Riding the T.R.A.I.N. Down the G.D.R. Line

Proper Assessment & Documentation: Reducing Unnecessary Psychotropics
Presented by: DADS Quality Monitoring Program

Why are we here today?

  • Describe strategies to monitor and target behaviors in the long-term care population
  • Explain the relationship between pain management and psychotropic medications
  • Explain best practice pain management strategies
  • Stress the importance of good documentation and a supportive interdisciplinary team

Chemical Restraints 1987 OBRA Legislation

  • Specified that residents in nursing homes must be free from physical and chemical restraints imposed for the purposes of discipline or convenience
  • The Federal Congress reacted to public outcry noting that nursing home residents were over-medicated and excessively restrained
  • Many residents received psychotropic medications (esp. antipsychotics) without indication or monitoring

Reference: Richard E. Powers, MD "Overview of OBRA Guidelines for Psychiatric Care in Nursing Homes" 2008 Bureau of Geriatric Psychiatry/Dementia Education & Training Program for the State of Alabama

What are psychotropic medications?

Drugs that affect brain activity by altering either mood or behavior

  • Antipsychotics
  • Anti-anxiety meds
  • Anticonvulsants
  • Hypnotic meds
  • Antidepressants

Consent for Psychotropics

  • Texas law states that there must be signed consent before administering psychotropic drugs, unless it is a documented emergency
  • TAC Rule §19.1207 Prescription of Psychoactive Medication
    • Must outline the condition being treated
    • Note beneficial effects expected on that condition
    • State probable significant side effects of the drug
    • Indicate proposed duration of treatment
  • The right to revoke is noted in writing
  • Refusal to consent must be documented in the clinical record

Current Focus: Antipsychotics

Emphasis on reducing the inappropriate use of antipsychotics to treat behaviors

  • Aripiprazole (Abilify§)
  • Haloperidol (Haldol§)
  • Olanzapine (Zyprexa§)
  • Quetiapine (Seroquel§)
  • Risperidone (Risperdal§)

Why Antipsychotics First?

  • In the nation, Texas has the second highest antipsychotic use in the nursing home setting
  • Antipsychotics have the strongest evidence for negative consequences when used in older individuals, especially those with dementia
  • The FDA has warned medical professionals that using antipsychotics for dementia-related behaviors or dementia-related psychosis puts residents at a risk for possible death -FDA Black Box Warning

Antipsychotic Mechanism of Action

  • Block neurotransmitters in the brain at dopaminergic, histaminic, cholinergic, and serotonergic receptors in the brain
  • The main action is to block dopaminergic pathways to reduce the core symptoms of psychosis: hallucinations, delusions, and paranoid ideation

Dementia Disease Process

  • Permanent degenerative changes in the brain
    • Lack of acetylcholine presence
    • Beta-amyloid plaques causing inflammation and brain cell death
    • Tau protein tangles causing brain cell dysfunction and cell death
  • The "psychosis-like" symptoms seen in dementia are unlike the psychoses in chronic mental illness (e.g. schizophrenia)
  • Disturbances arise from short-term memory/recall problems causing disorientation to time, place, and environment

Antipsychotic Side Effects

  • sedation; drowsiness/dizziness; disorientation
  • confusion; memory or functional impairment
  • risk of delirium
  • fall risk; orthostatic hypotension (sudden drop in blood pressure when standing)
  • constipation, urinary retention, dry mouth; blurred vision
  • restlessness; inability to sit still; anxiety; sleep disturbances
  • tremor; slowed movements; muscle rigidity; strong muscle spasms (neck, tongue, face, or back); drooling
  • tardive dyskinesia
  • low white blood cell count; irregular heart rate; seizures; metabolic issues; neuroleptic malignant syndrome; increased risk of sudden cardiac death

Antipsychotic Risks

  • Worsening or complications with dysphagia
  • Increased risk of aspiration pneumonia and upper respiratory infections
  • Increased risk of urinary tract infections
  • Contribute to the risk of developing delirium
  • Increased risk for pressure ulcers
  • Declines with decision-making capability (think about safety awareness)
  • Increased risk of falls
  • Decreased ability to be understood/understand
  • Declines in functional ability and independence

Antipsychotic Challenges for Dementia

  • Behavioral disturbances tend to be episodic and can diminish spontaneously
  • Antipsychotics are likely to be prescribed with comorbid conditions and many medications
  • Antipsychotics are more likely to be prescribed for those already on psychotropic medications
  • Over time, antipsychotics are barely more effective than placebo

Diagnoses

CMS sets the approved diagnoses for antipsychotics in the nursing home setting

  • Schizophrenia (plus: schizo-affective &§ schizophreniform)
  • Delusional disorder
  • Mood disorders (e.g., bipolar disorder + MDD)
  • Huntington's disease
  • Tourette's disorder

CMS also lists other acute short-term diagnoses

Dementia: Unapproved/Off-Label

  • CMS recognizes that antipsychotics are started in hospitals or in the community setting
  • CMS places the responsibility on the nursing home to evaluate the continued need for the antipsychotic
  • Evaluations for continued necessity must be in the clinical record on admission or within 14 days after admission to the nursing home

Anti-anxiety & Hypnotic Medications

  • Can be utilized as potential chemical restraints by administering for discipline or convenience
  • Are subject to the same standards as antipsychotic drugs with monitoring, care planning, gradual dosage reductions, and periodic review for necessity
  • Indicated for long-term scheduled use for diagnoses of primary anxiety disorders or primary insomnia disorders (generalized anxiety disorder (GAD), panic disorders, parasomnia, etc.)

