A new day. Reducing Antipsychotic Use in Long Term Care

Reducing Antipsychotic
Use in Long Term Care
April 2, 2015
Maine Nursing Summit
Tarsha Rodrigue, RN BSN, Clinical Nursing Supervisor
MaineGeneral Rehab and Long Term Care
Glenridge Living Community
A new day.
Aging Population/Incidence of
Dementia
• The geriatric population accounts for over
12% of the population in America but over
half of the hospital resources.
• 25% of hospitalized older adults have
dementia.
• 90% of people diagnosed with dementia will
have at least one or more behavioral
symptom.
A new day.
CMS Challenge
• At the end of 2011 Centers for Medicare and
Medicaid Services challenged nursing homes to
reduce the rate of antipsychotics in their facility by
15%.
• CMS used December of 2011 as baseline data for
the challenge. Nursing facilities would have one
year to achieve this goal.
• There are 3 approved diagnoses for use
A new day.
Challenge Accepted
• After researching the CMS challenge, and the
evidence against the use of these medications
our facility went into action.
• A committee was formed that included
primary nurses, nurse managers, our medical
director, administration and social workers.
• Our antipsychotic rate at Glenridge was
46.9% in December of 2011.
A new day.
Action Plan:
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Research
Build a Committee
Action steps into place
Education to staff and
families
• Evaluate
• Stay Passionate
• Stop Making Excuses
A new day.
Action:
 Each month every resident on an antipsychotic was
reviewed individually. Residents medications were
reduced slowly, in collaboration with the entire
team. Behaviors and mood were evaluated each
shift.
 A consent form was developed as education for
family members.
 Every resident in our facility on an antipsychotic for more
than 7 days will have education provided by a physician or
Nurse.
 Family Response
A new day.
Education:
 “Dementia Beyond Drugs” by Dr. Allen Powers was read
and discussed in a book club format.
 Education was provided at CNA meetings, Med Tech
meetings, License Nurse meetings with emphasis on
WHY and on Evidenced Based Practice.
 Specific residents have required Focus Groups that have
brought direct care workers together with Employee
Health.
 Our facility joined the Maine Partnership to Improve
Dementia Care. The purpose of the team is to reduce
the use of antipsychotic medications in LTC state wide.
A new day.
Education:
 We evaluated the required education for all staff in
Long Term Care.
 Dementia Training on Hire
 EASE Training biannually
 Several informal educational opportunities were
provided as well.
◦ Poster presentations in the break room with candy for staff.
◦ Information was included at Skills Fairs in the facility.
◦ An antipsychotic questionnaire was sent out with prizes to
staff that got answers right.
A new day.
Education: The Unmet Need
• What is the resident trying
to tell you by their
behavior?
• Individualized Care Plans
• Life Story
• Dedicated RN and CNA
Assignments
A new day.
Side Effects of Antipsychotics
• Blurred vision, confusion, constipation,
diabetes, dry mouth, drowsiness, effects on
motor control, headache, hypotension
(orthostatic), increased heart rate, intense
dreams, involuntary repetitive movements
(tardive dyskinesia: may be irreversible even
when the medication is stopped), lethargy,
muscle weakness, sweating, tremors, urinary
incontinence, retention and weight gain.
A new day.
Education: Myth Busters
• “The reduction task force is trying to reduce all behavior
medications for our residents”
• The risks of the medication is worth the benefits…
• Our residents NEED these medications to have quality of life.
• These medications help our residents with hoarding,
wandering, repetitive verbalizations, and yelling out
• These residents are violent….Someone is going to get hurt.
• There is nothing that the nurse can give the person when
they get agitated right now.
A new day.
Results
• In February of 2014 we reached a new low of 9.7%.
Our current rate March 2015 was 12.8%.
• Behavior incidents between residents has decreased
over 50% in the past 2 years.
• In 2012 we had an 11% reduction at Glenridge in
Reported Staff Incidents and Accidents. This was
maintained in the following years.
• Significant improvement in resident engagement,
interactions, and self care.
A new day.
Results
• In February of 2014 Glenridge was able to present
their positive outcomes to the Maine State
Legislature Department of Health and Human
Services Committee.
• In December of 2014 and January of 2015 Maine was
recognized as the #1 most improved state in the
nation.
• Our facility was asked to mentor other facilities in
Maine on successful reduction of antipsychotics.
A new day.
A new day.
Glenridge Antipsychotic Use: Tracking Our Success
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
A new day.
Increasing our Scope
• The Reduction Team at Glenridge has been tracking
admissions since July of 2012.
• 39% of residents are coming to our facility on an
antipsychotic.
• As a result of this trend:
– Ongoing work with the Maine Partnership to Improve
Dementia Care
– Education to Family Medical Institute physicians
– MaineGeneral Health was recently NICHE certified.
• Nurses Improving Care for Healthsystem Elders.
A new day.
Glenridge Admissions
• 45% of residents
have had
successful d/c
within 30 days
• 62% of residents
have had
successful d/c
within 90 days.
A new day.
Discontinued Antipsychotics within
90 Days
Bronze Award Recipient
A new day.
Conclusion
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Research-Stop Making Excuses
Utilize front line workers on your team
Put Action steps into place
Education: Make it fun
Evaluate
Stay Passionate
Celebrate
A new day.
Do the best you can until
you know better. Then
when you know better, do
better.
~Maya Angelo
A new day.
Resources:
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Powers, G. (2010). Dementia Beyond Drugs. Health Professions Press.
Briesacher BA, Limcango MR, Simoni-Wastila L et al. The quality of antipsychotic drug prescribing in
nursing homes. Arch Intern Med 2005; 165 (June): 1280-1285.
Rochon P, Normand S, Gomes T et al. Antipsychotic therapy and short-term serious events in older adults
with dementia. Arch Inter Med 2008; 168:1090-1096
Wang, P., Schneeweiss, S., Jerry, A., Fischer, M., & Mogun, H. (2005). Risk of Death in Elderly Users of
Conventional vs. Atypical Antipsychotic Medications. New England Journal Of Medicine. Retrieved from
http://www.nejm.org/doi/full/10.1056/NEJMoa05827
Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. (2005).
JAMA. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15687315
CMS Updates Survey Guidelines for Antipsychotic Drugs in Dementia Care. (2013, May 31). McKnight's
Long-Term Care News.
Schneider L, Tariot P, Dagerman K. Effectiveness of atypical antipsychotic drugs in residents with
Alzheimer’s disease. N Engl J Med 2006: 355;1525-1538
The American Geriatrics Society. (2012). American Geriatrics Society Updated Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults. Journal of American Geriatrics Society. New York.
A new day.