1. Antipsychotic Medication Reduction in Long Term Care
Grace Showalter RN, BSN
Quality Improvement Advisor
ext. 211

2. Overview Why reduce antipsychotic medications?
Indications for appropriate usage
Pathway to reduce inappropriate usage
Success stories
Resources for action… get started!
But First…
Why is it important to do this? Why are we dedicating 25 minutes to this topic?
Want to show you that this can be successful, without being resource-intense, and leave you with resources that you can use to take action in your beneficiary population.
But first, let’s do an activity…. Get our bodies moving and blood flowing! Volunteers?

3. 1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data
Influenza Activity
Symptoms Diagnosis Treatment Symptom Management Inappropriate Responses
1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data

4. Why? Align with HHS Initiatives
Align with CMS National Initiative (National Nursing Home Quality Care Collaborative- NHQCC)
MDS Composite score*
Five Star Rating*
Federal LTC requirements and interpretive guidelines
Decrease in antipsychotic medications can improve other areas of MDS composite score and other quality measures
*= affects short stay and long stay measures
MDS #11 is % of residents who received antipsychotic medications
Federal LTC Requirements/Guidelines:
Unnecessary Drugs
F329

5. Why? (cont.)
Antipsychotic medications often represent highest number of “missed” opportunities for care
Contribute to other high rate missed opportunities
Due to side effects, antipsychotics can contribute to resident sedation, leading to decline in ADL independence, pressure ulcers, weight loss, falls, and even depression

6. Why? (cont.) Few drugs actually help “problem behaviors”
Antipsychotics are the main drug treatment of “problem behaviors” associated with dementia
Frequently prescribed
Not effective, high risk profile
Non-pharmacological methods are preferred
Very few drugs help for problem behaviors or psychosis in dementia
Antipsychotics are the main drug treatment
~22% of NH residents get inappropriate antipsychotic treatment1
Varies widely by state (~ %1) and facility
Effectiveness is modest- less than 20% of those treated demonstrate meaningful improvement in behaviors/symptoms. Some studies suggest this number may be as low as 7%
Serious side effects-- sedation, falls, movement disorders—also known as extrapyramidal side effects, weight gain, and diabetes. Their use has also been associated with strokes, or cerebrovascular events. The risk of stroke was about twice as high in people getting antipsychotics compared to placebos
including death-
Non-drug methods are preferred
Providers may feel or be poorly trained to use non-drug behavior management techniques
1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data
Jeste et al, Neuropsychopharmacology 2008;33:957-70
Adapted from « Improving Antipsychotic Approriateness in Dementia Patients presentation, Ryan Carnahan

7. Why? (cont.) Antipsychotic Medication Problem per CMS Standards
% of claims
Excessive Dose
10.4%
Excessive Duration
9.4%
Inadequate Indication
8.0%
Inadequate Monitoring
7.7%
Presence of adverse effects that indicate dose should be reduced or discontinued
4.7%
In May of 2011, the Office of the Inspector General for the U.S. Department of Health and Human Services released a report on antipsychotic use in nursing home residents.
After reviewing medical records for a sample of patients treated in the first half of 2007, it was concluded that about 22% of antipsychotic prescriptions in nursing homes were not given in accordance with Centers for Medicare and Medicaid Services standards regarding unnecessary drug use . As you can see from the table, many of these drugs were given at too high of doses, for too long, without an acceptable reason, without enough monitoring, or in the presence of adverse effects that indicated the dose should be reduced or the drug discontinued entirely.
Office of Inspector General
Adapted from « Improving Antipsychotic Approriateness in Dementia Patients presentation, Ryan Carnahan

8. Why? (cont.)
Better Health
Better Care
Lower Costs

9. Review: Behavior, Symptoms & Diagnosis
Wandering
Nervousness
Poor Self-Care
Uncooperativeness (refusal or difficulty receiving care)
Restlessness
Impaired Memory
Fidgeting
Mild Anxiety
Inattention or indifference to surroundings
Insomnia
Sadness or crying alone that is not related to depression or other psych diagnosis
What are “problem behaviors”? These are behaviors that may be symptoms of dementia, or may just be behaviors of your resident
Adapted from « Improving Antipsychotic Approriateness in Dementia Patients presentation, Ryan Carnahan

