What do we do when the antipsychotics are gone?
Dr. Richard Juman
The agents referred to as “unnecessary drugs” or “chemical restraints” in skilled nursing facilities go by another name in hospitals and outpatient settings. They're called “medicine.”
For some time, nursing homes have been under tremendous pressure to reduce or eliminate the use of antipsychotics, and now benzodiazapines are starting to receive similar attention. Obviously there are many benefits to reducing the use of medications that are not effective, especially those that cause deleterious side effects. But the vast majority of residents in these facilities have significant psychiatric disorders, and staff members are confronted by challenging behaviors on a daily basis.
Let's face it, nursing homes are mental health settings just as much as they are medical environments. Most residents in nursing homes suffer from dementia with behavioral disturbances, a mood disorder, or both. Factoring in other residents who are admitted with pre-existing histories of chronic psychiatric illness, there is a clear, widespread need for evidence-based treatment of psychiatric illness and behavioral disorders in post-acute care. One could argue that effectively treating and managing behavioral issues — the “psychosocial” elements of the biopsychosocial model — is the most important factor in providing excellent post-acute care.
Adapting the care model
Because facilities are being asked to reduce the use of antipsychotics and other “unnecessary drugs” while simultaneously providing excellent care, there must be a fundamental shift in their approach to care delivery. Simply reducing the use of psychotropic drugs would have deleterious outcomes, including psychiatric hospitalizations, resident-to-resident attacks, abusiveness towards staff, staff attrition, unhappy families, poor survey results and declining 5-Star ratings.
Fortunately, behavioral health interventions combined with appropriate staff training can actually be more effective than the medications that they are being called upon to replace. A recent meta-analytic study published in The BMJ reveals what many of us on the front lines of resident care have always known: Non-pharmacological interventions are significantly more effective than antipsychotics in managing the behavioral symptoms of dementia.
The study demonstrates that changes in the care environment — exactly those improvements in resident care that should come from the psychological assessment of residents and implementation of an individualized, “person-centered” approach to care — were shown to be more effective than antipsychotics in managing behavioral symptoms. But the gains involved go well beyond the residents, as these types of approaches lead to improvement in staff and family satisfaction as well.
Creating this type of psychologically informed, individualized approach to care begins with an appreciation of many resident variables, including:
Underlying personality structure, psychiatric history and baseline mood
Historical response to personal challenges
Interpersonal style and reactivity
Individualized response to situations and events that trigger problematic behaviors
Strengths and weaknesses in a variety of cognitive, emotional and interpersonal domains
Optimal levels of resident involvement in care planning and other decision-making
With this understanding of resident dynamics in hand, psychologists, beyond their direct interventions with the residents, can then work with staff to tailor individualized approaches to avoiding and managing problematic behaviors. This work includes:
Teaching direct caregivers to communicate with residents in a manner designed to soothe and resonate with the resident
Creating optimal routines for dining, dressing, bathing, toileting, bedtime, exercise and other typical activities
Creating therapeutic recreation schedules and content likely to engage the resident
Involving family members as valued and effective members of the care team, with guidance to families similar to that given to staff
Providing opportunities for interpersonal contact and connection based on residents' preferences for interpersonal activity
Training direct caregivers to recognize signs that the resident is in pain, which may be different (less direct) than in a cognitively-intact population
Understanding that “inappropriate” behaviors are often a form of communication of unmet needs that need to be investigated
Behavior management planning designed to promote consistent responses to problematic behaviors, including aggressiveness, inappropriate verbalizations, wandering and other common manifestations of dementia.
Integrating behavioral health services
Achieving the appropriate changes to the care environment requires integrating behavioral health providers into a skilled nursing facility's interdisciplinary care team.
In the past, psychological services were often thought of as an ancillary or optional treatment that could benefit just those residents who presented with poor adjustment to the facility. That understanding is detrimental to succeeding in the current outcome-based environment. We know from years of experience that facilities in which behavioral care is embedded into the fabric of facility care are much more likely to achieve the “Triple Aim” of improved outcomes, enhanced patient experience and cost savings.
Psychological services should be viewed as a critical aspect of an interdisciplinary approach applied to most residents. The medical and behavioral presentations of nursing facility residents are typically so complex and inextricably connected that a “full court press” of care is a must. On an operational level, that means establishing care teams wherein medical, psychiatric and psychological providers work in a truly interdisciplinary clinical manner. This produces better communication, improved coordination of care and enhanced outcomes when compared to the same care rendered by unrelated, uncoordinated providers. Facilities that are able to truly integrate care, and include families in the process, will emerge in the “post-antipsychotic era” without experiencing a deterioration in the quality of life for their residents, families and staff — or their survey results and 5 Star ratings.
For example, psychologists who provide services in post-acute facilities work directly with residents, providing psychotherapy, motivational interviewing, relaxation training and family therapy – but they may only see a particular resident once per week. Between sessions, the psychologist's understanding of that resident should help inform the approach that all staff members use when working with that individual. The psychologist may provide specific recommendations to help staff serve as allies in the patient's psychological treatment. The recommendations may include a description of the residents' strengths and weaknesses, what the resident should be encouraged to do, what behaviors should be positively reinforced, and the best ways to respond to any specific problems or behaviors.
I think of skilled nursing facilities as psychosocial environments in which the provision of appropriate psychiatric and psychological care is essential. All post-acute admissions are psychologically stressful and deserve aggressive treatment to avoid negative events and outcomes, so psychological services shouldn't be construed as a “specialty service” but rather as a critical aspect in the care of most residents. Individualized psychological care improves outcomes and avoids both psychiatric hospitalizations and the medical re-hospitalizations that often result from non-compliance, anxiety, depression and a variety of other behavioral issues. Staff education and support around difficult populations improves outcomes and staff satisfaction, and family therapy and education foster realistic expectations of care and improved family satisfaction.
In an era of outcome-based care, it is imperative that facilities successfully integrate evidence-based behavioral health services. Achieving outstanding short-term rehabilitation outcomes, avoiding re-hospitalizations and staying in compliance with regulations around psychotropics all require state-of-the-art psychiatric and psychological care woven into the overall medical care that facilities provide.
Richard Juman, Psy.D., is a psychologist and Regional Director with IPC of TeamHealth.