Federal initiative seeks to decrease use of antipsychotic drugs

Washington The federal government has launched an initiative to reduce the use of antipsychotic medications in nursing home patients, many of whom are elderly or have dementia and can’t always communicate their needs to physicians and other caregivers.

“Many clinicians, physicians, nurses as well as family members think these medications are necessary, but data show they can be ineffective, and in some cases dangerous,” said David Gifford, MD, MPH, senior vice president of quality and regulatory affairs with the American Health Care Assn.

Dr. Gifford joined Shari Ling, MD, deputy chief medical officer at the Centers for Medicare & Medicaid Services, and others on a conference call to unveil the Partnership to Improve Dementia Care. The initiative among federal and state partners, nursing homes, other health care professionals, advocacy groups and caregivers aims to reduce the use of antipsychotic drugs in nursing home residents by 15% by the end of 2012.

Achieving these reductions in AHCA member facilities means “we’ll see 18,000 individuals off these medications,” Dr. Gifford said. Focusing on the way that staff interacts with patients and other strategies could reduce the unnecessary use of antipsychotic drugs, he said. The association represents long-term and postacute-care facilities.

CMS data show that in 2010, more than 17% of nursing home patients had daily doses of antipsychotic drugs exceeding recommended levels, and the use of the drugs by nursing homes has grown, Dr. Ling said.

Patients and caregivers often are not told about the risks of these drugs, and residents often are medicated without their consent. These antipsychotics can function as “chemical restraints,” Claire Curry, legal director of the Legal Aid Justice Center’s Civil Advocacy Program, said during the conference call. The Food and Drug Administration has issued “black box” warnings about these drugs, indicating they can cause death in dementia patients, Curry said.

CMS, as part of a recent rule-making, had solicited comments on how to reduce overprescribing of these drugs. In a May 22 response, the American Psychiatric Assn. stated that it shared CMS concerns about inappropriate prescription of antipsychotics in long-term-care patients and that nonpharmacological interventions in some instances “may be sufficient to reduce a patient’s symptoms of dementia.”

However, there are times when a psychiatrist’s ordering of these medications is medically necessary and appropriate, the APA wrote, noting that “evidence demonstrating the efficacy of nonpharmacological interventions for [long-term-care] patients, particularly those suffering from dementia, is weak.”

The Pharmaceutical Research and Manufacturers of America is reviewing this initiative, Matt Bennett, PhRMA’s senior vice president, said in a statement. “While we encourage efforts to support the appropriate use of medicines, it is important that these initiatives do not inadvertently restrict patient access to needed treatments. Research shows that use of appropriately prescribed medicines can dramatically improve patient health as well as reduce avoidable and costly medical care, such as unnecessary hospitalizations and nursing home admissions,” Bennett said.

Dr. Ling mentioned that CMS didn’t have data on “the frequency in which antipsychotic drugs start in hospitals prior to transfer to nursing homes and other settings. This is clearly an area to be mindful of in our future work.”

As part of its initiative, CMS is emphasizing nonpharmacological alternatives for nursing home residents, such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities. The agency also has developed a training series for nursing homes to emphasize person-centered care, prevention of abuse and high-quality care for residents.

CMS is making data on each nursing home’s antipsychotic drug use available on its Nursing Home Compare website, and the agency plans to conduct research to understand better the decisions related to use of antipsychotic drugs in residents with dementia (link).

Long-term care pharmacy providers “look forward to participating as this initiative gets under way,” said Kevin Schweers, spokesman for the National Community Pharmacists Assn.