Caregivers should prepare for some residents to 'get worse' during antipsychotic drawdown, CMS officials urge

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Leaders in long-term care facilities should take steps to ensure that residents with dementia are not unnecessarily put back on antipsychotic medications, according to officials who spoke on a call with providers Monday.

In many cases, when a resident resumes taking an antipsychotic medication, the only explanatory note provided in documentation is “got worse,” said Michele Laughman, CMS coordinator for the National Partnership to Improve Dementia Care in Nursing Homes. This should in fact be expected, and caregivers should know how to address this issue without defaulting to restarting medication, according to Laughman.

When antipsychotic medication is suspended or a dose is reduced, residents may become more active and “appear worse” due to increased behaviors, Laughman said. Behavioral therapy can address many of these behaviors, but the resident may take time to respond to the therapy. Therefore, leaders should have practices in place — clearly delineated in a care plan — addressing this stage of a resident's transition.

Having floor nurses contact the director of nursing before going to a physician or nurse practitioner is one best practice that many successful providers have adopted, Laughman said. The DON can then provide needed support, preventing the caregiver from simply putting in a medication request.

Pain and sleep are effective focus areas, said Alice Bonner, Ph.D., a CMS contractor and former director of its Division of Nursing Homes. Although many providers already have pain assessments in place, Bonner urged leaders to review their practices in this area, given that pain is “much more difficult to detect in people with dementia.” Noting that it is not a website officially endorsed by CMS, she nonetheless suggested providers explore resources available at

Simple steps such as limiting interruptions and making sure rooms are as dark as possible can help improve sleep and diminish behaviors related to antipsychotic withdrawal, Bonner said.

At the request of providers, a new resource has been developed for the Advancing Excellence in America's Nursing Homes program, Bonner announced. The tool provides a list of specific therapies that are suggested for particular behaviors associated with dementia. It will be posted to the Advancing Excellence website within about a week, according to Bonner.

The officials spoke on a Medicare Learning Network Connects National Provider Call. A recording and transcript will be available here

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