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Improving Antipsychotic Use in a Veterans Affairs Community Living Center
Affiliations: 1 Tennessee Valley Healthcare System, Murfreesboro, TN 2 Lipscomb University College of Pharmacy, Nashville, TN 3 Tennessee Valley Healthcare System, Nashville, TN 4 Tennessee State University, Nashville, TN
Abstract: The purpose of this study was to determine the prevalence of antipsychotic use in a Veterans Affairs long-term care community living center and assess trends in administration and documentation of as-needed antipsychotic therapy over a 2-year period during which quality improvement measures were implemented. The authors observed that as a result of quality improvement initiatives and use of an electronic system to document behaviors, the percentage of as-needed antipsychotic prescriptions with documented behavioral symptoms increased in this period. The documentation of nonpharmacologic interventions also increased significantly.
Key words: Antipsychotics, agitation, dementia, veterans.
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Behavioral and psychological symptoms of dementia (BPSD), which include agitation, anxiety, delirium, and wandering, are common and are not often well documented in the medical record.1 These symptoms may pose a danger to the patient or caregiver and can interfere with delivering optimal patient care. Because management of BPSD can be challenging, many elderly patients with dementia are placed in nursing facilities.2 Patient-specific treatment plans to address management of BPSD in these settings should include appropriate documentation of behavioral symptoms, evaluation of potential and existing underlying causes, and a determination as to whether any current treatments are effective.3,4 First-line management of BPSD consists of nonpharmacologic interventions that are tailored to the individual patient, such as modification of environment or daily activities; these interventions should be attempted before any medication is prescribed.3
There are currently no pharmacologic therapies approved by the US Food and Drug Administration (FDA) for the treatment of BPSD. The American Psychiatric Association (APA) recommends the use of antipsychotic medications for BPSD only when nonpharmacologic methods fall short, or when the ongoing behavior has become potentially harmful to the patient or caregiver.5 Negative outcomes associated with both typical and atypical antipsychotics in dementia are well documented in literature.6,7 In 2005, the FDA issued a boxed warning about increased risk of mortality with the off-label use of atypical antipsychotic medications in elderly patients with dementia. This warning was expanded in 2008 to include conventional (ie, typical) antipsychotics.8
There are also limited data demonstrating comparative effectiveness of antipsychotics in patients with BPSD.5 In the CATIE-AD trial (Clinical Antipsychotic Trials of Intervention Effectiveness-Alzheimer’s Dementia) which compared atypical antipsychotics in patients with Alzheimer’s disease (AD)-related psychosis, aggression, or agitation, no significant difference was found between olanzapine, quetiapine, and risperidone with regard to treatment discontinuation or to improvement in Clinical Global Impression of Change scores at 12 weeks. However, the authors concluded that the adverse effects of atypical antipsychotics in patients with AD offset any advantages of the treatment.9
The APA supports the prescribing of antipsychotics in scheduled doses as standard clinical practice, rather than as-needed dosing, unless as-needed dosing is required (eg, if symptoms occur infrequently).5 There is some evidence supporting the use of scheduled antipsychotic medications for BPSD,9-11 however, no clinical trials have supported the use of as-needed antipsychotics. This has led some researchers to investigate ways to decrease as-needed antipsychotic use. Thapa and colleagues12 concluded that by changing an institutional policy to allow only “now” (ie, STAT) orders for unscheduled antipsychotic medications instead of as-needed orders, the number of as-needed doses decreased by 50% with no increase in reported BPSD.
