Antipsyched-out?

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Antipsyched-out?
Antipsyched-out?
When the federal government launched an initiative earlier this year to limit antipsychotic drug use in long-term care, some providers feared that the new requirements — which call for a 15% reduction in the off-label use of the drugs by year's end — would be too tough to swallow.

Given the heightened focus, and the fact that surveyors are carefully checking policies and procedures associated with the drugs' misuse, it's understandable that providers are on edge. Many fear they'll struggle to meet the reduction target and, perhaps won't be able to demonstrate that prescribed antipsychotics were warranted. Further, there are concerns that recent news reports underscoring the perils of overprescribed antipsychotics could lead some prescribers and alarmed family members to severely restrict their use, thereby limiting help for residents who might benefit.

“These drugs can and do help some people, but the reality is they are often overused. There does need to be a change,” acknowledges Cheryl Phillips, M.D., senior VP for advocacy for LeadingAge. “These medications have more risks than we believed and fewer benefits than we assumed. The key to using them safely and appropriately is having the right policies in place to make the best [prescribing] and care decisions.”

The benefits of prudent prescribing practices are vast. The emphasis on antipsychotics is spurring more targeted education for prescribers, facility staff and family members. It's also forcing providers to take a closer look at their overall policies and care practices, and make adjustments to improve quality. Even subtle shifts in the management of dementia residents who exhibit aggression or other potentially dangerous behaviors can help providers easily meet — or exceed — that 15% reduction, experts assure.

At the same time, these efforts can net providers big savings, while improving quality of life.

“Reducing the amount of psychotropic medications by 15% by the end of 2012 is not only doable, it has the potential to save facilities millions of dollars,” says Tom Conrad, cognitive behavioral specialist at HealthPRO Rehabilitation.

Pharmacy bills will decrease and resident quality of life will improve when they are not medicated to the point that they require total care, he explains. Caregiver turnover also will improve, along with resident and family satisfaction.

What's more, survey scores will soar and facilities can market their successes to gain a stronger competitive advantage, he says.

“As facilities learn to implement strategies to reduce the use of these medications, everyone wins,” he adds.

Off-label use defended

Even though antipsychotics aren't approved to treat dementia-related behavioral problems and have been shown to raise death risks in dementia residents, doctors and pharmacology experts agree there are times when off-label use is warranted.

“When patients pose potential harm to themselves and others, or their actions would affect treatment, such as pulling out intravenous lines, antipsychotic use can be justified,” reasons Scott Vouri, Pharm.D., assistant professor of pharmacy practice at St. Louis College of Pharmacy.

Still, prudence pays. The drugs should be used as a last resort, with risks and benefits carefully weighed, and targeted policies and procedures put in place well before the first dose is ever administered, experts say.

“Use of non-pharmacy treatments, like orienting the patient to the setting, making sure the patient is comfortable, and avoiding other issues, such as pain, constipation and infection that can irritate the patient, should always be the first line [of defense] for behavioral issues,” Vouri says. The Centers for Medicare & Medicaid Services advocates nonpharmacological alternatives, such as consistent staff assignments, increased exercise or time outdoors when possible, monitoring and managing acute and chronic pain and planning individualized activities.

Pain, infection, fear, loneliness, depression, drug side effects or anxiety may each cause behavior issues, especially in residents with dementia who may not be able to verbally communicate their discomfort, sources says. Diligent sleuthing to uncover and address the root cause of sudden or ongoing behavioral issues becomes paramount.
“These behaviors are a form of communication. It's up to us to determine what they are trying to tell us,” says DeAnna Looper, corporate nurse for Crossroads Hospice. “We need to be detectives, do our best to determine what's distressing them, and make sure all other approaches to addressing the issue have been exhausted. This is what's known as the step therapy approach. You don't just jump to antipsychotics.”

Communities that adhere to a resident-centric care approach may see a marked reduction in the use of antipsychotics, benzodiazepines, anticonvulsants, and other medications. Beatitudes Campus, a community in Phoenix that offers skilled nursing, rehabilitation services and dementia care, operates on the foundation that comfortable residents are happier residents. When residents are comfortable, adverse behaviors aren't as common.

“When a resident has dementia, we're on that journey with them. We need to honor that each individual is an expert in their own comfort and do for the resident what they would do for themselves if they were able,” says Tena Alonzo, Beatitudes' director of research and dementia programs. For Beatitudes, that means abandoning a structured care approach and allowing residents' own needs and preferences to dictate the day's course.

“If a person is afraid of the shower, for example, we give them a sink bath — anything to keep them comfortable. If a person wants to sleep all day and be up all night, that's fine, too, as long as that person is being managed with care. When you work with the resident, you avoid resistance and behavioral issues often resolved on their own,” he explains.

Beatitudes has a solid track record of improving quality of life and eliminating antipsychotic use — even in some of the most challenging residents with severe dementia and a host of other comorbidities. The community regularly admits residents who were discharged from other facilities due to behavioral issues. Upon arrival, many of these residents are on antipsychotics for dementia-related behavior issues, and Beatitudes works to transition all of them off the drugs.

