Antipsychotics in skilled care: Finding the right dose won't be easy

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John O'Connor
John O'Connor

It happens all the time in politics: After dissatisfied voters throw the rascals out, new rascals push back way too hard. Could the same thing happen to the use of antipsychotics in skilled care?

Antipsychotics have a less than proud history in this sector. They were once handed out liberally to residents with dementia and/or behavioral issues. The stated reason might have been to manage the symptoms. But if we are going to be honest, the meds were often administered to make annoying outbursts go away.

How pervasive was their use? In 2010, nearly 40% (39.4%) of skilled care residents who had cognitive impairments and behavior problems but no diagnosis of psychosis or related conditions were receiving antipsychotic drugs. That was the average, so it topped 50% in more than a few facilities.

Thankfully, times have changed. Five years ago, the Centers for Medicare & Medicaid Services led a campaign to reduce antipsychotic prescribing. As a part of the initiative, the agency enhanced educational efforts, stepped up regulations, and increased reporting — as the Five Star Nursing Home rankings illustrate.

By 2016, the American Health Care Association, which had instituted a similar campaign to CMS's, was noting that member facilities had lowered their off-label use of antipsychotics by 30% over four years. This was achieved largely by substituting non-pharmacologic interventions.

We often hear about the failings of nursing homes. But in this instance, some serious credit is due. To trim the numbers by that much in such a relatively short period of time is truly commendable.

In fact, some are wondering if such reductions are getting a bit too aggressive.

It's encouraging that we are seeing real collaboration here between the field and regulators. That must continue, as we are talking about literally strong medicine here.

There's certainly no justification for excessive use. Nor should residents be denied medications they need.

Let the search for the right answer — or answers — continue.

John O'Connor is McKnight's Editorial Director.

Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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