Antipsychotic use in patients with dementia has been evaluated in different settings within the Veterans Affairs (VA) healthcare system. A study of veterans aged 60 and older with newly diagnosed dementia found that of patients who had been prescribed an antipsychotic between 2001 and 2004, 31% had no documented symptoms.13 A cross-sectional study of veterans aged 65 and older residing for at least 90 days in a VA community living center (CLC) during January 2004 to June 2005 found that 25.7% of 3692 residents received an antipsychotic, of which 40.7% had no evidence-based indication of psychosis warranting its use.14 Residents were more likely to have been prescribed an antipsychotic if they exhibited aggressive behavior, resided in an AD/dementia special care unit, were younger (<75 years), or were taking concomitant medications including other psychoactive drugs.14 Another study found that, in 2007, 60.2% of all veterans who received at least one outpatient prescription for an antipsychotic medication within the VA healthcare system did not have an FDA-approved indication of schizophrenia or bipolar disorder, and 20% of the 54,346 patients with organic brain syndrome or AD had been prescribed an antipsychotic.15 Given the finding that daily doses of several atypical antipsychotics over a short term are associated with increased mortality among elderly male veterans with dementia,16 their fairly commonplace off-label use in this population is of concern.
Standard federal guidelines are in place to protect nursing home residents from receiving unnecessary antipsychotic medications.17 Requirements for psychotropic drug use set forth by the Centers for Medicare & Medicaid Services include appropriate patient assessment and documentation, presence of a care development plan, and occurrence of planned interventions.18 Several studies have shown that educational interventions and regulatory guidelines directed at reducing antipsychotic use in nursing homes are effective,19-23 and evidence is also available to guide practitioners as to which patients may be the best candidates for withdrawal of antipsychotic medications.24 However, a 2012 report by the Office of the Inspector General stated that 99% of sampled nursing records failed to meet at least one of these requirements for resident assessment and care plans, with 18% of records showing no documentation for planned use of antipsychotics.18
The purposes of this quality improvement study were to determine the prevalence of antipsychotic use in a VA long-term care CLC, to assess the administration and documentation of as-needed antipsychotic therapy, and to evaluate trends in antipsychotic use at the facility over a 2-year period. The CLC implemented several quality improvement initiatives between 2011 and 2013. In June 2011, the long-term care units transitioned from a paper documentation system to an electronic system called CareTracker® (Cerner Extended Care). This change allowed nurses to efficiently document resident behaviors and any nonpharmacologic interventions that were attempted. Clinicians could then access these data to make informed clinical decisions regarding resident care. An interdisciplinary approach was taken to improve the use of nonpharmacologic interventions and ultimately reduce the administration of as-needed antipsychotics. Formal education on the effective use of nonpharmacologic interventions was provided to the staff by several members of an interdisciplinary team.
Study Design
This was a retrospective, single-center study conducted within the CLC units at a VA medical center. The facility was a 238-bed CLC with seven separate units, four of which had secure access. Data were collected over a 2-month period during each of three consecutive years. Residents in the VA CLC units any time during January and/or February of 2011, 2012, or 2013 were included in the analysis if they had been prescribed a scheduled or as-needed order for a first- or second-generation antipsychotic medication. The primary outcome measurement was the average number of as-needed antipsychotic doses administered per resident for all residents who had been prescribed an as-needed antipsychotic in 2011 versus the 2012 and 2013 time frames during which quality improvement measures had been implemented. Secondary measures of interest included the average number of as-needed antipsychotic doses administered per CLC resident per time frame, as well as the percentage of residents receiving a scheduled versus as-needed antipsychotic, and their corresponding diagnoses. Additional recordings included the percentage of administered as-needed antipsychotics that had accompanying documentation of behavioral symptoms and nonpharmacologic interventions, the percentage of residents receiving psychoactive medications for other conditions, and the average daily haloperidol dose equivalent that was prescribed for patients on scheduled doses of antipsychotics. All scheduled antipsychotic orders were evaluated on the last day of each time frame. The total daily dose of scheduled antipsychotic(s) was converted to an equivalent dose of haloperidol for each individual patient according to available equivalency estimates.25-27 This was done to be able to see the average antipsychotic scheduled doses between the three time frames which would identify if there had been an increase or decrease in the scheduled doses accompanied by the anticipated decrease in the use of as-needed doses.
Documentation was defined as one of the following: written documentation on the psychotropic flow sheet describing behaviors and/or nonpharmacologic interventions on the date that an as-needed antipsychotic was administered; a progress note documented in VistA Computerized Patient Record System describing the behaviors and/or nonpharmacologic interventions within the 8 hours before or after as-needed antipsychotic administration; or logging of behaviors and/or nonpharmacologic interventions in CareTracker® 8 hours before or after as-needed antipsychotic administration.