10. Review: Behavior, Symptoms & Diagnosis (cont.)
Some behaviors are symptoms
Presence of symptoms is not sufficient for diagnosis
New diagnosis of psychosis should be made only after underlying causes of the symptoms have been excluded through a careful review process.
When are behaviors actual symptoms of dementia or psychosis? Overlap between “problem behaviors” associated with dementia and symptoms of psychosis that require antipsychotic medication treatment.

11. So your resident is taking an antipsychotic. Now what?
Diagnoses appropriate to receive antipsychotic medication treatment:
Diagnoses that should not receive antipsychotic medication treatment:
Schizophrenia
Bipolar Disorder
Tourette’s Syndrome
Major Depressive Disorder
Huntington’s Disease
Psychotic symptoms secondary to underlying illness (UTI/infection) or treatment modality
Stroke
Brain Tumor
Substance Withdrawal
Schizophrenia, Tourette's, Huntington's dx will exclude residents from consideration in quality measures

12. So your resident is taking an antipsychotic. Now what? (cont.)
Document
Documentation of existing diagnosis
Without a diagnosis, CMS offers guidelines for LTC facilities:
must present a danger to self or others or
must cause the person to experience one of the following:
inconsolable or persistent distress
a significant decline in function
substantial difficulty receiving needed care
What are the 3 diagnoses? (Schizophrenia, Huntington’s Disease, Tourette’s)
NOTE: even with documentation according to CMS guidelines, medications prescribed without one of the three diagnoses will affect your quality measures!
Drugs cannot be stopped suddenly- wean off, and replace with other interventions

13. So your resident is taking an antipsychotic. Now what? (cont.)
Discuss, Decrease, and Discontinue
Discuss diagnosis
Decrease Dosage
Discontinue when appropriate
What are the 3 diagnoses? (Schizophrenia, Huntington’s Disease, Tourette’s)
NOTE: even with documentation according to CMS guidelines, medications prescribed without one of the three diagnoses will affect your quality measures!
Drugs cannot be stopped suddenly- wean off, and replace with other interventions

14. Now What? Discuss and Document
Discussion with resident and family about the diagnosis
Course of disease
Normal symptoms of advancing disease
Treatment options and informed consent
Advanced care planning
Monitor closely for beneficial and/or adverse effects of any psychotropic medication
Reassess need to continue medication
Document, Document, Document!

15. Now What? Decrease and Discontinue
Decrease Dosage
Slowly decrease dosage
Other interventions to address behaviors/symptoms
Team approach
Discontinue Medications
When possible, discontinue entirely
Assess other psychosocial, mental, emotional and physical needs
Consider other pharmacological interventions if necessary
Document, Document, Document!
Team Approach and other interventions:
Behavioral health rounds/meeting
Assessment, Identify and Treat Contributing Factors:
Focus on one behavior at a time
Identify what leads to or triggers problems
Reduce, eliminate things that lead to or trigger the problem
Document outcomes
Medical/Behavioral co-management
Who manages the diagnosis list?
Who manages psychotropic medications?
Discussion of psychotropic medication usage in QAA meetings
If the antipsychotic medication clearly is working for symptoms, continue it
In most cases, efficacy is unclear, or absent. Medication should then be discontinued.
Many patients do not experience exacerbation of agitation when the medication is withdrawn and can again be managed with non-pharmacologic approaches.
Use periodic gradual dose reductions to assess continued need
At least twice yearly
Probably much sooner on initial prescription, e.g. 3 months max, but monitor closely for relapse
If used in delirium, DC or taper after resolution
Consider 25% decrease every 4-6 weeks as a general GDR guideline
More precise schedules are half-life dependent

