Nursing Homes Curb Use of Antipsychotic Drugs with Help from Feds, Nonprofit

Andrew Kitchenman | November 25, 2013 | Health Care
Alternative treatments used to control dementia-associated behaviors by elderly

Barbara Darlington, administrator of Gateway Care Center in Eatontown, said she was pleased with results of a pilot program aimed at reducing use of anti-psychotic drugs on patients with Alzheimer's and dementia.
Six New Jersey nursing homes are finding that activities such as taking walks, listening to music, and even getting hand massages can help reduce reliance on antipsychotic medication for patients with dementia or Alzheimer’s disease.

The six nursing homes reduced their use of antipsychotic drugs an average of 33 percent from December 2012 to September 2013 through their participation in a federally funded pilot program.”

The federal Centers for Medicare & Medicaid Services (CMS) has set national goals for reducing antipsychotic use and recommends using research-based treatment involving teams of healthcare providers to focus on individual patient’s needs.

The agency is also requiring nursing homes to publicly report their progress in reducing drug use and incorporate that statistic in how the quality of nursing homes is measured.

The six New Jersey nursing homes took part in the federal pilot program in the first six months of this year.

Barbara Darlington, administrator of Gateway Care Center in Eatontown, said she was pleased with the results at her facility. She said she was eager to find ways to reduce antipsychotic use after observing the troubling side effects of the medication.

Darlington said Gateway received assistance from Healthcare Quality Strategies Inc., a nonprofit designated by the federal Centers for Medicare & Medicaid Services to help improve healthcare quality in the state. That organization oversaw the pilot program, which focuses on team-based care.

“If you really want to institute new ideas and new ways of thinking, you really have to educate the whole team,” Darlington said of the pilot program, which partnered a pharmacist and nurses from HQSI with her facility’s staff. They created multidisciplinary teams that included certified nursing assistants, therapeutic recreation specialists, doctors, and psychologists to discuss medications, monitor side effects and assess the needs of the residents.

Antipsychotics are frequently prescribed to patients with dementia for “off-label” uses that haven’t been approved by the U.S. Food and Drug Administration. While the drugs are used for patients who are agitated, restless, confused or aggressive, the side effects include lethargy and sleepiness and are often associated with an increased risk of strokes and death.

Darlington said the focus of the project was to develop alternative approaches to reduce use of the drugs.

From late December 2012 to June 2013 — and on an ongoing basis since the project formally ended — the staff developed individual care plans that did not involve the use of drugs.

For some residents, the staff played music using digital music players. Others received hand massages. But the most successful approach was organizing twice-daily outdoor walks through the facility’s property. If there is inclement weather, the walks take place indoors. Of the 50 to 60 residents with dementia, roughly half participate in the “walking club,” Darlington said.

“They all stay together, they walk together and they love it,” Darlington said. “They’re behaviors are reduced and they have a better outlook on things.”

The nursing homes in the pilot program were well ahead of the statewide rate of reducing use of antipsychotic drugs. Darlington said 30 percent fewer patients are now prescribed the drugs, while another 40 percent have had their prescriptions scaled back. This was similar to the decline of 33 percent across the six homes in the pilot program, compared with the 12 percent decline in nursing homes’ antipsychotic prescriptions statewide.

While only a tiny fraction of the state’s 359 nursing homes took part in the pilot program, they all face public-reporting requirements from CMS on how much they are reducing their use of the drugs. Federal officials have set a national goal of reducing antipsychotic prescriptions by 15 percent.

“We’re still working on it,” Darlington said of driving down the use of the drugs even further. “This is a passion of mine.”

Darlington said the use of antipychotics arose to address real needs. “Some of these behaviors can be quite difficult if (patients) are combative, if they are resistant to care, if they do things like spitting at their food or just crying inconsolably or hitting their peers or pacing around until they’re exhausted,” she said.

While the strategies may appear to be straightforward, Darlington said HQSI was helpful in “just getting us going in the right direction.” HQSI didn’t include the names of the other five nursing homes included in the pilot program in its announcement of the results.

The statewide decline in nursing homes’ antipsychotic use was in line with a national decline from 23.5 in the first quarter of 2011 to 21.14 percent in the third quarter of 2012.

HQSI pharmacist Nicole Skyer-Brandwene, who led the pilot program, cited multiple examples of patients who had their antipsychotic prescriptions reduced after they received MP3 players with their favorite music.

“It’s clear that getting to know a person can make a significant difference in their care and quality of life,” she said in a statement. She added that the patients’ progress also had an effect on nursing home staff members, as they could see positive results from their efforts.