Antipsychotic medications are used extensively in nursing homes. When used for approved disease states - such as schizophrenia, Huntington's disease and Tourette's syndrome - their clinical benefits are widely accepted. In people with a predetermined or long-standing history of mental illness, the chronic use of an antipsychotic medication also may be deemed necessary to stabilize and improve functionality. Sometimes antipsychotic medications are prescribed for off-label use in Alzheimer's disease and other dementia-related illnesses where the effectiveness of the treatment can show mixed results. The off-label use of antipsychotic medications for dementia-related illnesses is unsupported in the literature.
In elderly residents who have dementia, antipsychotics are only appropriate in a small number of instances. Yet, despite the Food and Drug Administration's warnings of increased mortality, the use of antipsychotics as a chemical restraint in nursing home residents who have dementia still persists. Significant morbidity - including higher blood sugar and cholesterol levels, weight gain, increased risk of falls, and decreased cognition - also are associated with the use of antipsychotics. These complications can lead to or cause a worsening of other primary diagnoses known to affect older adults.
HHS Antipsychotic Reduction Initiatives
HHS has several initiatives to help Texas nursing homes reduce the unnecessary use of antipsychotics among residents.
Music & Memory
Some Texas nursing homes have begun using individualized music playlists with patients who have Alzheimer's and other memory disorders to try to reduce the use of antipsychotic medication.
The HHS Music & Memory program began in 2015 with 32 nursing homes. The goal is to help residents reconnect with the world through specific, music-triggered memories. Family members and nursing home staff will create personal playlists for use on digital music players, such as iPods.
Visit the Music & Memory webpage to learn how your facility can introduce this program to your facility.
One A Month Campaign For Reducing Antipsychotic Use
If your facility serves many residents with Alzheimer's disease or dementia, the thought of how to transition them from the medication may seem daunting.
Then why not try this approach: One a Month.
HHS, the Texas Health Care Association, Leading Age Texas and TMF Health Quality Institute have launched the "One a Month" campaign to encourage facilities to commit to transitioning at least one resident a month off antipsychotic medications. The campaign builds on the strides Texas nursing homes already are making in this area.
If successful, that would mean about 1,200 people a month — or nearly 14,000 a year — would be free of those medications and their undesirable side effects.
This toolkit includes resources that will help facilities improve the lives of residents by appropriately reducing the use of antipsychotic medications through proven, non-pharmacological alternatives.
- Survey & Certification Letter 13-35-NH: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual and Appendix PP in the SOM for F309 (PDF)
- Checklist-Review of Care and Services for a Resident with Dementia (PDF)
- Antipsychotic Alternatives (PDF)
- Assessing for Pain as an Unmet Need (PDF)
- Care Planning Dementia-Related Targeted Behaviors (PDF)
- Antipsychotic Medication Tracking Form (PDF)
- Antipsychotic Drug Use and Dementia – Information for Families (PDF)
- Antipsychotic Drugs and Dementia Care – Fact sheet (PDF)
- AMDA Dementia in the Long-term Care Setting Clinical Practice Guideline Excerpt (PDF)
T.R.A.I.N.: Texas Reducing Antipsychotics in Nursing Homes
If you were not able to attend one of the T.R.A.I.N. conferences, the information is still available. HHS Education Services has developed a Joint Training Opportunity, Reducing the Unnecessary Use of Antipsychotics in Nursing Homes, based on the content from the T.R.A.I.N. conferences.
Visit the HHS Provider Joint Training page for more information, and to view the training calendar.
Resources Created by HHS
- Improving Dementia Care: Strategies for Pharmacists (PDF) in long-term care facilities was developed as a resource for consultant pharmacists, as they work with prescribers to reduce the use of antipsychotic medications in nursing home residents.
- Improving Dementia Care: The Strategies for Prescribers (PDF) is a resource for physicians and other professionals who prescribe medications for nursing home residents. This brochure includes strategies prescribers can utilize to improve dementia care and reduce the use of antipsychotic medications.
- Improving Dementia Care: The Role of Prescribers (PDF) was developed as a resource for physicians, PA-Cs and Nurse Practitioners who work with nursing home residents. These professionals play a key role in the efforts to reduce the inappropriate use of antipsychotic medications in nursing homes.
- QIPP Quality Metric Resource Toolkit – Quality Measure 419: Antipsychotic Medications: This toolkit will provide resources for working with facility staff to address educational deficits in caring for individuals with dementia, including alternative interventions to address dementia-related behaviors.