Results
The study sample included 220, 209, and 157 CLC residents, respectively, during 2011, 2012, and 2013. Residents were predominantly male (>93%) and white (67%), with a mean age of 70 years. There were no significant differences in resident characteristics from year to year. The findings are outlined below.
Total Antipsychotic Use
Antipsychotic medications recorded throughout the 2-year period are provided in Table 1 and Table 2. Of 220 residents, 111 (50.5%) had been prescribed an antipsychotic in 2011. This number decreased to 77 of 209 residents (36.8%) in 2012 (P=.005) and 55 of 157 residents (35%) in 2013 (P=.0032). Residents with a schizophrenic disorder who received an antipsychotic showed a nonsignificant decrease from 29% in 2011 to 22% in 2013 (P=.16), and residents with dementia showed a nonsignificant decrease from 16% in 2011 to 9% in 2013 (P=.06). A small percentage of residents (3.8%–5.5%) received antipsychotic medication for another condition/s over the three time points examined. The average daily haloperidol dose equivalent for residents receiving a scheduled antipsychotic decreased from 11 mg/day (±13.5) in 2011, to 8.5 mg/day (±10.4) in 2012 (P=.2), and 7.2 mg/day (±7.2) in 2013 (P=.06).
As-Needed Antipsychotic Use
The number of CLC residents with a prescription for an as-needed antipsychotic significantly decreased from 76 (34.5%) in 2011 to 44 (21.1%) in 2012 (P=.003), and then to 33 (21.0%) in 2013 (P=.006). The number of CLC residents actually receiving an as-needed antipsychotic dose also significantly decreased from 45 (20.5%) in 2011 to 16 (10.2%) in 2013 (P=.008). A total of 343 as-needed antipsychotic doses were administered during January and February of 2011 and this decreased to 156 doses during the same time frame in 2013. There was no difference in average number of as-needed doses administered per resident with a as-needed order, the primary outcome. Many residents with an order for an as-needed antipsychotic received no doses, and a few residents received more than 10 doses during each year of the study (2011, n=8; 2012, n=6; 2013, n=4). When evaluating the average number of as-needed doses administered per resident during each study year, a significant decrease was noted (2011, 1.56; 2012, 1.05; P=.002; and 2013, 0.99; P=.002).
Behavioral and Nonpharmacologic Interventions
At each of the three time points studied, a significant increase from baseline was seen in documentation of the behaviors and nonpharmacologic interventions that corresponded to administered as-needed doses. The percentage of as-needed doses with documented behavior symptoms increased from 39.9% in 2011 to 51.1% in 2012 (P=.01) and to 74.4% by 2013 (P=.0001). Documentation of nonpharmacologic interventions attempted prior to administration of an as-needed dose increased from 30.3% in 2011 to 47.0% in 2012 (P=.001) and to 71.2% in 2013 (P=.0001).
Use of Concurrent Psychoactive Medication
Most residents received concurrent psychoactive medications. There was a trend toward reduction in the use of benzodiazepines, which decreased from 35.1% in 2011 to 25.5% in 2013, but was not a statistically significant change (P=.2). The use of concurrent antidepressants was common but not significantly different in 2011 versus 2013 (P=.6). The use of sedative/hypnotic agents was low, with no residents in 2013 receiving any concurrent with an antipsychotic.
Discussion
This observational study found a reduction in the administration of antipsychotic medications in a VA CLC over a 2-year period. Although change in the primary end point (ie, average number of as-needed antipsychotic doses administered per resident prescribed an antipsychotic in 2011 vs 2012 and 2013) was not significant, the number of as-needed antipsychotic doses administered to each resident showed a statistically significant decrease from 2011 to 2012 and 2013. Meanwhile, the percentage of documented nonpharmacologic interventions and behaviors that corresponded to as-needed antipsychotic doses increased. We did not see an increase in the concurrent use of anxiolytics or sedative/hypnotic agents. Antidepressant use was common in residents prescribed an antipsychotic as has been previously reported among VA CLC residents.28 Additional evaluation would be necessary to determine whether changes in antipsychotic prescribing patterns impacted psychoactive medication use in residents not prescribed an antipsychotic at our facility. One hypothesis would be that the nurses were using and also documenting more nonpharmacological interventions without having to utilize the as-needed antipsychotics ordered. However, we did not measure the overall documentation and use of nonpharmacological interventions that were not associated with the administration of an as-needed antipsychotic.
