Antipsychotic Drugs: Berwick Asks for Recommendations on Reducing Inappropriate Use

Members | November 16, 2011

On Oct. 26, 2011, CMS Administrator Donald Berwick asked nursing home stakeholders for recommendations on reducing the inappropriate use of antipsychotic drugs in nursing homes. In response, we urged CMS to frame the issue in terms of improving the care of residents with dementia and involving all members of the care team, including physicians, nurses, pharmacists and direct care staff as well as consumers. We pointed out that efforts to reduce inappropriate use should not focus on one class of drugs alone and that clear definitions of appropriate vs. inappropriate use are needed, based on adequate data.

In an October 26 meeting with key stakeholders in nursing home care, Dr. Berwick and several quality leaders at the Centers for Medicare and Medicaid Services (CMS) called for an improvement in how antipsychotics are used in the treatment of residents with dementia. 

Citing the FDA black-box warning and the fact that these medications have been linked to adverse outcomes in nursing home population, he asked the attendees to provide to CMS their proposals for how to reduce the use of these medications. 

While CMS has not yet responded to our letter of recommendations, we can share that our comments focused on 3 general areas.

First of all we called for adequate data to ensure not only current baseline measurement, but also clear definitions for “appropriate” and “inappropriate” use.

Secondly, we raised the concern that this should not be a target of one drug class alone, since that may trigger the unintended consequence of increasing the use of other medications which have an equal, if not greater, safety risk. 

Rather, we proposed that this be put in the context of the current CMS regulations of F-tag 329: The Avoidance of Unnecessary Drugs.

Lastly, we recognize that any sustained quality improvement in this area truly involves a collaborative effort of all the stakeholders involved; physicians, nurses, pharmacists, direct care staff, consumers and CMS, and is best framed in how to improve the care of residents with dementia. 

Advancing Excellence for American's Nursing Homes is our best model of such a collaboration, and with now almost 50% of nursing homes signed up, our best vehicle to reach nursing homes across the country.

While we are awaiting final recommendations and responses from CMS, it is clear from Dr. Berwick’s statements that this will be an area of focus for the CMS surveyors. 

Watch for additional information from LeadingAge and CMS in the up-coming weeks. Meanwhile it is a good idea to review with your clinical staff the key principles of “avoiding unnecessary drugs:” 

  • Does each medication have a clear indication? 
  • Is there documentation of a positive response? 
  • Are clinical staff monitoring for adverse effects? 
  • Is the drug being used at the lowest effective dose and is the need for continuing the medication being assessed at regular intervals? 

Additional areas of focus include whether or not non-pharmacological interventions are indicated or have been tried, and whether or not the family or designated decision-maker has been informed of the risks and benefits and concurs with treatment.

Optimum care for residents with dementia is really at the core of person-centered care. 

We know that this is not driven by a “one-fix” solution, but rather a broad, evidence-based approach that includes the entire team.