GAO has good points in how, why antipsychotics are given
Elizabeth Leis Newman
When it comes to antipsychotics, we tend to speak in generalities. The long-term care industry knows it wants to reduce the use of antipsychotic medications for residents with dementia, and we occasionally speak about the progress (or lack thereof) in certain states, but one question worth revisiting is: Where are we giving these medications, to whom, and why?
Despite how you may feel about yet another government report criticizing long-term care, the Government Accountability Office report, released Monday, has several analytic points worth discussing. The main takeaway is the government recognizes the progress made in nursing homes with reduction of antipsychotics for residents with dementia, but it also notes that many Medicare beneficiaries are living in less-regulated assisted living facilities and receiving the drugs. It's part of a continuing narrative where the government is not super interested in paying for inappropriate medications that can harm seniors.
“HHS has taken important steps to educate and inform nursing home providers and staff on the need to reduce unnecessary antipsychotic drug use and ways to incorporate non-pharmacological practices into their care to address the behavioral symptoms associated with dementia,” the report states. “However, similar efforts have not been directed toward caregivers of older adults living outside of nursing homes, such as those in assisted living facilities and private residences.”
Research reviewed by the agency indicates certain characteristics are associated with higher antipsychotic prescribing rates. It's not a surprise that residents who have anxiety or depression without psychosis are more likely to be taking the medications, and that three research articles noted that men were more likely to be prescribed an antipsychotic. Yet while men have a higher prescription rate when they are in a nursing home, females have a higher rate when they live in the community. The data on race is more mixed: One article found black nursing home residents were more likely to be prescribed antipsychotics, while another one said they were less likely. Either way, it's worth examining how we define residents, and if behaviors considered OK by one resident are feared to be more dangerous from another person of a different gender or race.
Also worthwhile to look at is what the report says regarding culture and leadership. The knowledge of the nursing home leaders and staff “often set the tone for prescribing antipsychotic drugs,” and physician training is often lacking, it says. One study found almost all of certified nursing assistants were aware of the serious risks that can result from use of antipsychotics. Most administrators I've spoken with blame physicians or family members for the antipsychotic prescription, but it's also necessary to look at the training given to nursing aides administering direct care. They are the people who notice new behaviors and how the resident is communicating, and they create a safe, routine environment.
There are resources to help. A report released this week by the University of Michigan Health System highlighted that education for the caregiver, more effective communication between the caregiver and person with dementia, simplification of tasks, and more structure and safety in the resident's environment help with behavior issues. Another necessary strategy for a long-term care facility is to provide meaningful activities for a person with dementia.
Finally, study researchers point out behavioral issues can come from “hidden” medical issues in dementia patients, such as urinary tract infections, dehydration or pain, and drug interactions can also cause someone to act out. One nurse told me recently she found Claritin, a common allergy medication, was causing one of her residents to become aggressive due to a bad interaction with other medications. Once the facility stopped the Claritin, he returned to his normal, calm state.
Some of this isn't new for nursing homes that have achieved their goal for reduction of antipsychotics. But for those on the assisted living side with high rates, turn to your friends in long-term care or researchers to find tried-and-true methods. Even though the GAO report was mostly a gentle carrot, I suspect a stick isn't far behind.
Elizabeth Newman is senior editor for McKnight's Long-Term Care News.