RALEIGH — By Thomas Goldsmith
Statistics from a collaborative effort to reduce the use of antipsychotic drugs to control troublesome behavior by people with dementia in nursing homes shows that North Carolina led the nation in achieving reductions.
Nursing homes in the state are administering such medications to 23 percent fewer residents than they were in early 2012, according to the federal Centers for Medicare and Medicaid Services.
The agency had set a target reduction of 15 percent.
North Carolina has become a national leader in the movement to encourage medical professionals and nursing home staff to use alternative methods, including massage, exercise and familiar music, to deal with residents with dementia, who might otherwise act out, hit, kick, bite or scream.
Overuse of antipsychotics can result in lessened independence, confusion, falls and increased risk of strokes, according to the federal Administration on Aging.
“I think this is good news for North Carolina,” said Thomas Konrad,chairman of the board of Friends of Residents in Long Term Care and a research professor in Health Policy and Management at UNC-Chapel Hill’s School of Public Health.
“It involves upgrading staff and training people how to communicate better and focusing their attention on the resident, rather than, ‘Let’s just drug them,’ and then they fall down in the middle of the night and then they’re in the emergency. room.”
Early last year, the federal Centers for Medicare and Medicaid Services started a national effort to reduce unnecessary use of powerful antipsychotic drugs on people with dementia. Finding in 2010 that about nearly one in four long-term nursing-home residents was getting more than the recommended dose of antipsychotics, the agency started the National Partnership to Improve Dementia Care.
The partnership recommended the following steps:
• Highlighting improved means of dealing with difficult behavior in people with dementia.
• Improving training for nursing-home employees and state employees who survey the facilities.
• Making the problem known to the public through a rating system, Nursing Home Compare.
Nationally, the effort has reduced by 30,000 the number of people on antipsychotics, federal health officials said. The North Carolina coalition to reduce the drugs’ use including state regulators, representatives of the long-term care industry and educators as well as the Carolinas Center for Medical Excellence and the Long Term Care Ombudsman program, part of the state Division of Aging and Adult Services.
Consistent staffing and increased time spent outdoors have also been shown to reduce difficult behaviors among residents with dementia.
Leslie Jarema, director of health services for the Forest at Duke, a continuing care retirement center in Durham, said the home has long worked to lower the numbers of residents on antipsychotics, but ramped up its efforts with the national drive.
The needs of the patient first
“It was a good alert to us to take even a closer look,” Jarema said. The Forest at Duke had 17 of 92 residents on the drugs when it began its training and other efforts, a number that was reduced to four residents within three months.
“Those four we review every week,” she said. “We are trying to get it down to none.”
At the Forest at Duke and other successful facilities, staff may try several different methods before finding the best means to soothe an agitated resident.
“We use massage,” Jarema said. “For a bed patient, it might even be a hand massage or shoulder massage.”
Aromatherapy, lifelike mechanical cats and dogs, and a popular program called “Music and Memory” have also produced good results. A group of homes in the Carolinas that received intensive training and monitoring of patients was able to reduce unnecessary use by two-thirds, according to the federal Medicare and Medicaid services agency. In addition, webinar training was produced for doctors, who must prescribe any medication.
“Antipsychotics have been ordered for so long in situations where we seemed to need urgent management,” said Polly Welsh, vice president of the N.C. Health Facilities Association, a nursing home trade association that was closely involved in the program to reduce unnecessary drug use.
Reduced use of strong drugs is part of what’s sometimes called “culture change” or “patient-centered care” in long-term residential facilities. That means putting the needs and wishes of residents before practices that may have been more convenient for staff.
“It really focuses on root-cause analysis,” Welsh said, or working to get at the cause of a resident’s behavior rather than reacting to the symptoms.
‘Trying to do the right thing’
Alice Watkins, executive of Alzheimer’s North Carolina, said she is seeing improvement from the days when adult children would find a parent dull and unresponsive after receiving a drug such as Haldol at a nursing home or hospital.
“It’s not like it used to be, where people would say, ‘I went to see Mom today and she was so totally out of it,’ ” Watkins said. “I do think most of the care facilities are really trying to do the right thing.”
Konrad, with Friends of Residents in Long Term Care, complimented the nursing home organization on its involvement with state workers such as ombudsman Carmelita Karhoff. However, he said, some facilities continue to use prescriptions for these drugs with residents who act out, rather than trying the new techniques that seem to be succeeding in calming down some people with dementia.
“Everyone sort of agrees how central this is to good care – not keeping people drugged,” Konrad said. “But you’re always worried about the people at the bottom. There’s always a bottom 10 or 20 percent.”