- The Center for Excellence in Aging Services and Long-Term Care: A collaboration between HHSC and The University of Texas at Austin School of Nursing, the Center is a web-based educational platform for the delivery of best practices. Phase I of the Center focuses on Antipsychotic Medications and alternative interventions for managing dementia-related behaviors.
- Limiting the Use of PRN Psychotropic Medications (PDF) provides prescribers and nursing home staff with helpful information regarding the use of psychotropic medications on a PRN basis.
- Evidence-based Best Practice for Antipsychotic Medications (PDF) provides evidence-based best practice guidelines for addressing management of antipsychotic medication use in the long-term care setting.
- Care Planning Dementia-Related Targeted Behaviors (PDF) is a sample care plan for managing the behavioral and psychological symptoms of dementia without using antipsychotic medications.
- Antipsychotic Medications and Dementia Care (PDF) provides information about antipsychotic medications prescribed for the off-label use in treating behaviors associated with dementia. Typical and atypical medications and their side effects are discussed.
- Reducing Unnecessary Antipsychotic Medications (PDF) provides information for routinely monitoring antipsychotic drug usage, dosages, gradual dose reductions, the outcomes of those reductions on behaviors, and suggested timeframes for conducting dose reductions.
- Alternatives to Antipsychotic Medications (PDF) discusses the stages of cognitive impairment, the components of a behavior management program, causes of behaviors (such as medical conditions and environmental triggers), suggestions for alternatives, and monitoring the results of using alternatives.
- Antipsychotic Medication Tracking Tool (PDF) helps nursing home staff reduce the inappropriate use of psychotropic medications. It can be helpful in documenting pre-psychotropic medication root-cause analysis, promoting a proper decision-making process by identifying targeted behaviors, adjusting dosages accordingly, and reducing the length of time in which unnecessary medications remain within an individual's drug regimen. The target audience is clinical staff.
- Antipsychotic Education Form (PDF) includes the potential benefits, risks and burdens of antipsychotic medications and presents alternatives to antipsychotic medications.
- Be DADS Wise with the Use of Antipsychotics (PDF) provides helpful information about antipsychotic medications and reducing the inappropriate use of these drugs in long-term care settings.
- Basic Guidelines for Quarterly Psychotropic Medication Evaluation (PDF) provides guidance for conducting quarterly psychotropic medication evaluations and evaluating the effectiveness of non-pharmacological behavior interventions.
- Basic Guidelines for Behavior and Side Effect Monitoring (PDF) describes techniques for conducting effective behavior and medication side effect monitoring.
- Antipsychotics: What's the Big Deal? (PDF) includes types of antipsychotic medications, side effects, prescribing considerations, risk factors with dementia, behaviors, and quality of life issues.
Resources from the Centers for Medicare & Medicaid Services
- National Partnership to Improve Dementia Care in Nursing Homes
- Hand in Hand: A Training Series for Nursing Homes Toolkit
- Survey & Certification Letter 12-44-NH: “Hand in Hand: A Training Series for Nursing Homes,” on Person-Centered Care of Persons with Dementia and Prevention of Abuse (PDF)
- Survey & Certification Letter 13-02-NH: Clarification of Guidance Related to Medication Errors and Pharmacy Services (PDF)
- Survey & Certification Letter 13-34-ALL: Release of Mandatory Surveyor Training Program on Care of Persons with Dementia and Unnecessary Antipsychotic Medication Use-Release of Third Video (PDF)
- Survey & Certification Letter 13-35-NH: Dementia Care in Nursing Homes: Clarification to Appendix P State Operations Manual and Appendix PP in the SOM for F309-Quality of Care and F329-Unnecessary Drugs (PDF)
- Survey & Certification Letter 14-19-NH: Interim Report on the CMS National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011-Q1 2014 (PDF)
- Adverse Drug Event Trigger Tool (PDF)
Resources from Other Organizations
- American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides access to the 2015 revision to the Beers Criteria and related resources. Note: Access to these resources requires registration at the AGS website.
- Sane Use of Psychotropic Medications (PDF) addresses behaviors, altered mental status and treatment options.
- Diagnostic Checklist Clues to Identifying Causes of Common Behavior and Psychiatric Disturbances (PDF) can be used as a guide to match up findings related to the resident with known patterns and combinations of symptoms that may suggest a specific diagnosis.
- AP Resources 2014 (PDF) is a literature review and reference for best practices for antipsychotic/psychotropic medications.
- Dementia and Challenging Behavior Series is a series of six, web based modules, designed specifically for training nurse aides to work with residents with cognitive impairments. Registration is required before accessing this resource.