How to Communicate with Alzheimer’s, and in an accompanying DVD. Kohler uses the combination face-to-face and DVD program to teach staff communication strategies for attaining “emotional connections” when speaking with residents. These “emotional connection” strategies aim to get residents’ attention, encourage listening, promote speaking calmly even in difficult circumstances, use “yes” or “no” questions to facilitate responses, help orient and reorient the resident to the conversation, use touch, and avoid arguments, Levy-Storms explained.

The slides for each of these four lectures have been posted on the AGS Website at https://bit.ly/LfF2Wg. If you weren’t able to attend this important session, or attended but would like a refresher, we encourage you to take a look. The May meeting also included a session offering an overview of the 2012 AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which was published in the Journal of the American Geriatrics Society in March and is an invaluable source of information about safe prescribing for older people. The criteria and a wealth of information for clinicians and patients alike are also available on the AGS Website at https://bit.ly/MdMM9e. If you haven’t already, we hope you’ll take a look at these as well. 

References

1. US Centers for Medicare & Medicaid Services. CMS announces partnership to improve dementia care in nursing homes [news release]. May 30, 2011. https://go.cms.gov/LB5J6j. Accessed June 7, 2012.

2. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012;344:e977.

3. Liperoti R, Pedone C, Corsonello A. Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Curr Neuropharmacol. 2008;6(2):117-124.