Recent Journal Articles on Antipsychotics Use in Nursing Homes

1. Recent Journal Articles on Antipsychotics Use in Nursing Homes CMDA Monthly Meeting Presentation Sing Palat MD, CMD

2. Background • Antipsychotics are still used off-label despite black box warnings, increased adverse effects and only modest efficacy in behavioral- psychological symptoms of dementia (BPSD). – Shaw/ Communication Article • In 2017 antipsychotics use in nursing homes remained 16% US, 19% England, and 27% Western Europe. – Walsh/ Prescribing Behaviors Article

3. Educating Nursing Home Staff in Dementia Sensitive Communication: Impact on Antipsychotic Medication Use Clarissa Shaw, MSN, Kristine N. Williams, PhD, FNP-BC, Yelena Perkhounkova, PhD; Journal of the American Medical Directors Association; Volume 19, Issue 12, Pages 1129-1132 (December 2018) ; DOI: 10.1016/j.jamda.2018.09.030 Hypothesis: Formal communication training will lead to decreased antipsychotics use.

4. Communication • Eleven nursing homes in Kansas • 43 to 163 beds • Profitand non-profit • Metropolitanand rural • Average Star Rating 3.85 • Intervention: CHAT, or CHAnging Talk program

5. Communication • CHAT reduces elderspeak, baby talk or infantilizing speech • Features: high pitch, overly-nurturing tone, inappropriate terms of endearment (“honey”), collective pronoun (“We” not “You”) • Well intentioned, caring staff, but… • Stereotypes of incompetence and dependency

6. Communication Intervention • CHAT has been shown to decrease elderspeak and behaviors in dementia • Three x 1 hour sessions of in-person training for nursing aides

7. Communication Data • Tracked antipsychotic use 2 quarters prior and 2 quarters after CHAT • Compared antipsychotics use to state average for the same time period.

8. Communication Results/ Limits • Participating NH more motivated? • Effects may not last over time

9. Communication Takeaway Points • Effective communication lowers antipsychotics use and can be taught. • Compare facility data to state-wide data. • Effects did not last: Education is an ongoing effort. • Formal vs. Informal, or “Just in Time,” education

10. Exploring Antipsychotic Prescribing Behaviors for Nursing Home Residents With Dementia: A Qualitative Study Kieran A. Walsh, MPharm, Carol Sinnott, PhD, Aoife Fleming, PhD, Jenny Mc Sharry, PhD, Stephen Byrne, PhD, John Browne, PhD, Suzanne Timmons, MD; Journal of the American Medical Directors Association;Volume 19, Issue 11, Pages 948-958.e12 (November 2018) DOI: 10.1016/j.jamda.2018.07.004 • The study focuses on understandingprescribing: What determines whether an antipsychotic will be prescribed or not?

11. Prescribing Behaviors Qualitative Method • Theoretical Domains Framework of open ended interviews • Six NH: 23 interviews including nurses, administrators, family members, physicians, pharmacists • Identified themes until no new ideas emerged, then conducted 3 more interviews

12. Prescribing Behaviors Found 38 behavior determinants that influence antipsychotic prescribing One conceptual model (diagram) Model is called A Fine Balance

13. Prescribing Behaviors

14. Prescribing Behaviors • I think it’s the hardest disease out there to manage. It’s one I would NOT like to get myself. – Administrator • Concept: Human Suffering

15. Prescribing Behaviors • Sometimes you need to take a step back, who are you treating? Are you treating the staff members who are treating the patient because they want a peaceful night or a peaceful day on the ward, or are we making a decision to make our own lives easier? - Physician • Concept: Human Suffering

16. Prescribing Behaviors Human Suffering Ideas • Decipher who precisely is distressed by behaviors. • Be empathetic. Acknowledge the emotional impact of behaviors. • Include training on appropriate assessments, managing expectations. • Eg. OASIS training; CHAT education

17. Prescribing Behaviors • I think just knowing the person, knowing that they have been on antipsychotics for years. Looking at them now, their state of deterioration and you know in your heart and soul they don’t need them. - Nurse • Concept: Human Suffering; Power and Knowledge

18. Prescribing Behaviors • I think people can be a little bit biased in how they can present a case to you at times to get to the ends that they want. I know there has been one incident where a staff member was overheard saying “sure just tell her she’s had hallucinations.” -Physician • Concept: Power and Knowledge

19. Prescribing Behaviors Power and Knowledge Ideas • Managers with both power AND knowledge leverage their influential role. • Recognize negative consequences of regulations. (Increase in schizophrenia diagnoses) • Utilize evidence-based, standardized approach to prescribe and deprescribe. • e.g. DICE approach; Deprescribing Algorithm

20. Prescribing Behaviors • They haven’t enough staff and they seem to think that the cheapest way is to dose them, and keep them quiet. – Family • Concept: Interface Between Resident and Nursing Home

21. Prescribing Behaviors • You go to different nursing homes and attitudes are very different. – Nurse • If you meet the manager, you can usually see the tone of the home. – Physician • Concept: Interface Between Resident and Nursing Home

22. Prescribing Behaviors Interface between Resident and Nursing Home - Ideas • Staff need to care for all residents efficiently • Antipsychotics are perceived as essential. • Understand financial and staffing constraints. • More evidence needed for quality designs of future NHs.

23. Prescribing Behaviors Takeaway points • Prescribing / deprescribing is A Fine Balance. • Model not limited to prescribing of antipsychotics • Even with more evidence on risks and benefits of antipsychotics and regulations governing their use, ultimately prescribers are human.

24. Prescribing Behaviors Prescribers are human.