Maine nursing home finds way to reduce antipsychotic use

Physicians at the Durgin Pines nursing home in Kittery, Maine, had been concerned about the use of antipsychotic drugs for the facility's residents. When they pulled data from the pharmacy in July 2012, they found nearly a quarter of residents were being prescribed antipsychotics such as Risperdal. But most residents were receiving the drugs for reasons other than psychosis, such as to reduce agitation or stop aggressive behaviors.

“I have been frustrated by this for years,” said Dr. Jabbar Fazeli, a geriatrician who serves as medical director of the 81-bed for-profit facility. He says the rest of the nursing home staff was shocked.

In April 2005, the Food and Drug Administration issued an alert about the increased risk of death in elderly patients with dementia receiving antipsychotic drugs following a review of 17 trials that found increased risk of heart failure, sudden death and pneumonia.

A few months before Durgin Pines started its effort, a CMS public-private partnership on nursing home safety urged facilities to achieve a 15% reduction nationally in nonclinical uses of antipsychotic drugs. The CMS estimated that 39% of nursing home residents with cognitive impairment but no diagnosis of psychosis received antipsychotics between July and September 2010.

Patients with dementia have limited ability to respond to adversities in their environment, said Dr. Susan Levy, vice president of the Society for Post-Acute and Long-Term Care Medicine. For years, nursing homes have addressed the problem with medications developed for conditions such as schizophrenia and bipolar disorder. These patients' difficult behaviors, she said, are frequently triggered by subtle unmet needs. “People think a pill can make the problem go away,” she said.

Leaders at Durgin Pines outlined a comprehensive plan to reduce the overall use of antipsychotics 20% by the end of 2012 and an additional 15% by June 2013. The plan included what the facility called “global stimulus reduction” to address environmental factors that made residents' experience more stressful. “Nursing homes are extremely overstimulating places,” said Nick Bridges, the facility's administrator. “Stimulants contribute to the problem and can often be removed.”

Durgin Pines got rid of loud alarms used to alert staff about patient falls. Hard-of-hearing patients who watched TV with the volume on high were given wireless headsets. The entry doors to the long-term-care unit were opened on weekdays so patients did not feel shut in, which also reduced noise from the double doors opening and closing.

Nursing home leaders noticed that on-call physicians received more staff requests for antipsychotics in the middle of the night, when demented patients were more likely to have behavior episodes. To improve sleep quality and reduce such episodes, the wattage of hallway lights was reduced. Taking vital signs in the middle of the night was discouraged. And residents known to show more aggression in the evening were given their baths earlier in the day.

Even the dining service was restructured. “Imagine having lunch and someone is screaming right next to you,” Fazeli said. “It's not a happy experience.” Durgin Pines changed the schedule so fewer patients dined at the same time, and those needing less assistance could take their meals separately from those needing a lot of staff attention.

Managers held meetings and walkthroughs on every shift to explain the new policies, including that physicians would question the appropriateness of every antipsychotic drug request.

“The results have been remarkable,” Bridges said. Over 13 months, there has been a steady decline in antipsychotic use. In August 2013, no patient was taking the drugs. No more than 3% of residents have been on antipsychotics at any given time since then.

Durgin Pines' efforts were recognized by the American Health Care Association, and its leaders presented data on their antipsychotic drug reduction program at the association's annual conference in Washington on Oct. 8.

Last month, the CMS' national partnership, which includes the AHCA, announced the previous national goal had been exceeded. Experts say nursing homes across the country have found innovative ways—from music and aroma therapy to rethinking staffing schedules—to achieve the reductions. The partnership now is aiming for a 25% national reduction from the original base line by the end of 2015 and a total reduction of 30% by the end of 2016.

In January, the CMS' quality star rating for nursing homes will be based partly on the percentage of residents receiving antipsychotic drugs.

Though Durgin Pines staffers initially worried the changes would lead to more patients with uncontrolled behaviors, “it wasn't anything like we thought,” said registered nurse Kathryn Chick. “In the end, it was a good thing, because it forced us to look at what was really making the patients upset.”

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