The results of this study cannot be attributed to one intervention, but to several quality improvement initiatives that were implemented at the study facility between 2011 and 2013. In June 2011, the long-term care units transitioned from a paper documentation system to an electronic system that allowed nurses to efficiently document resident behaviors and attempted interventions and provided these data to the clinicians managing their care. An interdisciplinary approach was used to improve the use of nonpharmacologic interventions and to ultimately reduce the administration of as-needed antipsychotics. Formal education on the effective use of nonpharmacologic interventions as first-line management was provided by several members of an interdisciplinary team. More recently, the VA implemented an initiative known as STAR-VA, which includes an individualized behavioral intervention plan, that should continue to reinforce the importance of nonpharmacologic interventions, and accompanying documentation, for BPSD.29 Our study collected data prior to its implementation, but we anticipate continued reductions in antipsychotic administration with its utilization.
There are several limitations of this study. Diagnoses were identified via ICD-9 codes and were manually verified, but it could not always be determined which condition an antipsychotic medication was intended to treat because many residents had multiple psychiatric diagnoses. The number of admissions to the CLC decreased in 2012 and again in 2013 as the facility moved toward private rooms and consolidation of the short-term rehabilitation unit into other existing units. We did not identify nurse-to-resident staffing ratios, which may have impacted the utilization and documentation of nonpharmacologic interventions being evaluated. However, most of the reductions in antipsychotic use and improvements in documentation showed significance in 2012, prior to the larger reduction in resident population that occurred in 2013. A few CLC residents received substantially more as-needed doses of antipsychotics and the majority who were prescribed an antipsychotic had documented schizophrenic disorders. These are important findings to guide future quality improvement initiatives and development of resident-specific treatments at our facility. We did not identify whether the overall decrease in antipsychotic use was related to residents being discharged who had been prescribed antipsychotics, or to discontinuation of antipsychotics in residents who remained in the CLC. Concurrent psychoactive medication use was common, but we did not evaluate psychoactive use in residents who were not prescribed antipsychotics. It is possible there may have been an increase in use of other psychoactive agents when antipsychotics were not administered or discontinued.
To our knowledge, an observational study of this nature that highlights quality improvement initiatives for the use of as-needed antipsychotics at a VA CLC, has not been previously published. There are studies that report the prevalence and risk factors of antipsychotic use in veterans. Of VA patients who received an antipsychotic in fiscal year 2007, Leslie and colleagues15 found that individuals with a diagnosis of psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Gellad and colleagues14 found that 25.7% of VA CLC residents aged 65 and older received an antipsychotic between January 2004 and June 2005, which was fewer than our current findings. Their study also identified that residents with aggressive behaviors, polypharmacy, those residing in AD/dementia special care units, and users of antidepressants, anxiolytic/hypnotics, or drugs for dementia were more likely to receive antipsychotics. Our review did not exclude residents under age 65, which may partially explain the higher rate of antipsychotic use. We found a higher proportion of residents prescribed an antipsychotic for schizophrenia (22.3%-29.1%) than what was previously reported as the prevalence of schizophrenia diagnosis (12.2%) in a review of all VA nursing homes.30
Conclusion
Quality improvement initiatives implemented at our facility and the use of an electronic system to document behaviors and interventions were accompanied by decreases in the use of antipsychotics and administration of as-needed antipsychotic doses, as well as an increase in the documentation of behaviors and attempted nonpharmacologic interventions. Further research would be needed in order to identify and differentiate the specific factors that contributed to the overall improvement.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Brent E. Salvig, PharmD, VA Tennessee Valley Healthcare System, 3400 Lebanon Pike, Murfreesboro, TN 37129
