Antipsychotic Reduction: Key Ideas

Clinical staff in nursing homes across the country are aiming to reduce use of antipsychotics. As a guest on the JAMDA On-The-Go podcast recently, GuideStar Founder & CEO Steven Posar, MD, shared some key ideas that can help.

Consider neurology first. Continuing research informs the understanding that neurocognitive impairments have “downstream effects on psychiatric status”. Thus, a useful orientation is to understand the primary issue as neurologic. Then “you benefit from having neurology in the lead,” he said.

Clear up diagnostic confusion. Virtually all nursing home residents with neurocognitive impairment will eventually experience psychiatric impairment, according to MDS data, said Dr. Posar. Yet only 5% have a history of serious mental illness. “There’s a tremendous amount of mythology about the diagnostic status that can be cleared up,” he explained. Psychiatric symptoms secondary to a neurocognitive impairment do not warrant a psychiatric diagnosis. As an example, he said, “There literally is no such thing as geriatric onset schizophrenia; it doesn’t exist.”

Reframe the language. Residents living with dementia who experience psychiatric symptoms are not psychiatric patients. “They are neurology patients with downstream psychiatric symptoms,” he said.

Clean up polypharmacy. Noted Dr. Posar, “There is a lot of misunderstanding about the impact of polypharmacy on folks’ cognitive and psychiatric status, so cleaning up their medications makes a big difference.” Anticholinergics are a class of medications “you want to virtually get rid of,” he said, and some calcium channel blockers (dihydropyridines) can be associated with delirium, he notes.  (Learn more about medication dangers for nursing home patients in the blog, Get to Know the 2023 BEERS Criteria®.)

Get to know three classes of drugs. “You can make a huge change in patients’ clinical status,” said Dr. Posar, by focusing on three classes of drugs:

• Acetylcholinesterase inhibitors
• NMDA blocker (memantine)
• Selective serotonin reuptake inhibitors (SSRIs)

“With this approach,” he said, “you can eliminate or mitigate distressing delusions and hallucinations before you get to the point where you need an antipsychotic—so it’s really prophylactic as much as it is therapeutic.” Related research published in JAMDA demonstrated a 68% reduction in use of antipsychotics; fewer than 10% of patients remained on an antipsychotic medication, he explained. The combination of an acetylcholinesterase inhibitor and memantine “works better for BPSD than for cognition—and can continue well into the early levels of late-stage dementia."

“The latest addition is SSRIs,” he noted. “This comes out of a lot of research looking at serotonin disruption as a driver in Lewy body psychosis.” An SSRI should not be “added automatically” but can be added in response to “changes and signs of psychiatric distress.”

Research is indicating that certain medications may slow cognitive decline as well. Galantamine “slowed progression from moderate to severe dementia,” and acetylcholinesterase inhibitors can “slow the transition from mild cognitive impairment to dementia,” he said.

Be patient. A default that works well for many nursing home patients is the combination of an acetylcholinesterase inhibitor and memantine, said Dr. Posar. It is almost always effective for diagnoses such as Alzheimer’s disease, vascular dementia, and Lewy Body dementia. “There are contraindications, and a few diagnoses won’t respond. For example, frontotemporal dementia doesn’t respond at all.”

Following a review of polypharmacy and implementation of neurology-driven medication protocols, patience is paramount, Dr. Posar advised. Effects are not usually immediate. Nursing staff and all clinicians have to join hands and take a deep breath to achieve this paradigm shift, he said. In the JAMDA research cited earlier, the effects of gradual dose reduction took several months to manifest.

Rewards: gradual dose reduction

But patience can be rewarded with “significant improvement in the incidence, duration, and severity of BPSD,” said Dr. Posar. Learn more about the steps the GuideStar team uses in antipsychotic stewardship, and get in touch if we may be of assistance to you and your residents.