Annals of Long Term Care

The purpose of this article is to review current perceptions of appropriate use of antipsychotic medications for behavioral problems in skilled nursing facility residents (SNF) with dementia. This is especially critical now given the public concern. While evidence regarding the pharmacologic treatment of behavioral problems in patients with dementia is sorely lacking, public focus is moving clinicians to stick to the evidence that is available or face some potentially significant consequences. The front page of The Wall Street Journal, a publication likely to capture the attention of regulators, recently had two headline stories dealing with the treatment of behavioral problems in patients with dementia. The first article, entitled “Prescription Abuse Seen in U.S. Nursing Homes,” noted some significant statistics such as the fact that nearly 30% of the total nursing home population is receiving antipsychotic drugs.¹ It goes on to quote the Centers for Medicare & Medicaid Services (CMS) as saying that nearly 21% of nursing home patients who do not have a psychosis diagnosis are taking antipsychotic medications. The conclusion drawn is that there is a relationship between medication use and quality of care by implying that high use of antipsychotics in a nursing home can be an indicator of inadequate staffing. The relationship with staffing is thought to be based on the belief that these drugs may serve as “chemical restraints,” in that they can be used to sedate and subdue patients.²

A second front-page article, entitled “Nursing Homes Struggle to Kick Drug Habit,” again addressed the issue of management of behavioral problems such as agitation in patients with dementia, with an examination of new therapies such as music and massage.³ While good evidence of the effectiveness of this treatment is less than plentiful, there are data provided to support the notion that atypical antipsychotics should be used more sparingly. It is this notion that will likely drive state surveyors, malpractice attorneys, and, prescribers.

As with any treatment plan, it comes down to assessing the evidence and determining individual risks versus benefits. Only when benefits outweigh risks should a treatment be undertaken. Our goal remains first, to do no harm, and second, to work to improve patients’ quality of life. Therefore, a discussion of treatment of behavioral problems, such as agitation in patients with dementia, starts with assessment of the risks and benefits of treatment options, as well as an examination of alternative therapies that may have a place.

While long-term care (LTC) is a major focus of much of the government and press attention in this area, for those geriatric providers not involved in LTC this discussion is still critical, because as CMS pushes for “payment following the patient,” much of the regulation and oversight will be patient-specific in the future. This means that regulations that now apply only to LTC residents will be applied to LTC-like residents who live in the community. As a result, knowledge of what is happening in LTC is critical for all physicians.

Black Box Warning
As geriatric providers are aware, atypical antipsychotic medications carry a black box warning because of increased mortality in elderly patients with dementia-related psychosis:

WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSIS
Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of seventeen placebo controlled trials (modal duration of 10 weeks) in these patients revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times that seen in placebo-treated patients.