Intervention to Reduce Antipsychotic Use May Have Moved Needle

      Nursing homes exposed to a comprehensive web-based educational program on the appropriateness of antipsychotic drugs in dementia patients — as well as to the Centers for Medicare & Medicaid Services Partnership to Improve Dementia Care (CMS Partnership) — appeared to have modestly reduced antipsychotic and anticholinergic use without an adverse effect on symptoms, according to a recent evaluation of these programs’ impact.
      Researchers used assessment data from the Minimum Data Set (MDS), Medicare, and other sources for Iowa nursing home residents from 2011 and 2012 to try to evaluate the impact of a training program and toolkit of clinical decision aids. The resources include an algorithm for treating the behavioral and psychological symptoms of dementia (BPSD), a tip sheet for managing a behavioral crisis, and laminated pocket guides. In addition to the web-based training, the content was delivered through presentations at professional meetings.
      Of 426 eligible nursing homes in Iowa, 114 were exposed to the program — called the Improving Antipsychotic Appropriateness in Dementia Patients (IA-ADAPT) program — during the study period (71 through the website only, 29 through presentations, and the rest through both). For the purposes of the study, “exposure” to the program meant at least one facility staff member participated; the study did not measure any additional dissemination of the material.
      The researchers evaluated antipsychotic use and anticholinergic use on a monthly basis, measured the changes in BPSD, then calculated the odds ratios (OR) per month after exposure to the IA-ADAPT program. The focus was on dementia patients, but those without dementia were also included in the primary analyses. (The nursing home residents included in the evaluation had to have been eligible for 6 continuous months.)
      The CMS Partnership was announced near the beginning of the intervention period, so the researchers attempted to control for its effects and its own impact on the outcomes.
      The IA-ADAPT program was associated with reduced antipsychotic use (0.92 OR per month after exposure) and anticholinergic use (OR 0.95), reduced use of excessive antipsychotic doses per CMS guidance (OR 0.80), increased odds of a potentially appropriate indication among antipsychotic users (OR 1.04), and decreased documentation of verbal aggression (OR 0.96). The facilities with two or more staff members exposed to the educational program had greater reductions in both antipsychotic and anticholinergic use compared with the nursing homes with only a single staff member participating.
      “A main question for nursing homes is where do we start? When you take someone off an antipsychotic and they get a lot worse, it doesn’t motivate you to do it again.”
      The CMS Partnership, which set goals for reducing antipsychotic use in nursing homes, was also associated with reduced antipsychotic use (OR 0.96) as well as decreased documentation of any measured BPSD (OR 0.98) and delirium specifically (OR 0.98).
      “It’s not a massive sea change, but it does suggest a trend of impact,” lead author Ryan M. Carnahan, PharmD, of the department of epidemiology at the University of Iowa College of Public Health, told Caring. “Over 6 months, the odds ratio for antipsychotic use might translate into something like 0.80, which gets a little more meaningful.”
      Evaluating the specific impacts of such interventions is challenging, he explained. “There is so much going on in the background [in nursing homes] that we can only look and see what the trends are that are associated with interventions,” Dr. Carnahan said. Given the study’s quasi-experimental design, which is subject to selection bias, “we can’t say for certain that the IA-ADAPT intervention itself caused [the improvements].”

      Reduced Anticholinergics

      It is notable, however, that IA-ADAPT exposure was associated with reduced anticholinergic use. The program highlighted anticholinergic toxicity as a cause of delirium and BPSD, and discouraged anticholinergic use in residents with dementia. While this was a specific target of the program, the CMS Partnership at the time was focused on reducing antipsychotic use but not anticholingeric use, the investigators said (Alzheimers Dement (N Y) 2017;3:553–561).
      Anticholinergic use was common in nursing homes, with an average facility rate of 28% at baseline, the investigators noted. “Dementia was only mildly protective of anticholinergic use,” they said. But “more promisingly, increased age and the number of months an individual was in the data set were associated with reduced odds of anticholinergic use in all residents and those with dementia.”
      The content of the IA-ADAPT program was based on an Agency for Healthcare Research and Quality–sponsored comparative effectiveness research review on off-label use of antipsychotics and on CMS guidance for surveyors of long-term care facilities. By now, staff in about half of Iowa’s nursing homes have participated, Dr. Carnahan said, and he noted that most participants have been nurses.
      More recently, Telligen, the region’s Quality Improvement Organization, has developed the Antipsychotic Reduction Resident Prioritization Tool. The tool provides an algorithm for nursing homes to identify those residents who should be considered first for dose reduction (, and it is a helpful supplement to the IA-ADAPT program, Dr. Carnahan told Caring.
      “A main question for nursing homes is where do we start? When you take someone off an antipsychotic and they get a lot worse, it doesn’t motivate you to do it again,” said Dr. Carnahan, who assisted in the development of Telligen’s tool. “This resource helps rank the residents to determine which ones are most likely to do well coming off an antipsychotic. It asks questions like, Did symptoms improve while on the drug? How long was the resident on the drug? How severe were symptoms in the first place?”
      Other recent research suggests that transitions of care are a critical time for drug evaluation. Dr. Carnahan and his coinvestigators used a linked dataset of Medicare claims and MDS data to determine the setting of antipsychotic initiations. Of approximately 7,500 nursing homes residents who had new use of antipsychotics, 64% had the drugs initiated in the nursing homes, 18.6% appeared to have them initiated during hospital stays, and 17.5% had them first dispensed as outpatients [J Am Geriatr Soc, Jan. 22, 2018; doi:10.1111/jgs.15223].
      “A substantial minority were started in the hospital or in the outpatient setting, as best we could tell,” Dr. Carnahan said. “So education and communication around antipsychotic use need to cross our health care silos … We need good communication with hospital providers, for instance — a clear picture of what the purpose of an [antipsychotic] was, and whether it actually seemed to be helping.”
      Christine Kilgore is a freelance writer in Falls Church, VA.