WHAT YOU NEED TO KNOW ABOUT THE USE OF ANTIPSYCHOTIC DRUGS Barbara Anthony, RN, LNC La. Dementia Partnership Project Coordinator Baranthony51@gmail.com 225-235-7411 Introduce myself and recognize Dr. Jolie if she is present. Housekeeping – Bathrooms and cell phones, Tickets in back of badge for door prizes. Go over registration packet. CEU forms, evals and handouts. If RN and Adm, will need to do 2 evals. Must see the eval is being turned in. I need to know if everyone brought the information they were supposed to bring. Go over reports briefly and see if someone needs a sample set. Also give out the packets as we give out the exercise handout.

CMS NATIONAL PARTNERSHIP INITIATIVE In early 2012, the Centers for Medicare and Medicaid Services (CMS) established the National Partnership to Improve Dementia Care in Nursing Homes in response to an Office of the Inspector General (OIG) report underscoring the high use of atypical antipsychotic medication for “off-label” indications among nursing home residents.  

Black Box Warning The US Food and Drug Administration (FDA) requires a warning on the label of all antipsychotic drugs. Such “black box” warnings are only required for drugs with serious risks. The warning includes the following: Warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.

WHAT IS AN ANTIPSYCHOTIC DRUG? An antipsychotic (an-tie-sy-COT-ick) drug is a medicine that works in the brain, which may help to block certain chemicals that can cause symptoms of psychosis, such as hallucinations or delusions. Hallucinations are when a person sees or hears things that are not there. Delusions are when a person believes something that isn’t true, even after being told. Some people with some mental illnesses like schizophrenia and bipolar disorder often have these symptoms and require the use of an antipsychotic.

WHAT ARE SOME COMMON ANTIPSYCHOTICS? Haldol Quetiapine (Seroquel) Olanzapine (Zyprexa) Aripiprazole (Abilify) Risperidone (Risperdal)

WHY AM I HEARING SO MUCH ABOUT THEM? Recent scientific studies from both universities and government agencies have found: That these drugs are often used too much in people with dementia That these drugs do not work as well as people first believed in people with dementia.

F329 – ANTIPSYCHOTIC DRUGS There is a federal regulation that nursing homes must follow regarding the use of Antipsychotic Drugs. It states: Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive GRADUAL DOSE REDUCTIONS, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. When it comes to antipsychotic use, the pharmacist should also play a key role in assuring the facility remains in compliance with these regulations. The 2nd part of F329 is specific to the use of Antipsychotic Drugs. (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

F329 – ANTIPSYCHOTIC DRUGS (cont.) This regulation relates to any resident receiving an antipsychotic. We will be discussing residents who have Dementia or Alzheimer’s because use for these residents can be more dangerous. However, these regulations apply to other residents in the nursing home receiving an antipsychotic.

GRADUAL DOSE REDUCTION (GDR) Within the 1st year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated After the first year, a GDR must be attempted annually, This will be a little different timelines for a resident with dementia who does not have a mental illness requiring PASSR Level II screening. We will discuss this scenario this afternoon.

GRADUAL DOSE REDUCTION (cont.) There are ways to find the right dose or know when to discontinue the medication.. When the reason for the clinical condition has improved/ stabilized, When the underlying causes of the original target symptoms/behaviors have resolved, and/or When non-drug interventions, including behavioral interventions, have been effective. When addressing behaviors, the skilled care givers must first attempt to use non-drug interventions to alter the resident’s behavior unless the behavior is causing a danger to the resident or others. So, what is the ultimate goal a gradual dose reduction? In order to find the optimal dose or discontinue the dose, it will be important to ensure staff are adequately monitoring and documenting residents behaviors to determine improvement, stabilizations, resolution of target symptoms, and the effectiveness of behavioral interventions.

MENTAL ILLNESS Mental illness is a psychiatric disorder of the brain involving a chemical imbalance which may cause psychotic symptoms. Schizophrenia, a type of mental illness, is a severe brain disorder in which people interpret reality abnormally. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior. Schizophrenia is a chronic condition, requiring lifelong treatment.

DEMENTIA/ALZHEIMER’s DISEASE Dementia, a neurological disorder, is caused by damage to brain cells. This damage interferes with the ability of brain cells to communicate with each other. When brain cells cannot communicate normally, thinking, behavior and feelings can be affected.

WHY WOULD THESE DRUGS BE USED IN PEOPLE WITH DEMENTIA? These drugs should be only for those residents with dementia who have exhibited psychotic symptoms, hallucinations or delusions. Studies show that many behaviors in people with dementia are normal reactions to something they find scary, upsetting or uncomfortable.

WHAT CAN THESE DRUGS NOT DO? These drugs do not help: Stop yelling or repeating questions over and over; Calm the resident who is being restless, fidgety or uneasy, Stop memory problems; Persons do more for themselves; Persons interact better with others; or Stop inappropriate things being said.

In fact, for many people with dementia, these drugs slow them down, making them drowsy or groggy. These drugs don’t get to the heart of the reason for the person’s actions.

WHAT ARE THE RISKS? People with dementia who are given these drugs are more likely to: be unsteady when they walk fall break their bones have incontinence (“pee in their pants”) have a stroke die sooner

IS IT SAFE TO STOP THESE DRUGS? Studies in nursing homes show that it is very safe to try stopping these drugs in people who: are taking a low dose, below the recommended therapeutic dose; have not had any actions recently; or did not have hallucinations or delusions before starting the drugs.

IS IT SAFE TO STOP THESE DRUGS? (cont.) Many experts suggest trying a lower dose or stopping these drugs can be safe because: in nursing homes, staff watch to see if there is a reason to keep using these drugs; many of the actions these drugs are used for are about unmet needs and cannot be fixed by drugs; and about one out of three people will still act in challenging ways, whether the drug is continued or not.

WHAT SHOULD I DO? If your loved one is already taking these drugs, ask: What type of drug is my loved one on? What caused the drug to be prescribed? How has the care team tried to help solve the problem without drugs? What is the plan to decrease or stop the drug?

WHAT SHOULD I DO? (cont.) If your loved one is not currently on an antipsychotic, BEFORE any are prescribed, ask: What is causing the drug to be prescribed? What has the care team tried to respond to my loved one’s challenging behaviors? How will they track the behaviors once the drug is started? What is the plan to decrease or stop the drug?

HOW CAN I HELP? Staff will never know all that you know! You can help by providing answers to questions such as: How does your family member express themself when they are scared, angry, anxious, and hungry? What, in the past, has comforted them? What is their typical daily routine? Are there any behaviors that you have found more difficult to respond to than others? What have you tried to prevent them? Stay involved in your loved ones care and attend care plan meetings.

For more information, visit qualityinitiative.ahcancal.org