Download Reducing Antipsychotics for Dementia Patients in Nursing

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EDITORIAL PANEL
Lynda Beth Milligan, MD, FAAFP, CPE, CHCQM; Michael Moody, MD; David Nelsen, MD, MS;
Steven Strode, MD, MEd, MPH; J. Gary Wheeler, MD, MPS
Reducing Antipsychotics for
Dementia Patients in Nursing Homes
BY KIM GARNER, MD, JD, MPH;
PRASAD PADALA, MD, MS; and
SHEILA COX-SULLIVAN, PHD, RN
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pproximately 19.4 percent of
patients with dementia residing in nursing homes in the
United States receive antipsychotic
medications. This rate is decreasing. In
the fourth quarter of 2014, Arkansas
had the third highest rate of change in
the nation, declining to 17.9 percent.1
Antipsychotic medications have many
appropriate uses including treatment
for psychotic disorders such as schizophrenia, psychotic symptoms such as
delusions and hallucinations, and behavioral and psychological symptoms
of dementia (BPSD) in certain situations. Regrettably, second generation
antipsychotics (SGAs) are often used
at higher doses than recommended and
for longer duration than needed.2 The
use of SGAs to treat behavior associated with dementia is an off-label use,
generally not supported by research
and associated with higher rates of
cerebrovascular accidents.3 As a result,
the Food and Drug Administration
(FDA) has issued a “black box” warning for SGA use in older persons with
dementia. In addition, SGAs increase
the risk of death, falls with fractures,
hospitalizations and other morbidity
resulting in poorer health and higher
healthcare costs.4 This article presents
reasons to reduce use of SGAs and
encourage alternative strategies for
responding to the challenge of BPSD.
ASSESSMENT OF BPSD SYMPTOMS
Behavior and psychological symptoms are typically identified by nursing
staff. They should conduct a thorough
assessment of the patient with specific attention on the context of the
behavioral occurrence. This assessment should consider the behavior or
symptoms from the patient’s perspective. In addition, any activities that
may have precipitated the behavior
need to be reviewed in deriving a
specific treatment approach. There are
several frameworks to assess BPSD; one
popular method is ABC. Antecedents
(A), behaviors (B) and consequences
(C) are considered for each episode
of BPSD to gather information about
patient, caregiver and environmental
contributions to BPSD.5
Another important framework
to assess BPSD is as a manifestation
of “unmet needs.” Unmet needs can
be environmental, such as excessive
stimulation (noise, number of people,
clutter), under-stimulation (boredom,
poor lighting), issues of room temperature (too hot or cold), and difficulties
finding a desired location (bathroom,
his/her own room, or a dining room).
A thorough medical assessment must
also be completed to rule out any
medical issues contributing to BPSD.
The differential diagnosis should include infections, constipation, urinary
retention and/or unrecognized pain.3
NONPHARMACOLOGICAL
MANAGEMENT
OF BPSD SYMPTOMS
Substantial evidence shows that
nonpharmacologic management of
BPSD can yield high levels of patient
and caregiver satisfaction, quality of
life improvements and reductions in
behavioral symptoms. Nonpharmacologic treatments involve either a
general or targeted approach in which
precipitating conditions of a specific
behavior are identified and modified
(see Table 1).
An important but often inadequately utilized approach to reduce
behavioral and psychological symptoms is physical activity. With training,
simple activities such as taking routine
daily walks with staff can enhance feelings of well-being and improve sleep.
Purposeful psychomotor activities with
interest or meaning to the patient
and graded to their capabilities (e.g.,
executive function, motor abilities)
can reduce agitation and other BPSD.
For example, a patient with interest
in fishing may be able to organize a
tackle box, sort plastic equipment, look
through a fishing magazine or watch
a video on fishing. Purposeful and
THE ARKANSAS FOUNDATION FOR MEDICAL CARE, INC. (AFMC) WORKS COLLABORATIVELY WITH PROVIDERS, COMMUNITY GROUPS AND OTHER STAKEHOLDERS TO PROMOTE
THE QUALITY OF CARE IN ARKANSAS THROUGH EDUCATION AND EVALUATION. FOR MORE INFORMATION ABOUT AFMC QUALITY IMPROVEMENT PROJECTS, CALL 1-877-375-5700.
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regular activities that tap into previous
interests and memory can be utilized.
There is evidence these approaches
effectively decrease the incidence
of BPSD. Programs such as Simple
Pleasures (http://www.health.ny.gov/
diseases/conditions/dementia/edge/
interventions/simple/) or STAR-VA9
have effectively decreased the severity
and frequency of BPSD.
