Dementia, Anti-psychotic Use and Therapy

Decreasing the use of anti-psychotics in the long term care setting sounds like a no-brainer, doesn’t it?

As therapists and nurses, we know that anti-psychotics can have some pretty rough side effects on this population. We also know that these medications are sometimes ordered for the “wrong reasons.” Well, Centers for Medicare and Medicaid Services (CMS) has also taken note and continues to put changes into place to help optimize the qualify of life and function of residents, with specifics for those with dementia. Changes put into place in May of 2013, as well as updates in September of this year, impact us and we should all take note.

Background:

On March 29, 2012, CMS launched the National Partnership to Improve Dementia Care and Reduce Unnecessary Anti-psychotic Drug Use in Nursing Homes (this is now referred to as the Partnership to Improve Dementia Care in Nursing Homes). This was followed in July by the on residents and anti-psychotic use. CMS noted it was common practice to use anti-psychotics in nursing homes to try to address behaviors without first determining if there was an underlying cause for the behavior. CMS also noted that the problematic use of this type of medication was part of a larger, growing concern that nursing homes may use medications as a “quick fix” for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions.

Residents with dementia who have behavioral or psychological symptoms of dementia are frequently prescribed anti-psychotics. According to CMS, when anti-psychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, side effects are harmful. The Food & Drug Administration (FDA) Black Box Warnings Regarding Atypical Anti-psychotics in Dementia provides, “Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death compared to placebo.”

Anti-psychotics:  Are you ready for a trip back to pharmacology class?

Anti-psychotics affect neurotransmitters that allow communication between nerve cells by altering the effect of certain chemicals in the brain – dopamine, serotonin, noradrenaline and acetylcholine. These chemicals have the effect of changing behavior, mood and emotions.

The following are those anti-psychotics targeted by CMS. Those underlined are the ones we see most often in long term care.

First generation (conventional) agents:
• chlorpromazine (Thorazine)
• fluphenazine (Generic only)
• haloperidol (Haldol)
• loxapine (Loxitane)
• mesoridazine (Serentil)
• molindone (Moban)
• perphenazine (Generic only)
• promazine (Sparine)
• thioridazine (Generic only)
• thiothixene(Navane)
• trifluoperazine (Generic only)
• triflupromazine (Suboxone)
Second generation (atypical) agents:
• asenapine (Saphris)
• aripiprazole (Abilify)
• clozapine (Clozoril)
• iloperidone (Fanapt)
• lurasidone(Latuda)
• olanzapine(Zyprexa)
• paliperidone(Invega)
• quetiapine(Seroquel)
• risperidone (Risperdal)
• ziprasidone(Geodon)

What are the side effects?

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rash
• Major weight gain
• Rigidity
• Persistent muscle spasms
• Tremors
• Restlessness
• Tardive dyskinesia

So What Are The Recent Changes And How Do They Impact You?

In May 2013, clarifying portions of the State Operations Manual (SOM) regarding Dementia Care in Nursing Homes. This document  introduced information specific to Quality of Care, F309, the portion of the SOM that therapists should know by heart.

This update to the SOM included new language adding “care of a resident with dementia (see below)”  which impacts how we care for those with dementia.

 (see page 13 – All items in red are new additions to the manual)
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
Intent: §483.25
The facility must ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident’s right to refuse treatment, and within the limits of recognized pathology and the normal aging process.
NOTE: Use guidance at F309 for review of quality of care not specifically covered by 42 CFR 483.25 (a)-(m). Tag F309 includes, but is not limited to, care such as care of a resident with dementia, end-of-life, diabetes, renal disease, fractures, congestive heart failure, non-pressure related skin ulcers, pain, and fecal impaction.

This F309 Quality of Care regulation is what drives therapy practice (or it should!) in long term care. Therapy is responsible, just as are all team members, to ensure residents are evaluated and recommendations are made to allow residents to attain and maintain highest level of function. Some therapists have the mindset that dementia and therapy do not go hand in hand, and as such, many residents with dementia are overlooked for therapy. The addition of the phrase above now draws attention to the care for residents with dementia.

Physical, Occupational and Speech Therapists all have valuable input for recommendations and care of the resident with dementia. We often receive referrals that may be related to the medication side effects, including: falls, decreased self care, swallowing difficulty, muscle stiffness, contractures, cognitive changes, etc. Therapists should provide treatment and make recommendations with the focus on attaining and maintaining highest level of function. Therapists that were hesitant to provide skilled care to the dementia resident for fear of lacking medical necessity and/or progress, let this most recent update to the SOM be your guiding principle.

Since 2011, anti-psychotic use has seen a This initial success led to an announcement in September 2014 with new goals of reducing the use of the drugs in nursing home residents by 25% at the end of 2015 and by 30% in 2016 from the baseline rate in December 2011.  Anti-psychotic reduction and dementia focused care are in the spotlight and will likely trigger additional changes in the future.

In Your Corner,

Dolores