Reducing Polypharmacy in Dementia Care

Polypharmacy is a concern among older patients and nursing home residents, and antipsychotics for managing neurobehavioral symptoms are of particular concern. They are sometimes misused as a form of chemical restraint; they can lead to adverse health effects such as falls, fractures, and cardiovascular events—and they can lead to ER visits or hospitalization (Cioltan, H. et al.). A backdrop of polypharmacy can make the assessment process challenging as well.

Polypharmacy and accurate diagnosis

The polypharmacy issue begins during assessment, which requires understanding causes and effects of clinical symptoms. Many nursing home residents have comorbidities, and CMS reports that the average Medicare enroll takes, on average, almost 7 drugs. (Learn more about Co-Occurring Diagnoses in Alzheimer’s Patients)

In skilled nursing facilities, as many as 74% of patients could be taking 9 medications or more (Cioltan, H. et al.). Side effects, drug interactions, and other unintended consequences can cloud the clinical picture, imposing challenges to accurate differential diagnosis, effective treatment, and patient well-being.

A comprehensive assessment considers medications as part of the neurobehavioral picture; this can help practitioners develop accurate diagnoses. If a symptom is drug-induced, pinpointing that is essential. Sometimes the effects of a drug treatment can lead to cognitive changes in a resident that would be easy to misinterpret. Older patients can be particularly susceptible to drug effects due to metabolic changes associated with aging. For example, some anticholinergic medications can reduce cognitive functioning (Cioltan, H. et al.). For a patient with Parkinson’s disease dementia, medications that increase dopamine can produce psychosis. Even dehydration, from medications or other factors, can lead to impaired cognitive function (Wilson and Morley) that could be misunderstood.

Once an accurate diagnosis or diagnoses are confirmed, polypharmacy can continue to create issues, especially for patients with dementia.

Off-label antipsychotics and dementia

In 2005, the FDA placed a black box warning on antipsychotic medications for the elderly. The OBRA Nursing Home Reform Law of 1987 created quality standards that include freedom from chemical restraint, freedom from unnecessary drugging, and freedom to refuse treatment among its quality standards for nursing home residents.

“Antipsychotic medications (APMs) are approved by the FDA for the treatment of schizophrenia and/or bipolar disorder but are increasingly used to treat the behavioral symptoms of dementia, an off-label use,” according to Cioltan et al. They also note, “The effectiveness of APMs for off-label use to treat behavioral symptoms of dementia is not supported by strong evidence and the use of APMs in patients with dementia increases the risk of adverse health events with little evidence of effectiveness.”

CMS and gradual dose reduction (GDR)

“Protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need” is an important priority of CMS. In fact, they’ve formed the National Partnership to Improve Dementia Care in Nursing Homes to track usage of antipsychotic medications in nursing homes. They are partnering with federal and state agencies, providers, and caregivers to “implement practices that enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident” (CMS National Partnership to Improve Dementia Care in Nursing Homes).

Over a recent 9-year period, CMS reports a reduction in use of antipsychotic medication for nursing home residents from an average of 41% to 14.1%. However, they note that medication practices are far from uniform across the country. In surveys, CMS is looking for policies, procedures, and/or protocols for dementia care that holistically address each resident’s needs, according to its memorandum, Focused Dementia Care Survey Tools.

CMS reports the “percentage of long-stay residents who got an antipsychotic medication” as a parameter on its consumer-facing Nursing Home Compare website, benchmarking it against state averages, to help consumers make informed nursing home choices.

Implementing gradual dose reduction (GDR) for antipsychotic medications requires a sound clinical approach and neurobehavioral expertise. At GuideStar, specialized Nurse Practitioners deliver extensive experience and guidance in the GDR process to ensure patient comfort and safety.

Using antipsychotics in dementia care

There is a limited body of literature that evaluates how well antipsychotic medications work in dementia care, according to Cioltan, H. et al. They explain that the American Psychiatric Association has created guidelines for short-term use of antipsychotics for dementia patients who experience a psychotic episode. In long-term care, use can be limited to a situation in which the patient is “exhibiting hazards to self or others”.

Psychotic behavior or pain?

It is easy to misinterpret pain in advanced dementia patients as psychotic behavior, according to CaringKind. The reason is that confusion and weakened communication skills may make it difficult for a patient to articulate what’s wrong. A caregiver may notice moaning, agitation, or even striking out. In response, sometimes an antipsychotic may be prescribed, but this is the wrong solution, they say. “Anti-psychotic medications do not help pain… and may mask pain with sedation, making it even harder for the resident to communicate his/her discomfort or pain” (Palliative care for people with dementia). Instead, they suggest helping a patient express pain in order to address negative behaviors.

Alternatives to medications

As with the advice above, medical literature suggests that psychosocial interventions can be a viable alternative to antipsychotic medication in nursing homes (Cioltan, H. et al.). They outline strategies that can help:

• Redirection and reorientation techniques
• Environmental intervention
• Simplifying tasks
• Participation in activities
• Optimizing sensorium
• Ensuring social engagement
• Maintaining the sleep-wake cycle.

A holistic, team approach to polypharmacy

Interdisciplinary, person-centered care is essential to reducing polypharmacy. Anita Reid, MSN, APN, FNP-BC, GNP-BC, Senior Vice President, Nurse Practitioner Services, explains that specialized Nurse Practitioners play a crucial role in reducing polypharmacy and gradual dose reduction for patients served by GuideStar Eldercare: “The role of the Nurse Practitioner is to evaluate and assess psychotropic medications, manage those within the facilities, and to help the residents achieve quality of life with the least amount of medications possible.” Comprehensive assessment, accurate diagnosis, an aligned plan of treatment, ongoing vigilance, and staff training can help in achieving this important goal to actively promote the safety, functionality, and dignity of our vulnerable elders in long-term care.