As rates of antipsychotic use drop at nursing homes, worries increase for patients

After years of criticism, nursing homes have curbed administering antipsychotics, but some providers are questioning whether the across-the-board cuts are preventing some seniors from getting needed medications.

The prevalence of use of antipsychotics among nursing home residents who have been in care for at least 100 days is 15.7% down in 2017 from 23.9% at the end of 2011, according to new data from the CMS. The reduction is due to a partnership between industry and the CMS in which nursing homes look for ways to reduce their reliance on the drugs. The National Partnership to Improve Dementia Care in Nursing Homes, which began in 2012, sparked by a report from HHS' Office of the Inspector General that found 83% of atypical antipsychotic drug claims were for elderly nursing home residents who had not been diagnosed with a condition for which antipsychotic medications were approved by the Food and Drug Administration.

The partnership includes the American Health Care Association, the American Health Quality Association, LeadingAge, the American Medical Directors Association and Advancing Excellence.

"For people with cognitive dysfunction, whatever from, there isn't a cookie-cutter approach," said Dr. Victoria Walker, chief medical officer at Good Samaritan Society, which has 160 facilities across 24 states. "It's not a simple as take this pill; it has to be more person-centered than that."

Her company's nursing homes are in some states that the CMS has noted had the sharpest drops in use of antipsychotics, including Arkansas, which has seen a 10.87% drop in use among long-term care residents since 2011 and Florida, which has seen a 9.21% decrease.

The long-term care industry has taken aggressive steps to ensure only patients who truly need the drugs will get them. This approach centers on creating a customized care plan for patients to uncover the underlining reason for aggressive behavior and to address those without using antipsychotics.

For instance, if a patient is reluctant to take a bath in the morning, instead of relying on drugs as a way to make them more compliant, staff members may reach out to family who may reveal that patient usually take baths at night, which is a simple fix that wouldn't require medication.

"By decreasing the use of antipsychotics, we have seen an increase in engagement in both our staff and our elders," said Annette Wenzler, chief nursing officer at Signature Healthcare, a long-term-care company with 125 locations in 11 states. "For our staff, education and regular team huddles improve communication, which improves medication management. For our elders, they experience a trust and familiarity with their daily caregivers."

Despite the progress made, advocates are hopeful the CMS and industry won't put on the brakes.

"We're not done. There's been a significant decrease, but there's a long way to go," said Beth Kallmyer, vice president of constituent services at the Alzheimer's Association. "Ultimately antipsychotics are not indicated for people with dementia. They should not be a first intervention, and unfortunately in many long-term care facilities, it still is."

Some clinicians have felt that federal surveyors have an expectation that nursing homes are working toward a 0% rate of antipsychotic use that puts patients truly in need of the drugs at risk, according to Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, which represents nursing homes.

As this partnership continues, work needs to be done to figure out what an appropriate rate of use is that ensures that patients that actually need the drugs will get them.

"There is a feeling among some providers that people who might benefit from the drugs shouldn't get them or else they may get themselves in trouble," Gifford said. "If there are people for which these drugs are indicated and they are not getting them, then you've crossed a line."