By Mary Evans, M.D, C.M.D.
I probably never will forget a patient of mine with “advanced dementia with behaviors” whom I cared for years ago. She had been in a nursing home for several years and took scheduled anti psychotic medication daily. I was told that she had been nonverbal for years and didn’t really participate in life. She spent her days staring into space and rocking back and forth in her wheelchair. When I took over her care, I wanted to decrease her long list of medications, including her anti-psychotic medication. The nursing staff warned me that she had “gone crazy” prior to coming to the facility, and they strongly resisted my suggestion that we try to wean her off of her antipsychotic medication. Despite their warnings, I decreased and discontinued her antipsychotic over a period of months, while watching for worsening behaviors. My patient did fine.
At one point during the taper, this patient began to talk. Not only did she begin to talk, but she spoke with a vocabulary that was much more sophisticated for the rural area where she had lived. As it turns out, she told me that she had been a high school English teacher, and she had loved to write. Once she started talking, she was rarely quiet. I asked her if she remembered me talking to her in the previous months (yes, she had) and why she didn’t answer my questions (she said she didn’t feel like saying anything). It makes me sad to think of the years she lost, unable to communicate or participate in her surroundings, while medicated with an antipsychotic. I am also reminded of a friend who suffers from bipolar disorder. She told me when she was younger and needed to be on antipsychotic medication, she felt her daily routine of living was like trying to swim through molasses – everything was thick and fuzzy and difficult. I shudder to think that this is what it must be like for my patient when she was on antipsychotic medication, and why my patient never felt like talking or participating.
Every LivingCenter is challenged to reduce unnecessary use of antipsychotic meds, especially if the patient doesn’t have a bona fide medical diagnosis to support their use. Currently recognized indications include schizophrenia, Tourette’s syndrome and Huntington’s disease. Although Golden Living has, as a company, achieved reduction in antipsychotic use by just over 15 percent last year, I think we can do better as caregivers. In this issue of First Monday, I’d like to propose that you look at some new approaches and consider implementing them in your LivingCenter.
If your Golden LivingCenter doesn’t have a current, ongoing plan to decrease unnecessary antipsychotic use, particularly if the medication is used to control “behaviors” in residents with dementia, you may want to consider using a method developed by Mark Coggins, PharmD CGP, one of our GLC pharmacy leaders. Dr. Coggins recognized the need to decrease the use of inappropriate antipsychotic meds in our vulnerable elderly population, long before the OIG authored its opinion and CMS issued its challenge to decrease antipsychotic use by 15 percent in each facility across the nation. His approach included the novel idea of including the consulting pharmacist in a multi-disciplinary group at the facility level to review residents in a bi-weekly “at risk” mega-meeting which covered not only patients with behaviors, but also residents who had falls, weight loss, pressure ulcers and other adverse outcomes. He instituted a six month pilot program in 2009 at GLC Hendersonville in North Carolina. His plan proposed using a multidisciplinary group including the ED, DNS, unit managers, therapy, activities, CNA’s, social work, dietitian and other facility members as needed, to review what would be the best approach to each individual patient’s needs.
One of the most important things to recognize is that patients in our facilities generally have pain. Dr. Coggins realized that behaviors (that sometimes lead to starting a restraining medication like antipsychotics) are often caused by untreated pain. He instituted starting scheduled acetaminophen or other daily pain medication for residents who were having behaviors. By just addressing the need for adequate pain medication, the prevalence of behaviors declined significantly.
In addition, Dr. Coggins recognized that residents who have dementia, which prevents them from participating in activities such as church services and games like Bingo, require different types of activities to occupy their time and keep them engaged. Appropriate activities for residents with dementia also helped decrease the need for medications like antipsychotics and anxiolytics.
Other aspects of the pilot implemented therapy screening and treatment for positioning, mobility and pain relief, dietary review and supplementation for residents with weight loss, screening and treatment for depression.
Dr. Coggins’ pilot project at GLC Hendersonville achieved tremendous results. Not only was the interdisciplinary team able to decrease antipsychotic and anxiolytic use significantly, but they saw improvement in many adverse clinical outcomes, including pain, falls, discharges for psychiatric reasons, fractures, untreated depression, and others.
Earlier this year, Golden Living’s National Director of Clinical Practice Melissa Purvis and I were fortunate to visit a couple of Golden LivingCenters that excel at caring for residents with dementia and behaviors – without antipsychotic meds. We interviewed leadership and staff members at GLC Fresno in California and GLC Wabasso in Minnesota and found some striking similarities between these LivingCenters. Both centers were absolutely dedicated to caring for residents with behaviors without resorting to the use of antipsychotic or anxiolytic mediations. Both centers had identified a staff “champion” to spearhead efforts within the facility, but also felt strongly that the whole staff had to be on board with their approach to care.
Both of these Golden LivingCenters excelled at treating the residents as unique individuals. Melissa and I were struck by the homelike environment in both of these LivingCenters, and that all of the staff were very familiar with the needs and quirks of each of their residents. Both LivingCenters had developed their own more focused versions of staff orientation programs and activities programs that were geared toward their population with behaviors, with the goal of minimizing unnecessary medications. Both GLC Fresno and GLC Wabasso held regularly scheduled interdisciplinary meetings that truly focus on the individual needs of their residents.
Both LivingCenters recognized that what works for one resident may not work for another, and that what works one week for one resident may not work well the next. We heard things like, “We have to be creative and keep thinking of ways to keep them engaged and interested.” Another key to the success of both LivingCenters is constant communication of the staff in the form of morning meetings, huddles at shift change, and white board communication in staff areas for sharing information about what was going on that day with their residents. The members of the teams functioned as a cohesive unit and problems were identified and addressed immediately to avoid escalation of behaviors. We heard things like, “When Sally starts getting wound up in the afternoon, we know she likes to have a cup of coffee and come and sit with me in my office until she calms down.”
Hopefully you can take some of the information from this issue of First Monday and apply it to your own LivingCenter. Think about how you can address pain proactively in every one of your patients. Think about how you can work with your leadership team at the LivingCenter to approach the decrease of unnecessary medications, particularly anti psychotics and anxiolytics, with a unified team approach and effective communication. Above all, think about what it might feel like to try to function in the haze of an antipsychotic medication, and how you would want to spend your days if you were that resident in the wheelchair.