Dementia Care, Antipsychotics, and the New Survey Process

Every 66 seconds, someone in the United States develops Alzheimer's dementia, which is forecasted to increase to every 33 seconds by mid-century. Currently, 68% of nursing facility residents 85 and older have cognitive impairment from Alzheimer’s or a related disorder.

The National Partnership to Improve Dementia Care—which includes federal and state agencies, nursing facilities, other providers, advocacy groups, and caregivers—is a 2012 initiative by the Centers for Medicare & Medicaid Services (CMS) to promote comprehensive dementia care and therapeutic interventions for nursing facility residents with dementia-related behaviors. Goals of the initiative include a person-centered focus on care and reducing unnecessary antipsychotic medication use. In October 2017, CMS announced that the Partnership’s initial goal—reducing antipsychotic use among long-stay nursing home residents by 30% by the end of 2016—had been reached.

An ambitious new national goal has now been set for improved dementia care: a 15% reduction in antipsychotic medication use by the end of 2019 for long-stay residents in those facilities with currently limited reduction rates.

How to get started at improving your facility’s dementia care

The new survey process starts with the Matrix for Providers, which requires the provider to divulge a list of residents to the surveyors, specifically noting diagnoses of Alzheimer’s disease or dementia of any type, as well as residents receiving any of the newly defined psychotropic medications (any drug that affects brain activities associated with mental processes and behaviors), such as antipsychotics, antidepressants, antianxieties, and hypnotics.

Gather the list of residents compiled on the Matrix, identify a resident with dementia, and reach for the Critical Element Pathway for Dementia Care:

Can you observe appropriate dementia care treatment and services being provided?

Is the care plan person-centered; reflective of the resident’s goals; and written to maximize dignity, autonomy, privacy, socialization, independence, and choice?

What non-pharmacological interventions are being used to maintain the resident’s well-being?

How do staff modify the environment to accommodate the resident’s care needs? (Think about noise levels and adequate lighting—bright in the daytime and dark at night.)

Ask a member of the interdisciplinary team what the facility’s dementia care guidelines and protocols are.

Ask about the dementia management training the staff member received.

Can the staff member identify and assess behavioral expressions or indications of distress with enough specific detail to identify the cause?

Was the resident and/or family/representative involved in care plan development?

In addition, facility leaders should ensure that a staff member has been designated as the champion for their dementia care program. And the revised Appendix PP definition of psychotropic drugs should serve as a reminder to audit your Nursing Home Compare measure for use of an antianxiety or hypnotic medication and the surveyor measure for the prevalence of use of those drugs, which will be a focus for the surveyors. Consider whether reductions were attempted, what monitoring took place during the reduction, and whether the residents triggered accurately.

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