Reducing Antipsychotics in Skilled Nursing Facilities

By Leesha Lentz

Experts try to reduce use of these medications in patients with dementia-related psychosis.

Since 2010, IPC Healthcare, a national physician group practice focused on the delivery of hospital medicine and related facility-based services, has partnered with University of California, San Francisco (UCSF) to create a yearly fellowship program where participants are required to undertake a quality/operational improvement project in their own hospitals. Last year, one identified patient safety challenge was to reduce the antipsychotic drug use in skilled nursing facilities. Antipsychotic drugs are often appropriate treatment for schizophrenia and psychotic symptoms including delusions and hallucinations; however, these medications often are given off-label to older adults who experience behavioral and psychological symptoms of dementia (BPSD).

Antipsychotics may have serious side effects when administered to dementia patients, according to Rafael Rondon, MD, a post acute care specialist in internal medicine and geriatrics for IPC Healthcare, who worked on this project in a skilled nursing facility in Tampa, Florida. They carry a black box warning, stating that they are not approved in elderly dementia patients because of the increased risk of hospitalization and mortality.

"Antipsychotics are not FDA approved for dementia-related psychosis," Rondon says. "They are costly in many ways to the health care system and, more importantly, to the patient, [since antipsychotics] may cause serious side effects, including death. Why give a medication to our loved ones that would cause more harm than benefit?"

With the FDA issuing this warning on antipsychotics for dementia patients, skilled nursing facilities are encouraged to limit antipsychotic use, opting for nonpharmacologic interventions as the first line of defense in patients experiencing BPSD. Yet approximately one-half of nursing home residents may be given inappropriate prescriptions for antipsychotic medications, according to Rondon. Additionally, at the start of this IPC/UCSF project, about 65% of the residents in the Florida facility were taking them. The medication's prevalence suggests that physicians should screen patients for possible dose reductions or to determine whether medications are being administered long after symptoms have resolved.

Gradual Dose Reduction
The project's objective was to reduce antipsychotic use by 3% each month for three consecutive months. To accomplish this, an antipsychotic committee was formed, consisting of physicians, psychiatric advanced registered nurse practitioners, pharmacists, and the director of nursing. Together the committee discussed behavioral changes in patients twice per week, either through direct observation or nurses' assessments, and assessed for possible recurrences of the BPSD. The pharmacist measured drug interactions, side effects, and costs, while the director of nursing provided proper education to the entire nursing staff.

Rondon believes that teamwork was an essential component of this project. "The team was created to target all the aspects in the patient care," he says. "It is well known that care improves when interdisciplinary rounding is performed. A key and very important point for the success in the program was to maintain excellent communication among each other to closely monitor change in behavior once doses had been adjusted."

The committee's goal was to identify patients taking antipsychotics who were good candidates for gradual dose reduction. They selected 20 patients, 10 of whom were administered risperidone and 10 who were administered olanzapine. The patients administered risperidone had the dose of 2 mg twice daily reduced to 1 mg twice daily, and the patients administered olanzapine had the 20 mg daily dose cut to 15 mg daily. By the end of the three months, there was a 6% reduction in antipsychotic doses.

Positive Outcomes
Rondon and his team found measurable results through dose reduction, especially in cost savings for the facility and health care system. Within three months, there was a total savings of approximately $17,100, saving about $300 per month per patient for those taking olanzapine, and $270 per month per patient for those taking risperidone.

Felix Aguirre, MD, SFHM, vice president of medical affairs for IPC Healthcare, points out some areas where antipsychotics reduction can generate cost savings. "When an unneeded antipsychotic drug is reduced in a post-acute care facility, health costs savings can be generated by the actual cost of the unneeded medication that is reduced, costs savings related to the reduced staffing need for the administration of these medications, costs savings related to reduction in the management of the common side effects, and reduction in the number of unnecessary hospitalizations," Aguirre says.

And most importantly, the project led to improvements in patient care, according to Rondon. When patients are administered antipsychotics, they are at risk of side effects, such as sedation, increased risk of falls, and pressure ulcers, he says. By reducing the dose, patients experienced fewer of these side effects. "We had different patients that benefited from the reduction and that is the beauty of the program since these medications were specifically indicated 'to help' them with their behavioral disturbances and psychosis and instead were giving them side effects, increasing the risk for falls, pressure ulcers, and unnecessary hospitalizations," Rondon says. "One particular patient spent most of the time in bed kind of groggy and not participating in activities. Now the patient is interacting more and has less behavioral disturbances."

Rondon hopes to extend this program to more skilled nursing facilities in Florida and beyond. The ultimate goal is to have patients continue the dose reduction until they can be taken off the medication entirely, if feasible. However, physicians must carefully consider antipsychotic medications and frequently reassess older adult patients to determine the best intervention.

According to the Alzheimer's Association, "there are instances where BPSD pose a greater risk to individuals and families living with dementia than antipsychotic medications. This is especially true in cases of individuals with recurrent behaviors that pose a threat to life, progressive decline in nutrition and mobility related to BPSD and severe-stage dementia with terminal delirium. In these instances the greater harm may result from lack of aggressive control of behaviors with antipsychotic therapy."

But in the right patients, through careful reassessments and an interdisciplinary team approach, physicians may be able to decrease or stop medication altogether to minimize the overutilization of antipsychotics. Rondon says one of the next steps is to create a culture change among physicians that would allow the antipsychotics committee to review their patients as well.

The Alzheimer's Association offers tips on nonpharmacologic interventions that physicians and caregivers can implement with their patients, as well as a list of considerations for when antipsychotic therapy may need to be employed. Their position statement and tips can be found at www.alz.org/national/documents/statements_antipsychotics.pdf. To learn more about BPSD and caregiver tips, see "Behavioral Expressions in Dementia Patients" in the January/February issue of Today's Geriatric Medicine.

— Leesha Lentz is a freelance writer based in Louisville, Kentucky.