The Rate of Use of Acetylcholinesterase Inhibitors and/or the NMDA Antagonist Memantine in Long-Term Care Residents With Dementia at Risk for BPSD

Most residents of long-term care facilities (LTCFs; eg, those residing in skilled nursing facilities and assisted living memory care) have neurocognitive impairment, and most of these individuals have neurodegenerative disease.¹ According to published studies, essentially all residents with neurocognitive impairment qualify for an axis I diagnosis during their residence.^1-4 Further, most residents meet US Centers for Medicare & Medicaid Services (CMS) criteria for severe mental conditions during their residency.⁴

The current regulatory standard of care for these residents requires behavioral health clinicians to undertake care of these conditions. However, only 5% of these individuals have had a preexisting serious mental illness prior to the onset of their neurologic disorders.⁵ Yet within the past 10 years, approximately 25% of these residents were prescribed antipsychotic medication on a scheduled basis. Under increased CMS scrutiny, over a 5-year period, the rate of antipsychotic use in LTCFs decreased to 14.5% for exempted diagnoses.⁶ For all diagnoses, the rate has decreased only 1.5%.6 Despite CMS initiatives to further improve LTCF behavioral health clinical outcomes, additional progress to decrease antipsychotic use has not materialized. During this later period, the diagnosis of schizophrenia in LTCFs has increased by 200%, causing concern and increased CMS enforcement.⁷ 

Beginning in 2007, studies have reported that certain neuropharmaceuticals used for cognitive support also have a beneficial effect on the behavioral and psychological symptoms of dementia (BPSD). As this literature has evolved, it is consistently supportive of the positive effects of three classes of medication, individually or preferably in combination: acetylcholinesterase inhibitors (AChEIs), the N-Methyl-D-aspartate (NMDA) receptor antagonist memantine, and various selective serotonin reuptake inhibitors (SSRIs).^8-10 According to Atri and colleagues, the use of an AChEI and memantine in combination results in overall clinical benefits that are additive compared with individual monotherapies.² Preclinical evidence suggests that the mechanisms of action of AChEIs and memantine are complementary, and the preponderance of clinical evidence indicates that memantine-AChEI combination therapy is superior to monotherapy with either drug or drug class.^2,3,8,9 In a study, the combination of memantine and donepezil outperformed the placebo group and the monotherapy groups of each medication at study end point for cognition, function, behavior, and global clinical status. The group that received memantine-donepezil combination treatment was the only group that did not demonstrate a significant baseline-to-end point decline.² 

The authors recently published a study quantifying the BPSD impact of using these agents as a foundational element in a neurologically focused clinical paradigm (“neurology forward”) across the entire population of LTCF residents with Alzeimer's disease and related dementias (ADRD) in multiple buildings.⁷ This study demonstrated a 68% reduction in antipsychotic use, representing a material decrease in BPSD severity, with this neurology-forward approach. These data are the first published to quantify improvement in this specific, desirable, and easily measurable clinical outcome. By addressing the residents’ primary neurologic disorders first, their neuropsychiatric clinical status was mitigated. 

Informal surveys among LTCF medical directors coupled with our significant direct practice experience indicated that LTCFs generally have not adopted this approach to the care of their patients with ADRD. In an initial attempt to further define this clinical opportunity, we studied the neuropharmacology of 121 LTCF residents in 4 buildings. These are well established community skilled nursing facilities in Ohio, Michigan, and Indiana, which were new to our practice. Because SSRIs are not primary neurologic medications, we elected to exclude this class of medication from the scope of this study. 

The authors, from the Steven L. Posar, MD, Eldercare Foundation, worked with the Foundation’s clinical affiliate, GuideStar Eldercare. Four buildings that were new to GuideStar Eldercare services were selected for this study. An audit of all residents with an ADRD-compatible diagnosis was completed, either through permitted clinical chart access or blinded pharmacy reports. For all LTCF residents with an established ADRD diagnosis, we recorded the use of any AChEI and/or memantine use prior to initiation of our services. We did not capture any data indicating the rationale for not using these medications.

Of 122 total LTCF residents in 4 skilled nursing facilities, 27 were receiving any BPSD-specific neurologic medications (22%), 6 (5%) were optimally treated with the combination of the 2 classes of medication, 17 (14%) were receiving AChEIs only, 4 (3%) were receiving memantine only, and 95 (78%) were not receiving any medications. A review of medication usage data by building is shown in the Table. 

Table. Medication Usage Among Residents (N=121) With ADRD Across Four Buildings

Abbreviation: ADRD, Alzheimer’s disease and related dementias.

The BPSD-related clinical neurology of LTCF residents with ADRD can be daunting. Such secondary conditions as non-convulsive seizure, pseudobulbar affect, obstructive sleep apnea, and REM-based sleep disorders, and various forms of agitation can present both diagnostic and therapeutic challenges to even experienced primary care and psychiatric clinicians. This difficulty is exacerbated by the near total absence of bedside neurologic consultation in LTCFs. However, Alzheimer’s disease and vascular, mixed, Parkinson, and Lewy body–related dementias comprise approximately 90% of cases of ADRD among LTCF residents, and all are amenable to this primary approach to BPSD intervention. Recognizing and capitalizing on this unmet need represents one of the more important opportunities in this environment and can be initiated and managed by the existing LTCF clinical team.

This study suggests that adding a proven “neurology-forward” clinical model to the existing standard of care for residents with ADRD is potentially one of the larger quality improvement opportunities in LTCFs.

Steven Posar, MD¹ • Anita Reid, MSP, APN, FNP-BC, GNP-BC² • Daniel Heiser, PsyD³  

Affiliations:

^1-3 GuideStar Eldercare 

Disclosure:

The authors report no relevant financial relationships.

Address correspondence to:

Anita Reid, MSP, APN, FNP-BC, GNP-BC
Email: anitadreid@gmail.com

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