Another key aspect is to refrain
from using physical restraints. Providers
should discourage this practice at every
opportunity, particularly since restraints
are also associated with increased falls,6
more rapid cognitive decline, decreased
mobility7 and death.8
PHARMACOLOGY
FOR BPSD SYMPTOMS
There are no FDA-approved medications for BPSD10 and second-generation antipsychotics (SGAs) have
modest benefits at best.2 In addition,
patients with dementia are predisposed
to greater side effects from SGAs. For
these reasons, non-pharmacologic
treatments should always be tried first.3
However, if antipsychotic medications are used, they should be used in
an appropriate and safe manner. Best
practices in the use of any antipsychotic should include ongoing clinical
management and provider documentation of:
n Appropriate indication with specific goal of therapy
n Monitoring effectiveness in achieving goal by repeated assessment of
BPSD
n Monitoring for adverse effects
n Lowest effective dose for shortest
possible duration4, 10
FUTURE EFFORTS
The CMS is monitoring antipsychotic use and has a goal to decrease
the off-label use of SGAs. Other
TABLE 1. Nonpharmacological
approaches to BPSD management
GENERAL APPROACH
nCaregiver education and training
nCommunication
nExercise
nActivity programs
nConsistent staff
nNoise reduction
TARGETED APPROACH
nTask simplification skills
nNighttime routines to address sleep
disturbances
nPain control
nBowel regimen to prevent
constipation
nTreatment of infection
organizations have joined the effort
to provide guidance on appropriate
antipsychotic prescribing in nursing facilities. Recently, the National
Partnership to Improve Dementia
Care reported that the first goal of a 15
percent national reduction in SGA use
for the treatment of dementia has been
met. The partnership has set new goals
of a 25 percent reduction by 2015 and
30 percent reduction by 2016.10 s
Dr. Garner is board certified in family
medicine, geriatrics and hospice and
palliative medicine. Dr. Cox-Sullivan is a
doctorate level nurse. Dr. Padala is board
certified in psychiatry, geriatric psychiatry
and psychosomatic medicine at the
Department of Veterans Affairs VISN 16
Geriatric Research Education and Clinical
Center (GRECC) and the Department of
Geriatrics at the University of Arkansas
for Medical Sciences.
REFERENCES
1. CMS Quality Measures Report.
Partnership to Improve Dementia Care
in Nursing Homes: Antipsychotic Drug
Use in Nursing Homes Trend Updates
(2014). Accessed online May 1, 2015
at: http://www.cms.gov/Outreachand-Education/Outreach/NPC/
Downloads/2014-10-27-Trends.pdf
2. Agency for Healthcare Research
and Quality (2007). Off-label Use
of Atypical Antipsychotic Drugs:
a summary for clinicians and
policymakers. Accessed online, March
27, 2015: http://effectivehealthcare.
ahrq.gov/repFiles/Atypical_
Antipsychotics_Off_Label_Use.pdf
3. Meeks, TW (2008). Beyond the
Black Box: What is the Role for
Antipsychotics in Dementia? Curr
Psychiatr, 7(6): 50-65.
4. Chiu, Y., Bero, L., Hessol, N.A., Lexchin, J., and Harrington, C (2015). A
literature review of clinical outcomes
associated with antipsychotic medication use in North American nursing
home residents. Health Policy, accessed
online, April 3, 2015: http://www.ncbi.
nlm.nih.gov/pubmed/25791166
5. Smith, M (2005). Back to the A-BC’s: Understanding & Responding to
Behavioral Symptoms in Dementia.
Geriatric Mental Health Training
Series: Revised. Hartford Center for
Geriatric Nursing Excellence, Accessed
online, April 3, 2015: http://www.
nursing.uiowa.edu/sites/default/files/
documents/hartford/ABC-SuppMat.pdf
6. Luo, H., Lin, M., & Castle, N. (2011).
Physical restraint use and falls in nursing homes: A comparison between
residents with and without dementia.
American Journal of Alzheimer’s Disease & Other Dementias, 26(1), 44-50.
7. Evans, D., Wood, J., Lambert, L.
(2002). A review of physical restraint
minimization in the acute and
residential care settings. J. Adv. Nurs.,
40(6), 616-625.
8. Berzlanovich, AM., Schopfer, J., Keil,
W. (2012). Deaths due to physical
restraint. Deutsches Arzteblatt
International, 109(3), 27-32.
9. Karlin, B.E., Visnic, S., McGee, J.S.,
& Teri, L. (2014). Results from the
multisite implementation of STARVA: a multicomponent psychosocial
intervention for managing challenging
dementia-related behaviors of veterans.
Psychol Serv, 11(2), 200-8.
10.American Society of Consultant
Pharmacists (2011). Policy Statement:
Use of Antipsychotic Medications in
Nursing Facility Residents, Accessed
online, April 3, 2015: https://www.
ascp.com/sites/default/files/ASCPantipsychotics-statement.pdf