LTC: Neurology-First Care Yields Positive Results
“Approaching dementia care with a neurology-first mindset can bring positive results to residents in long term care,” said Provider in an introduction to its interview with Dr. Steven Posar, founder and CEO of GuideStar Eldercare. Dr. Posar is also a Clinical Professor of Geriatric Neuropsychiatry at Saint Mary’s College in Notre Dame.
He explained that a neurology-first approach can “safely reduce polypharmacy and reliance upon antipsychotic medications while increasing facility ratings, quality of life, and compliance,” reported Provider.
Neurology in LTC
The majority of long-term care residents actually have neurologic conditions, said Dr. Posar. Many of these relate to dementia, but there are other neurologic findings as well. “What we know about these folks from the MDS data is that functionally 100% of them will develop psychiatric impairment,” said Dr. Posar—behavioral and psychological symptoms of dementia (BPSD)— “and the majority of those will have severe BPSD.”
“We know that only 5% of this population had any kind of serious mental illness before they got organic brain disease,” he said. “So what you’re really looking at is 95% of this population were fine—perfectly OK—before they get neurologic disease.”
Ordinarily, when a person has a neurologic condition, “the first person they see is a neurologist,” he explained. However, in long-term care, that’s not the norm. This means we’re not building a complete clinical picture, he commented.
Neurology at the head of the table
“We put neurology at the table just because it made perfect common sense. Over time, what we discovered is neurologists not only belong at the table—they belong at the head of the table,” said Dr. Posar. An effective care model leads with neurology but by no means excludes other specialties, he added. Psychiatry, psychology, internal medicine, primary care, nursing, pharmacy, and other specialties need to be involved, he said, in a holistic approach.
“We know with this approach that we can remove the elements of BPSD that are pure neurology.” Underlying psychiatric and/or psychological conditions can remain, he said, and the specialized skills of the interdisciplinary team are crucial in developing individualized and effective plans of care.
A paradigm shift
As dementia has taken front-and-center in long-term care, we’ve been working with limited knowledge and inadequate tools for several decades, Dr. Posar said. Any time psychiatric symptoms of dementia develop, it’s been commonplace to call in psychiatry for help. Over the past 20 years, we’ve learned a great deal more about dementias—even though we still need to advance our understanding much further. Right now, the industry is challenged to apply emerging knowledge, he explained. “Medical practice in general is very conservative,” he said, so that change in clinical practice does not occur readily.
Dr. Posar sees our growing understanding of neurology and organic brain disease lighting the way to a paradigm shift in how we care for residents of long-term care. “You’re talking about a paradigm change, which tends to be a long, slow, generational process.”
Positive outcomes
Dr. Posar cited “remarkable” positive outcomes of the neurology-forward approach. “The suffering goes down enormously, the anxiety, the agitation. It’s just incredible…to see the positive change in these people‘s lives.”
The neurology-first approach has a quantifiable impact, Dr. Posar explained. He cited a 2023 publication demonstrating that a new collaborative care model piloted in three Indiana skilled nursing facilities reduced use of antipsychotics by 68% (see Reducing Antipsychotics in Nursing Homes: Results of a Peer-Reviewed Study).
More research is underway today, he noted. For example, the GuideStar team is preparing a publication documenting that the neurology-first approach can reduce acute inpatient psychiatric admissions by 40 to 70%, he said.
Dr. Posar spoke of positive transformation, not only in resident well-being, but also in the mood and culture of long-term care organizations. For residents, staff, and families, he’s found this approach “incredibly uplifting”. Stress levels drop, people are more engaged, and in his experience, compliance status improves.
Watch the full interview with Provider, and learn more about validated steps to reducing antipsychotic usage in long-term care in the GuideStar Eldercare blog.
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