Antipsychotic Use in Assisted Living

Think It's Only in Nursing Homes, Think Again

By using love and kindness and understanding to better know the resident you can reduce the use of antipsychotics and create a better experience. Dwight Eschliman

In early 2012, in response to the persistently high rate of antipsychotic medication use in nursing home residents with dementia, CMS established the National Partnership to Improve Dementia Care in Nursing Homes, a unique public-private partnership that outlined a multidimensional strategy to address this public health issue.

Two new measures of antipsychotic medications were posted on the Nursing Home Compare (NHC) website beginning July 2012.

The new measures included an incidence measure that assesses the percentage of short-stay residents that are given an antipsychotic medication after admission to the nursing home, and a prevalence measure that assesses the percentage of long-stay residents that are receiving an antipsychotic medication.

Over 18 months, the national prevalence of antipsychotic use in long-stay NH residents was reduced by 15.1%.

Assisted living is another story. The Government Accountability Office (GOA) issued a report that shows that 14% of antipsychotic use occurs outside nursing homes in such places as assisted living and home health.

None of the programs at the Department of Health and Human Services (HHS) have been directed to settings outside of nursing homes, such as assisted living facilities or individuals’ homes. While the National Alzheimer’s Plan has a goal to improve dementia care for all individuals regardless of residence, HHS officials said that efforts to reduce antipsychotic use have not followed that spirit of the plan.

The GOA says in their report that "Given that HHS does not specifically target its outreach and education efforts relating to antipsychotic drug use to settings other than nursing homes, older adults living outside of nursing homes, their caregivers, and their clinicians in these settings may not have access to the same resources about alternative approaches to care.

By expanding its outreach and educational efforts to settings outside nursing homes, HHS may be able to help reduce any unnecessary reliance on antipsychotic drugs for the treatment of behavioral symptoms of dementia for all older adults regardless of their residential setting."

When choosing assisted living care pay attention to this issue and ask about it. And consider a model that has emerged from Ecumen Senior Living called "Awakenings." Awakenings takes a more holistic approach to person-centered care.

One of our guest authors, Barbara Frank furthers illustrates how the use of antipsychotics manifests in senior living.

At an AHCA Conference she noted that "Resident interviews reveal amazing things if you slow down, listen and respond. Combine that with consistent assignment, mid-shift huddles and empowered CNA's and you have true culture change."

She made her point masterfully. Dealing groups of six cards, she put us through an exercise in which we had to figure how a routine patient in a nursing home ended up dying in the facility through a series of missteps that could have been prevented.

This person was a night owl, yet with little to do at night, he was bored. So what does the staff do but give him sleeping pills.

He falls the first night going to the bathroom.

Why? Because he was disoriented from pills he never took before. He is in a bed he not used to. No one bothered to observe him to watch his balance, gait and to make a safe passage to the bathroom.

Now because he has fallen an alarm is on his bed. And now he is incontinent. As a former fireman, he jumps at alarms and he soon realizes that he does not want his bathroom habits announced to the world.

So he stops drinking and then gets a urinary track infection. They give him more medications. He becomes agitated. He slugs a nurse.

And it all started with the sleeping pill and inattention to environment.

The resident interview is at the heart of the new MDS regulations and in many ways at the heart of person-centered care. But if we don't listen and pay attention it is all for naught. So when shopping for care, ask how the resident interview is conducted.

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