The appropriate use of medications is paramount in insuring the safety and well-being of residents in nursing homes. Almost any medication use could potentially be considered inappropriate if used in the wrong way, such as, being prescribed for too long a period of time, for the wrong reason, or in excessive doses. One class of medications that is frequently misused is antipsychotic medications. CMS has announced an initiative to reduce the inappropriate use of antipsychotic medications in nursing homes with their Partnership to Improve Dementia Care. As part of this initiative CMS has also released the Hand in Hand Training series, which has been free of charge to all nursing homes. This fact sheet will highlight different aspects when evaluating antipsychotic use within your facility.
What are antipsychotic medications?
– Antipsychotic medications are drugs used to treat symptoms of serious mental and emotional disorders such as schizophrenia or bi-polar disorder. Their use affects thinking and behavior by altering chemical substances in the brain. When prescribed properly these medications can help a person to think more clearly and take part in everyday life. Examples of antipsychotic medications include risperidone (Risperidol), quetiapine (Seroquel) and haloperidol (Haldol).
– Antipsychotic drugs are not approved to treat people with Alzheimer’s disease and other dementias, including people who have dementia related psychosis.
Why is reducing the inappropriate use of antipsychotic medications important?
– Nursing home leaders are charged with making sure that their residents receive appropriate care to prevent or minimize the symptoms or behaviors associated with mental illness, or dementia. When antipsychotics are prescribed to “quiet” a resident or for staff convenience, it could be considered a chemical restraint.
– The use of chemical restraints is prohibited by federal law. A skilled nursing facility is required to “provide services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, in accordance with a written plan of care.” (Social Security Act, Section 1819(3)(b)(2))
– In addition, antipsychotics have been shown to have possible adverse effects on the residents’ daily activities and quality of life. They can also contribute to and cause falls, metabolic disturbances, weight gain or loss, confusion as well as the associated increased incidence of heart attack and stroke.
– There is heightened scrutiny during the annual survey with regards to use of anti-psychotics; consumers looking for a nursing home may also evaluate your home based on the Quality Measures on anti-psychotic use.
Are there times when the use of antipsychotics may be appropriate and beneficial?
• When the individual poses a serious threat to herself or others, short term use of antipsychotics may be appropriate.
• Care planning should always include resident centered nonpharmacologic interventions and if antipsychotics are indicated they should be carefully monitored.
• If used appropriately, with informed consent and individualized care planning, nursing home residents may be better able to participate fully in care, translating into a safer environment.
How can nursing home leaders prevent the unnecessary use of antipsychotics? Various leadership techniques can support and promote care that prevents the unnecessary use of antipsychotics. Following are a few suggestions based on successful practices.
Increase staff training:
– Provide educational opportunities for all staff regarding assessment and management of behavior in ways that don’t require medications or at least minimize their use;
– Teach staff to recognize nonverbal signs of pain or unmet need, especially in residents with dementia, as these may be contributing to the behaviors;
– Teach staff the importance of documenting care, particularly the use of non-pharmacological, person-centered approaches to individuals with dementia.
Promote a person-centered culture:
– Build your systems including staffing adjustments to promote activity and meal schedules based on the preferred schedule of residents;
– Develop policies that direct the staff to identify resident-specific needs, optimize choices, and promote consistent assignment so that staff knows residents well enough to meet their specific care needs;
– Recognize staff that excel in assessment and creative management of behavioral problems;
– Promote communication and teamwork among all levels of staff; for example, include direct care staff who know the resident best in care planning meetings.
– Have a psychiatrist work closely with an interdisciplinary team composed of nursing, social services, therapeutic recreation specialist and a pharmacist to monitor the use of antipsychotics;
– Use the medical director to communicate between the interdisciplinary team and attending physicians to enhance information transfer, improve attending physician awareness of standards of care and regulatory expectations and monitor compliance.
– Require and document informed consent when antipsychotics are considered;
– Use the Advancing Excellence Medication tool when evaluating antipsychotic use. For instance, evaluate the incidences of prescribers failing to provide a relevant rationale for using an antipsychotic;
– Ensure chart reviews that monitor when an antipsychotic medication is prescribed indefinitely (for months or more) without any attempts to reduce or discontinue it;
– When the resident is not improving or is experiencing burdensome side effects from antipsychotic medications, it is the responsibility of care leaders to assure alternatives to antipsychotic medications are evaluated and implemented as appropriate for the individual.