Improving Medication Prescribing: Antibiotics and Antipsychotics

In the mainstream news lately, there have been quite a few headlines describing the urgent need to reduce inappropriate antipsychotic and antibiotic prescribing. Long-term care (LTC) providers have faced these two clinical challenges for years. However, with the topics of off-label antipsychotic use and antibiotic-resistant “superbugs” taking center stage in the public health forum, it is more important than ever for LTC professionals to develop better approaches for tackling these pressing concerns—that is the theme of this month’s issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC ).

A media spotlight has been cast on the problem of antibiotic resistance, with reports of patients being exposed to carbapenem-resistant Enterobacteriaceae (CRE) at the University of California at Los Angeles Medical Center. As thousands of nursing home residents transition in and out of hospitals on a daily basis, the importance of antibiotic stewardship cannot be overemphasized. Teena Chopra, MD, and Christopher Rivard, MPH, discuss the benefits of stewardship programs in LTC, outline the core elements of a good program, and offer their perspective on some of the most commonly reported barriers to program implementation. As a recent ALTC poll revealed, only 27% of readers reported that their facility has a stewardship program, with the remaining 73% reporting “no” or “not sure”. If you’re in the company of readers who do not have an antibiotic stewardship program, I strongly encourage you to work toward this goal for the benefit of your residents as well as the community at-large.

On March 2, 2015, the US Government Accountability Office (GAO) released an analysis of antipsychotic prescribing patterns in the United States according to 2012 data gleaned from Medicare Part D Prescription Drug Event claims and the Minimum Data Set. Although progress has been made in reducing antipsychotic use in nursing homes, the GAO identified an antipsychotic prescription in one-third of all long-stay nursing home residents with dementia who do not have a diagnosis of schizophrenia or bipolar disorder—the two FDA-approved indications for antipsychotics. This figure represents approximately 313,000 nursing home residents who are receiving a potentially inappropriate antipsychotic. The GAO report also noted concern about the excessive use of these medications in patients with dementia in assisted living and home settings.

There are many reasons why this harmful prescribing practice continues, including lack of education and low staffing levels, but it is the responsibility of clinicians to develop strategies that can further reduce the use of antipsychotics in older patients with dementia. Given the strong evidence of the harms associated with off-label antipsychotic use, inappropriate prescribing is now being factored into nursing home quality measures. In late February, the Centers for Medicare & Medicaid Services announced the addition of antipsychotic medication use in both short-stay and long-stay residents to the Five-Star Quality Rating System of the Nursing Home Compare website.

Reducing the use of antipsychotics in any setting cannot be achieved quickly or without an organized plan. Brent E. Salvig, PharmD, and colleagues describe the success of combined quality improvement efforts over a 2-year period to reduce as-needed antipsychotic use in a Veterans Affairs community living center. Their study revealed a significant reduction in the number of as-needed antipsychotic doses administered to residents with behavioral and psychological symptoms of dementia (BPSD), from 20% of residents in 2011 to 10% of residents in 2013. The authors attributed this outcome to a number of factors, including an interdisciplinary approach to care, transition from a paper records system to electronic documentation, and formal education of staff about use of nonpharmacological strategies as first-line management of BPSD.

Also in this issue, you will find the next article in our nutrition series. As poor nutrition has been closely tied to the leading causes of death and disability in the United States, Mary Litchford, PhD, RD, walks through the evidence supporting the role of nutrition in eight common geriatric syndromes, including cognitive impairment.

We hope that you find the articles in this month’s issue helpful in overcoming these two clinical challenges. Please send your feedback to our Managing Editor, Allison Musante, at amusante@hmpcommunications.com.

As always, thank you for reading!