Antipsychotic Stewardship Program: 6 Steps

The GuideStar Eldercare LTC Antipsychotic Stewardship Program® is a breakthrough approach to bedside care for nursing home patients with dementia. Across the LTC industry, management of Behavioral and Psychological Symptoms of Dementia (BPSD) needs a major reset, as outlined in the blog, Why LTC Needs an Antipsychotic Stewardship Program.

The challenge is to “prevent or mitigate BPSD without chemical restraint in neurologic patients with progressive or non-progressive neurocognitive disease,” GuideStar Eldercare presenters explained in a March 2023 presentation to PALTC about antipsychotic stewardship. “Proven primary neurologic-based pharmacotherapy will support this challenge,” they added.

GuideStar uses a 6-step treatment approach:

1. Neurologic, Psychiatric, and Psychological Diagnostic and Clinical Status Evaluation
   This step positions for success with an accurate diagnosis. When there is cognitive impairment, neurologic assessment is vital. For example, if a resident has only Alzheimer's on their diagnostic history, but is exhibiting severe behavioral changes and agitation, it very likely could be vascular dementia. Many dementias, in fact, are mixed.
2. Patient Total Pharmacology Review & Adjustment
   In this step, we review for any unnecessary medications and reduce polypharmacy where possible. This includes taking away medications that are not beneficial or counteract other prescribed medications. For example, when a resident is taking an acetylcholinesterase inhibitor (Aricept) in tandem with a bladder anticholinergic (Ditropan), we see a cholinesterase-based medication being canceled by the anticholinergic. In this case, Dr. Steven Posar says, “you’re just making expensive urine”.
3. Initiate Neurological Pharmacotherapy
   Our protocol of acetylcholinesterase inhibitors (Aricept, Galantamine) and an NDMA inhibitor (Namenda/Memantine) for all dementia residents who can tolerate them has proven highly effective in reducing the frequency and severity of BPSD. (See the poster session on this regimen, and watch for our next blog post explaining these medications.)
4. Reassess Psychiatric & Global Clinical Status
   This should occur 4-6 weeks after adjusting pharmacotherapy and initiating neurology-based pharmacotherapy.
5. Initiate and/or Amend Psychiatric & Psychologic Treatment
   Treatment should be based on the assessment. BPSD are much more responsive to psychiatric treatment following neurologic treatment.
6. Frequent Neurologic, Psychiatric, Psychologic Assessments
   A resident will change and decline. Thus, we continue assessing from an interdisciplinary position and making any needed therapeutic adjustments.

These steps improve clinical outcomes and are core to our mission— to enhance the quality of life for our shared patients by easing their suffering while actively promoting their safety, functionality, and dignity.

Learn more about antipsychotic stewardship strategies and benefits. For help in implementing these steps, feel free to reach out to the GuideStar Eldercare team.