As antipsychotic use appears to backslide among nursing home residents, risks mount

For more than a decade, patient advocates and federal regulators have called for a reduction in nursing homes’ use of antipsychotic medications, a class of drugs once widely associated with controlling unwanted behaviors.

A national campaign to provide safer dementia care seemed to have reduced the drugs’ use to more reasonable levels for a time.

But a damning report in The New York Times, recent criminal prosecutions of those who intentionally drug patients, and anecdotal stories about the drugs’ reemergence during COVID-19 show a major challenge still remains.

A  2020 study found the use of antipsychotics fell from being used in nearly 24% of all nursing home patients in 2011 to 14.3% in 2019, a 40% reduction. That study credited the turnaround to the national campaign launched in 2012. The campaign included public reporting elements, increased regulatory scrutiny and accompanying state and facility initiatives.

However, the Times investigation, published in mid-September, found that much of the success was due to a loophole allowing nursing homes to leave out antipsychotic use among patients with schizophrenia and similar diagnoses. Schizophrenia diagnoses jumped 70% during the reporting period.

Not a crutch

Antipsychotics shouldn’t be a crutch for facilities, not even during the ongoing pandemic, compliance experts and care providers recently told McKnight’s.

“They’re in a really tough place because they’ve lost a lot of staff,” said Betty Frandsen, RN, NHA, president of MedNet Academy, which offers compliance training. “There’s incredible scrutiny by regulators of infection control practices, and then you have residents who have to be socially distanced but they wander. This is probably what leads to people ordering more of these medications. … I can see where it could certainly have increased (during the COVID-19 pandemic).”

American Senior Communities has been working to reduce and keep low the use of antipsychotics at its 59 skilled nursing and memory care facilities in Indiana. The process has evolved to include behavioral health partners and routine reviews of practices.

The operator initially requested gradual dose reductions for residents who had been prescribed antipsychotic medications for off-label indications, said Janean Kinzie, director of social wellness and enrichment. But that resulted in a “boomerang effect,” a drop in medication use followed by an increase.

“When we focused on just the medication, we did not see lasting results,” Kinzie said. “Residents would either continue to have behaviors or have an escalation in behaviors. It was not until we shifted to a more educational focus that we began to see lasting results. We began by educating our interdisciplinary teams on how to assess behavioral expressions thoroughly to identify root causes and non-pharmacological interventions.”

COVID precautions

During the pandemic, the company’s CARE Companion Culture program provided extra psychosocial support. Each resident is assigned to a department head who checks on them daily, communicates regularly with their family and learns their life story. With restrictions in place, those visits focused on engagement and monitoring for signs of psychosocial wellbeing, freeing activities staff to focus on residents with dementia who needed more support.

Community reviews done in conjunction with behavioral health partners also help leaders recognize potential problems in performance metrics such as the antipsychotic quality measures, psychiatric hospitalizations and frequency of education to direct care staff. Communities with metrics above a set threshold get routine follow-up and support.

ASC’s average long-stay antipsychotic measure is now at 8.9%, compared to the national average of 14.2%.

Across the country, 1 in 9 nursing home residents is now documented as having schizophrenia, compared to 1 in 150 in the general population, according to the Times. And a study published Sept. 30 found schizophrenia diagnoses rose more significantly among Black nursing home residents with dementia. 

Many long-term care clinical experts and providers are acutely aware of the dangers of overprescribing antipsychotics, which are linked to increased risk of falls and deaths.

Frandsen warned that practices described in the Times report could endanger residents and open providers up to liability through the use of false medical records, inaccurate recording of quality measures through MDS and/or the administration of unneeded drugs paid for by Medicaid or Medicare.

She suggests operators review Ftag 757 for unnecessary drugs, understand what the rules are and then check for associated diagnoses within their facilities. A good sign that something could be amiss? High numbers of residents who aren’t tapering.

“When you have a resident on these types of medications, you’re supposed to be doing a gradual dose reduction,” she said. “If you use an inaccurate or fabricated diagnosis such as schizophrenia or Tourettes or Huntington’s, when the person doesn’t really have it, then what you’re doing is finding a way to give that medication that … really is not justified.”

She said providers should also brace for more criminal prosecutions for drug misuse, such as a September case in which a Kansas nurse pleaded guilty to unlawful administration of a controlled substance and battery. That case didn’t involve antipsychotics, but rather the use of Benadryl and Ativan to make a patient “sleepy.”

Such prosecutions and the high-profile nature of the Times story put antipsychotics back in the spotlight again, and that may put law enforcement and attorneys on high alert.

Providers, Frandsen said, should work with medical directors and rounding physicians to explain the importance of curtailing such drugs, even in response to nurses who may request them as a way to limit troublesome patient behaviors, she added.