Progress Continues for Dementia Initiative to Reduce Antipsychotics

Orlando—On March 29, 2012, the Centers for Medicare & Medicaid Services (CMS) launched a national initiative aimed to improve dementia care and optimize behavioral health in nursing home residents with dementia. Many of the diagnoses in nursing homes do not merit antipsychotics, but they are still prescribed. The CMS, in partnership with key stakeholders, set goals to reduce the use of antipsychotics because behavioral and other approaches are available to provide care more effectively and safely for dementia patients.

During a session at the ASCP meeting, stakeholders in The Partnership to Improve Dementia Care shared their perspectives on the challenges and opportunities surrounding the reduction of antipsychotic usage.

Evan Shulman, deputy director, division of nursing homes, CMS, provided an overview of the goals and intentions of the initiative. The Partnership to Improve Dementia Care promotes a multidimensional approach for nursing homes to rethink their method to dementia care, reconnect with residents via person-centered care practices, and restore good health and quality of life.

“It is more than just about the medication,” said Mr. Schulman. “We really have to rethink how we treat dementia.”

The partnership’s initial goal was to reduce the national prevalence rate of antipsychotic drugs by 15% in 2013, which was achieved. Between the end of 2011 and the end of 2013, the national prevalence of antipsychotic use in nursing home residents was reduced by 15.1%, decreasing from 23.8% to 20.2% nationwide. The partnership is working with nursing homes to reduce the rate even further. In September, the partnership announced a new goal of a 25% reduction by the end of 2015, and a 30% reduction by the end of 2016. At the time of the presentation, Mr. Schulman said the figures showed a 19% reduction.

He also spoke about the CMS’ surveying process for assessing nursing home compliance for dementia care. On May 24, 2013, the CMS issued a clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for Tag F-309 and Tag F-329. He said that new guidance related to Appendix P focuses on changes to the resident sampling process. F-329 includes new interpretive guidance related to the review of care and services for a resident with dementia and revisions to the antipsychotic medication section. F-329 also includes a new severity example at the end of the interpretive guidance for regulations related to unnecessary medications.

He said the CMS recently launched a Dementia Care Survey pilot program to take a more in-depth look at the process nursing homes use for prescribing antipsychotic medications, in addition to looking at other dementia care practices. At the conclusion of this pilot test, which is currently initiated in 5 states, the CMS hopes to streamline the current survey process and give surveyors a better way to accurately identify and cite deficient practices related to dementia care.

Douglas Englebert, RPh, MBA, pharmacy practice consultant, bureau of education services and technology, division of quality insurance, Wisconsin Department of Health Services, discussed Wisconsin’s efforts to improve dementia care in its nursing home residents. He said antipsychotic use has gone down in Wisconsin and F-309 citations may have contributed to the decrease.

“At a minimum, senior care pharmacists should make sure that all antipsychotic and other psychotropic medication orders for dementia residents are following dementia care principles,” said Mr. Englebert, noting that nursing homes in Wisconsin have a process for provider review within 7 days of a new initial order and within 2 weeks for residents admitted on an antipsychotic.

He emphasized the importance of pharmacy-centered care strategies for dementia residents and outlined Wisconsin’s plans, noting that they are applicable in all states:

• Coordinating medication changes with nonpharmacologic interventions
• Insuring an entrance plan for medication use
• Creating an exit plan for medication reduction

Dementia prevalence increases with age, and 60% to 80% of those living in a nursing home demonstrate some evidence of dementia/cognitive disorder, according to Susan M. Levy, MD, CMD, AGSF, vice president, American Medical Directors Association (AMDA), who focused on behavioral and psychological symptoms of dementia (BPSD).

AMDA recommends that antipsychotic medications not be prescribed for BPSD individuals with dementia without an assessment for an underlying cause of the behavior. She emphasized that nursing home staff have to evaluate the risks and benefits of antipsychotic use. Risks associated with antipsychotics include increased risk of death from cerebrovascular causes in those with dementia. She said antipsychotics may stabilize behavior, correct symptoms bothersome to the patient, and avoid harm to self or others.

Dr. Levy recommended that nursing homes ensure that all antipsychotic medication orders are in compliance with F-329 and that documentation supports use, monitoring for effect and adverse events, and that gradual dosage reductions
occur. Nursing homes should also examine routine medication reviews by the consultant pharmacist and share the reviews with the medical director.

For nursing home providers faced with the challenge to reduce antipsychotic use in dementia patients, implementation of a behavior management program may help clinicians better understand how to manage behavioral and psychological symptoms. Dr. Levy said a key component of the program includes collaboration among all members of the healthcare team with specific roles for each member.—Eileen Koutnik-Fotopoulos