The Rising Use of Anticonvulsants

  • Potential chemical restraints by administering for discipline or convenience due to their sedating effects
  • Considered off-label prescribing as a "mood stabilizer" in dementia care
  • Subject to the same standards as antipsychotic drugs with monitoring & care planning, gradual dosage reductions, and periodic review for necessity

Unmet Needs

  • Underlying medical issues
  • Pain and discomfort
  • Environmental triggers
  • Not being heard by others
  • Not being understood
  • The need for toileting
  • Thirst or hunger
  • Tired or exhausted
  • Boredom
  • Worry or fear
  • Loss of independence
  • Frustrations with abilities
  • Control over personal decisions
  • The need for a purpose/meaning
  • Activities of their choice
  • The need to feel wanted

Importance of Documentation

  • Permanent record of key healthcare facts
  • Excellent nursing practices for patient safety
  • Core of every patient/resident encounter
  • History of the nursing services that were delivered
  • Form of communication with other healthcare personnel*
  • Determines the basis for future decisions
  • Quality reporting in public health and reimbursement
  • Best evidence that staff members have adhered to the standards of care

Pre-psychotropic Documentation

  • Target the behavior first as a problem/risk in the care plan before starting medications
  • Discuss interventions and approaches with all members of the interdisciplinary team and obtain input from family members
  • Document individualized person-centered non-pharmacological interventions and therapeutic approaches in the care plan
  • Implement those interventions and approaches across various disciplines

Documenting Targeted Behavior

  • Without good documentation, there is the potential that psychotropic drugs are viewed as possible chemical restraints when the diagnosis is off-label
  • When antipsychotics or other psychotropic drugs are prescribed for behaviors there is a possibility of keeping them unnecessarily and longer than needed
  • When an antipsychotic drug is used for behavior(s) causing significant distress or harm to self or others in an unapproved or off-label diagnosis such as dementia, documentation is especially important

Who's on your IDT?

  • Include the physician, pharmacist, nurses, CNAs and med aides, social worker, activities director, and on occasion get input from housekeeping and maintenance personnel
  • Other disciplines may have more information to offer, or possibly add to brainstorming solutions
  • Get input from family members, because behaviors can be misinterpretations from the person's past experiences

Finding Your Quality Measure Data

Medicare Nursing Home Compare

  • https://www.medicare.gov
  • Click on "Finding nursing homes"
  • Search for your facility

Calculation: # of residents on AP (exclude Schiz, Hunt, Tour)§ X§ 100 divided by Current census

Eliminate Barriers

  • Address preconceived notions and fears of staff
  • Educate staff about long-term effects of medication
  • Assure accurate documentation of behavior
  • Educate and inform family members about:
    • The dementia process
    • Benefits and risks of medication
    • Consultant pharmacist recommendations
  • Discuss your goals with physicians and consultant pharmacist

Interaction with Physician and Pharmacist

  • Physicians may not be up-to-date with current guidelines for treating dementia
  • Primary care physicians may feel awkward about changing medications
  • Psychiatrists may feel threatened by possible consequences of reduced prescribing
  • Pharmacists may feel threatened when making recommendations

Alternatives to Antipsychotics

  • Non-medication Interventions and Treatments
    • Recommended first-line therapy for behavioral signs and symptoms of dementia (BPSD)
  • Antidepressants
    • SSRIs and SNRIs are preferred
    • SSRIs are FDA approved for anxiety
    • Consider delayed effectiveness
  • Anti-anxiety medications
    • Buspirone—delayed effectiveness
    • Short-acting benzodiazepines

Getting Started

  • Evaluate need for medication on admission.
  • Identify ALL residents on antipsychotic medications
  • Determine which antipsychotic medications are clinically appropriate
  • Implement gradual dose reduction as needed/indicated
  • Manage unmet needs (behaviors) through improved dementia care using person-centered interventions and treatments

The GDR Process

  • Titration of the dose downward occurs slowly at 1 to 2 week intervals by physician's orders.
  • All staff should know that dosage reduction is occurring and allow for periods of adjustment to new doses
  • Use non-medication interventions & treatments for behavior that occurs
  • Keep documenting and communicate with other staff members what does and does not work

Strategies for Success

  • Target specific behavior(s) and link them with treatment of a specific medication
  • Monitor for presence of targeted behavior(s) and side effects on each shift
  • Monitor resident§ for changes in cognition and function
  • Document non-drug interventions implemented and their effectiveness for targeted behavior occurrences
  • Periodically evaluate (at least quarterly) targeted behavior(s), effectiveness of drug and non-drug therapy, undesirable effects, and consider GDR

Resources

Advancing Excellence in America's Nursing Homes
https://www.nhqualitycampaign.org/goals.aspx

Survey & Certification Letters 13-35-NH and 14-19-NH
http://www.dads.state.tx.us/providers/communications/sc.cfm?PageNum_prosclist=2

Provider access to surveyor training on antipsychotics
http://surveyortraining.cms.hhs.gov/pubs/Archive.aspx

Serial Trial Intervention (STI) approach at GeriatricPain.org
http://www.geriatricpain.org/pages/SearchResults.aspx?k=sti