16. Now What? IA-ADAPT Non-Drug Management Pocket Guide
Step 1: Identify, Assess, Treat Contributing Factors
Step 2: Select and Apply Non-Pharmacological Interventions
Step 3: Monitor Outcomes and Adjust Course as Needed
The IA-Adapt tool uses these 3 steps. More about this program and tool are provided in the linked resources 16

17. 1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data
Success Story #1
Burns Nursing & Rehabilitation, Russellville, AL
1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data

18. Success Story #1 What They Did Tools Utilized
Virtual Dementia Tour Training
Certification in Dementia Care (2 staff members)
Interdisciplinary Team: physician medical director, primary care physician, CRNP, DON, Social Services RN, Clinical Resource LPN, Activities staff, Restorative staff, as well as other nursing staff and CNAs
Tools Utilized
Change Bundle: Avoidance of Unnecessary Antipsychotic Medications in Nursing Home Residents Living with Dementia
Five-point Bundle
QAPI Tools for steps 7, 8, & 9

19. Success Story #1 (cont.) Results
Antipsychotics decreased: 40.3 percent to 25.2 percent during 1 year
Reduced dosage on 22 residents
Discontinued antipsychotics on 20 residents

20. 1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data
Success Story #2
Jaquith Nursing Home (Madison Inn), Mississippi State Hospital
1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data

21. Success Story #2 What They Did
Staff Training: Plan of Care, Resident-Centered Care (In-services)
Focused evaluations of residents
Identify behaviors leading to antipsychotic medication use
Discern communication need behind the behavior
Daily nursing staff documentation of:
Behavioral onset
Redirection/Intervention provided
Outcomes
Weekly Treatment Team meetings
Alternatives to address behavior(s)
Dose reduction progress
Care Plan changes
Jaquith- high percentage of residents do require psychotropic medications

22. Success Story #2 What They Did Tools Utilized- QAPI Results:
Therapeutic and/or environmental interventions implemented as needed
Focused on 75 residents, total program 10 months
Tools Utilized- QAPI
Results:
20 residents (27 percent) reduced dosage
3 residents weaned completely
Haldol- 2
Risperdal- 1
Jaquith- high percentage of residents do require psychotropic medications

23. Success Story #2 (cont.)
Successful in reducing and discontinuing antipsychotics.
This was the work of one of our IQH-UMMC Fellows!

24. 1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data
Success Story #3
Silver Cross Health & Rehabilitation, Brookhaven, MS
1Briesacher et al, JAMA 2013;309(5):440-2, Sept 09-Aug 2010 data

25. Success Story #3 What They Did Tools Utilized
Created a Snoezelen© Room
Monitor for escalating behaviors
Social workers and nursing assistants would escort residents
Antipsychotic use added to daily stand-up
100 percent staff training on dementia and modifying Plan of Care
10 month program
Tools Utilized
QAPI
Snoezelen© methodology

26. Success Story #3 Results
Decreased Antipsychotic utilization rate 28.1%  22.2%
Decreased Antipsychotic orders
16% of residents with orders pre-intervention
12% of residents with orders post-intervention
This was the work of one of our IQH-UMMC Fellows!

27. Success Story #3
This was the work of one of our IQH-UMMC Fellows!

28. #47 in the nation Success Stories Q4, 2011= 26.6 percent
Mississippi= almost 30 percent reduction
But…
Mississippi is still ranked
#47 in the nation
on this measure
Prevalence of antipsychotic use in long-stay residents
Progress!

29. Resources to Get Started
LSSCC Archive from the atom Alliance
IA-ADAPT Training from the Iowa Geriatric Education Center
QAPI Methodology from CMS
Change Package with Antipsychotic Reduction Bundle from the NNHQCC
National Partnership to Improve Dementia Care in Nursing Homes
Leading and Sustaining Systemic Change Collaborative
National Nursing Home Quality Care Collaborative

30. Contact Information
Grace Showalter, RN, BSN atom Alliance ext. 211