Practical Research – Managing BPSDs
The clinical outcomes for about 95% of long-term care residents living with dementia could be improved by applying longstanding research to the bedside, report GuideStar clinicians in Annals of Long-Term Care. Practitioners can prescribe a combination of acetylcholinesterase inhibitors and memantine, often helping with behavioral and psychological symptoms of dementia (BPSD). But do nursing home standards of care reflect this?
The team of GuideStar clinicians recently investigated the neuropharmacology of 121 long-term care residents in four buildings that were new to GuideStar Eldercare services. The report appeared as a Practical Research article.
BSPD intervention – a missed opportunity
Researchers found that only 22% of residents were currently receiving any BPSD-specific neurologic medications, and only 5% were optimally treated with the combination of the two classes of medication.
The medications— acetylcholinesterase inhibitors plus memantine—are known to improve cognition, function, and behavioral and psychological symptoms of dementia (BPSDs). The newly published Practical Research article builds on existing knowledge that the mechanisms of action of acetylcholinesterase Inhibitors and memantine are complementary—and that using these medications together can improve clinical outcomes in residents living with dementia.
Most residents of long-term care facilities have neurocognitive impairment, note the authors, and most meet CMS criteria for axis I diagnosis during their residency.
“Alzheimer’s disease and vascular, mixed, Parkinson, and Lewy body-related dementias comprise approximately 90% of cases of Alzheimer's disease and related dementias among long-term care facility residents, and all are amenable to this primary approach to BPSD intervention,” said the authors.
Neurology-first care model
Over the past decade, about one-quarter of long-term care residents living with dementia have received prescriptions for antipsychotic medications, yet few of them had a verified psychiatric diagnosis, explain the authors.
It’s crucial to recognize dementia as a neurological condition, triggered by a range of neuropathologies, they add. In a neurology-forward care model, clinicians emphasize accurate diagnosis and then treat the neurological condition to optimize clinical outcomes.
An extensive body of research underpins the efficacy of prescribing acetylcholinesterase inhibitors and memantine in tandem—yet adoption in nursing home practice has lagged. For example, Atri et al. reported in 2013 that the combination of donepezil plus memantine for residents with moderate to severe Alzheimer’s led to improved cognition, function, and global status. They concluded, “Combination treatment produces substantially reduced rates of marked clinical worsening, has good safety and tolerability, and generates effect sizes that are both statistically significant and clinically meaningful.”
Reducing psychotropic medications
Antipsychotic use in dementia can lead to serious adverse outcomes. This is why CMS continues to urge curtailing unnecessary use of psychotropic medications and achieving gradual does reduction.
The bottom line is that “putting neurology at the head of the table” opens up effective treatment options for the symptoms of dementia, says Dr. Steven Posar. GuideStar has consistently demonstrated that neurology-forward care leads to positive results.
See the research article by Steven Posar, MD, Anita Reid, APN, FNP-BC, GNP-BC, and Daniel Heiser, PsyD, “The Rate of Use of Acetylcholinesterase Inhibitors and/or the NMDA Antagonist Memantine in Long-Term Care Residents With Dementia at Risk for BPSD,” in Annals of Long-Term Care (Jan. 16, 2025).