New England QIN-QIO Reducing Unnecessary Antipsychotic Medications Affinity Group Call Thursday, January 19 th 3-4:00 pm. Presenters.

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1 New England QIN-QIO Reducing Unnecessary Antipsychotic Medications Affinity Group Call Thursday, January 19 th 3-4:00 pm Call-In Information: Code: Log-In Information: Presenters - Sarah Dereniuk, NE QIN-QIO - Lynn McNicoll MD, SGSF, FRCPC - Nelia Odem, NE-QIN-QIO Agenda Time Topic 3:00-3:05 Welcome - Sarah - Affinity group introduction - Participant expectations 3:05-3:15 State-of-the-State - Sarah - Review long- and short-stay antipsychotic quality measures - Nursing home prevalence rates in New England, local and national initiatives to reduce unnecessary antipsychotic medications, and current progress 3:15-3:30 Antipsychotic Medication Use in Nursing Homes - Lynn - Dementia and antipsychotic medications - Why antipsychotics, benefits and dangers - Areas for improvement 3:30-3:40 Facility Assessment / Antipsychotic Reduction Tool - Nelia - How to use the tool - This month s activity 3:40-3:55 Discussion 3:55-4:00 Closing Remarks Upcoming Calls: February 16, 2017 (3-4:00 pm) QAPI (setting goals, PIPs) March 16, 2017 (3-4:00 pm) Staff stability April 20, 2017 (3-4:00 pm) Action planning, sharing best practices This material was prepared by New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC Facilitated by the New England QIN-QIO of 1-

2 New England Nursing Home Quality Care Collaborative (NE NHQCC) Reducing Unnecessary Antipsychotic Medications Affinity Group January 19, 2017

3 Agenda Introductions / Expectations State-of-the-State Antipsychotic medication QMs Antipsychotic Medication Use in Nursing Homes Facility Assessment / Antipsychotic Reduction Tool Discussion

4 What is an Affinity Group An affinity group a is a group formed around a shared interest or common goal and support each other and work together towards achieving the same goal.

5 Participant Expectations Join each monthly call Complete action period activities Join discussions Share best practices / lessons learned

6 Understanding the Antipsychotic Quality Measures Residents Who Newly Received Antipsychotic Medication (Short Stay) The percentage of short-stay residents who are receiving an antipsychotic medication during the target period but were not on their initial assessment. Residents Who Received An Antipsychotic Medication (Long Stay) The percentage of long-stay residents who are receiving antipsychotic drugs in the target period during a 7 day look-back. Source: New England QIN-QIO- Understanding the New MDS 3.0 Quality Measures Updated March 2016

7 Schizophrenia Antipsychotic Quality Measure Exclusions Huntington's Disease Tourette s Syndrome Source: New England QIN-QIO- Understanding the New MDS 3.0 Quality Measures Updated March 2016

8 Black Box Warning A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug. Residents who are taking an antipsychotic with a black box warning must have a signed consent on file that includes the actual wording of the Black Box Warning.

9 Quarterly Prevalence Rates, National Regions Source: National Partnership to improve Dementia Care: Antipsychotic Medication Use Data Report (September 2016)

10 Quarterly Prevalence of Antipsychotic Use for Long-Stay Residents, New England States CT ME MA NH RI VT Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q2 Source: National Partnership to improve Dementia Care: Antipsychotic Medication Use Data Report (September 2016)

11 Current Prevalence Rates and Relative Improvement CT: 16.03% ME: 16.82% MA: 18.16% NH: 16.48% RI: 17.55% VT: 16.83% 38.4% Improvement 38.2% Improvement 32.0% Improvement 35.4% Improvement 26.8% Improvement 33.7% Improvement Source: National Partnership to improve Dementia Care: Antipsychotic Medication Use Data Report (September 2016)

12 Antipsychotic Use in Long Stay Nursing Home Residents Lynn McNicoll, MD, AGSF, FRCPC New England QIN-QIO

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14 Does Rurality Matter? A NE QINQIO study Analyzed 6 New England states The rate of improvement in antipsychotic use did NOT differ by rural versus urban NH location Factors that were important were rate of schizophrenia or bipolar patients (p<0.0001) and median household income (p<0.0001) where the facility was located Harris D. et al. Submitted to Academy Health 2017

15 New APA Practice Guidelines for Using Antipsychotics in Dementia Management Am J Psych 173:5, May Do a full assessment of symptoms 2. Assess for pain and other potentially modifiable contributors 3. Use a quantitative tool to assess response to treatment 4. Develop a comprehensive treatment plan including appropriate person-centered nonpharm and pharmacological interventions 5. Use antipsychotics ONLY for severe, dangerous, distressing symptoms 6. Use nonpharmacological interventions and assess impact before using medications 7. Discuss risks and benefits with patient &/or family prior to initiation

