How to do it ... antipsychotics management

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1. Start with root cause analysis, says Denise Wassenaar, RN, MS, LNHA, MatrixCare. Remember that antipsychotics are not FDA- approved for behavioral symptoms in dementia.

“An above-average use of antipsychotics for behavior management without a corresponding medical diagnosis is an excellent QAPI opportunity,” Wassenaar says. “Excessive utilization can only be managed when the root cause of prescribing is identified.” 

Frontline staff are critical for identifying things like potential behavioral irritants, according to Golden Living's Steve Hord, RPh. Other root causes could be an infection or adverse drug reaction, adds Cathy Yurek, RPh, a consultant pharmacist at Waltz Long-Term Care, a member of Guardian Pharmacy. 

2. Experts say part of root cause analysis means spotting behavioral issues early — before antipsychotics are prescribed.  

“You need to figure out why people are behaving the way they are,” says Wassenaar. “Most of the time if you track, the behavior is much more manageable than if you just give them a pill.”

One key behavioral trigger could result from a new medication for unrelated conditions such as constipation, Hord adds.

3. Engage the physicians who are prescribing antipsychotics. They may not know specific behaviors residents are demonstrating, or the deleterious effects the drugs are having. 

“It's been part of the solution for a long time to prescribe these types of medications for behavior management, and it's only recently that there's been an emphasis to not use them because of the side effects,” says Wassenaar.

Of course, no one but the physician can actually authorize the tapering process. 

“Lowering rates starts with reducing doses of existing drugs, especially in patients with a dementia component to their psychosis,” says Rob Shulman, RPh, CGP, FASCPm, of Remedi SeniorCare. 

4. Reducing antipsychotics means asking the experts.

“One of the best strategies I've seen is to form a behavior management committee in each individual facility that involves the prescriber, psychiatrist or psychologist, director of nursing, charge nurse and consultant pharmacist,” says Shulman.

5. Many experts agree that antipsychotics have long been over-prescribed with little attention paid to safer, non-medicating approaches. 

“Redirecting away from behavior-producing stimuli can be helpful, and in many cases is all that is needed,” says Shulman.

It's Never 2 Late CEO Jack York is passionate about non-pharmacological solutions. 

“It's easy to look at brain fitness as irrelevant in people who are at the point of needing antipsychotics, but they are actually the ones it's most relevant for,” he says. 

“Providing programs that engage the residents in the necessary activities to stimulate tiredness and establishing calm quiet areas to prevent falls reduces behavioral issues and the use of antipsychotics,” adds Kirby Cunningham, RN, AOD Software.

6. What's next? Ongoing vigilance, for one.

“I lived through the time when they took away restraints in nursing homes without a plan,” recalls Wassenaar. “You just can't take antipsychotics away without having a really strong solution and that usually will come in the way of dementia programming and non-pharmacological approaches.”

Measuring and monitoring is another. Kasumi Oda of Catalyst says electronic medication administration records can be very helpful for data collection and for flagging potential areas of non-compliance.

“The key is to take on manageable projects and have measurable outcomes, and then apply what's been learned to effect even more positive change.”