“Everybody gets a gradual dose reduction and everyone, at some point, comes off those medications,” Alonzo says. “The good news for those with dementia is that the emotional part of their brain remains intact. We can't change the way they think, but we can change the way they feel by tapping into their five senses. When you [decipher] their non-verbal cues and determine what is behind their behavior and what brings them comfort, you can solve the problem, often without resorting to medication.”

Tap the right tools
Ongoing assessments, thorough diagnoses and solid data gathering are key to improving care and pinpointing problems that could cause behavior issues if left unresolved. Educating all staff and family members on dementia and the role that comorbidities and medications can have on a person's overall well-being is critical, sources says.

Conrad offered one example where lack of knowledge could prompt a misdiagnosis and the subsequent use of antipsychotics. If a resident with dementia is given the narcotic pain medication Percocet and develops an allergic reaction that causes severe itching — a common reaction — that person may be unable to effectively communicate the discomfort.

“Perhaps a resident with dementia has expressive aphasia and isn't able to vocalize that the medication is making her itch and scratch. Or perhaps the resident has agnosia and isn't able to say the medication is making her itch, but instead says the things crawling on her are making her itch,” he explains. The caregiver might blame the behavior on psychosis and hallucinations, and inappropriately seek anti-anxiety or antipsychotic medications as a result.

Such an example underscores the importance of multidisciplinary quality improvement teams. In addition to frontline caregivers, admissions and social services staff, dieticians, and activities coordinators, these committees must have active participation from prescribers and a consultant pharmacist. Prescriber and pharmacists should play a primary role in risk/benefit analyses to determine if antipsychotic use is appropriate, and then help steer ongoing assessments and drug monitoring.

“The pharmacist provides an initial review with all new prescriptions for allergies and/or drug interactions. A more in-depth review is provided every 30 days, including F-Tag 329, which relates to unnecessary drugs,” says Ronna Hauser, pharmacist and vice president of policy and regulatory affairs for the National Community Pharmacists Association. The pharmacist's role involves working closely with the prescriber and the long-term care facility to ensure that the diagnosis and previous clinical indicators warrant the use of an atypical antipsychotic. Working closely with the consultant pharmacist also can help the prescriber determine the safest medication with the fewest side effects, she says.

Consultant pharmacists and prescribers also perform regular medication assessments for each resident. Equally important, they offer targeted staff education and assist in reducing dosage and, ultimately, discontinuing the medications.

“We provide good assessments, so if a person's mental status changes, we can help determine if a recent drug that was added could be causing them to act out, or explore whether an underlying illness, such as a urinary tract infection or depression, could be causing the altered mental state,” notes Khristy McClelland, RPh, president and owner of Guardian Pharmacy of Jacksonville.

Ideally, a psychiatric evaluation and a prescriber statement on the risk/benefit analysis would come before an antipsychotic recommendation. The QI team also must ensure that the appropriate assessments, documentation and monitoring are in place.

A documentation checklist can help, says Jennifer Hardesty, Pharm.D., FASCP, clinical services manager for Remedi SeniorCare. The checklist helps ensure that diagnoses are correct in the resident's medical records and also verifies that problematic behaviors are clearly documented in the resident's chart. Behavior monitoring forms that identify target behaviors also should be completed by staff, she says, noting that documentation also should show evidence of gradual dose reductions, unless such reductions are clinically contraindicated.

“Alternative interventions prior to initiating medications should be documented as well, along with documentation of ongoing behavior modifications, even after antipsychotics are initiated,” Hardesty stresses.

Safe storage and dispensing of antipsychotics should not be overlooked, either, according to Stephen Cutshaw, administrator of licensed facilities at C.C. Young.

“In our facility, we utilize a remote dispensing system that is closely monitored by the pharmacy,” he notes.

Medications are available to nurses in single-dose packs. This system, provided by Talyst Inc., helps cut the risk of drug mix-ups and ensures that the drugs are administered according to physician orders, he says.

Documentation also drives safer administration.

“Without appropriate controls, facilities can become careless in their monitoring and storage of antipsychotics and other maligned medications,” adds Cutshaw. “Maintaining good records is critical [so] that the drugs are properly administered and secured.”

Resist the anxiety switch
Urged on by groups such as the American Health Care Association and LeadingAge, facilities are trying to reduce their use of antipsychotics. But Alonzo worries that some providers will do so by increasing the use of anti-anxiety medications.

“One of my greatest fears is that we'll see a reduction in antipsychotics because CMS is requesting it, but there will be more anxiolytics prescribed in their place,” he says. “These drugs have very poor outcomes in those with dementia.”

Such an approach is like ripping off one bandage and replacing it with another, she warns. “That just creates a wound that never heals. The goal should be to reduce all of these types of medications, and I believe the best way to do that is through resident-centered care.”
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