16 New APA Practice Guidelines for Using Antipsychotics in Dementia Management Am J Psych 173:5, May If deemed appropriate, then start at lowest dose and titrate up to minimum effective dose 9. If patient develops a clinically relevant side effect, risks and benefits should be reviewed consider tapering and discontinuation 10. If there is no clinically significant response after a 4-week trial of an adequate dose, the medication should be tapered and withdrawn 11. It patient has a positive response, still need to consider whether to continue or slowly wean off 12. Attempt to taper and withdraw within 4 months of initiation unless patient has experienced recurrence with prior attempts at taper

17 New APA Practice Guidelines for Using Antipsychotics in Dementia Management Am J Psych 173:5, May In patients who are being tapered, assess for symptoms monthly and for at least 4 months after discontinuation 14. Except for episodes of delirium, haloperidol should not be used as first line agent 15. Avoid using long-acting injectable antipsychotic unless they have cooccurring chronic psychotic disorder Any concerns with these guidelines?

18 FDA Use of antipsychotics to treat dementia and behavioral problems is NOT FDA approved

19 Potential Benefits of Antipsychotic Medications in Advanced Dementia Reduce anxiety and behavioral problems in some limited residents with advanced dementia Improve quality of life for some residents with advanced dementia with behavioral problems Calmer and safer environment in dementia units However, no robust evidence to support this use in the medical literature There is much controversy!

20 Antipsychotic Efficacy for Behavioral and Psychotic Symptoms of Dementia (BPSD) Maglione (AHRQ) 2011

21 Why are antipsychotics BAD? BLACK BOX WARNING: increases mortality likely from cardiovascular death and within 30 days by 1.6 to 1.7 NNH: For every 9 to 25 persons helped with these medications, there would be one death Increases risk for gait instability and falls Metabolic syndrome (diabetes, weight gain) Anticholinergic properties (constipation, urinary retention, etc) Dopaminergic properties (parkinsonism) Tardive dyskinesia and neuroleptic malignant syndrome

22 Why are antipsychotics BAD? CATIE-AD trial risperdal and olanzapine found to have modest improvements in inappropriate behavior but high discontinuation rate due to side effects Meta-analysis of 16 placebo-controlled trials showed increase death among those on antipsychotics (3.5% vs 2.3%) Benzodiazepines have shown similar rate of increased mortality Atypicals (second generation) may be better than typical (e.g. Haloperidol) antipsychotics

23 Other Issues with Antipsychotics 17% had daily doses exceeding recommended levels 18% had both inappropriate indications and high dosing (Breisach, 2005) Likelihood of a person with dementia getting antipsychotic was directly correlated with a NH antipsychotic prescribing rate, even after adjusting for confounder (Chen, 2010) So facility and physician variation EXISTS State to state variation EXISTS as well (Hawaii 13% to MA 28% using Q data)

24 TYPICAL ATYPICAL Medical Care 50(11);2012

25 BMJ 2012;344

26 Risk of mortality by Antipsychotic Kales, 2012

27 BMJ 2012;344

28 Risk for Men > Women JAGS 2013

29 Areas for Improvement in Dementia Care > The Low Lying Fruit Residents with advanced dementia who are no longer able to produce violent or aggressive behaviors Use of antipsychotics for disruptive behaviors (crying, yelling) and not aggressive or dangerous behaviors Use of antipsychotics for anxiety or depression without proper trial of SSRI or mood stabilizers or non-pharmacological strategies

30 The Low Lying Fruit Continued Continued use of antipsychotics started for reversible episodes of delirium or psychotic depression Continued use of antipsychotics started prior to nursing home admission Infrequently used PRN antipsychotics can probably be discontinued Use for psychotic symptoms that are not problematic to the patient (e.g. non-violent hallucinations)

31 The Low Lying Fruit Continued Patient on the wrong type of antipsychotic (e.g. haloperidol long term) Patient on higher doses than necessary Patient on prn doses only and has not needed it often (is use a convenience rather than a necessity) if antipsychotic was not present, would it be needed. Patients with no attempt at titration in a while

32 Potential Unintended Consequences of Focusing on the Rate of Antipsychotic Use If the medication has been successful in an individual patient and attempts at reduction have failed, stopping the medication may produce more harm than good NH may start to refuse residents who are already on antipsychotics More frequent ED referrals for agitation or behavior problems rather than addressing the issue internally Using other unsafe medications for the behavior (benzodiazepines, trazodone, etc)

33 How to address this problem KNOW YOUR DATA: Review all residents on antipsychotic medications for alternatives (pharmacological AND non-pharmacological) Do NOT replace antipsychotics with benzodiazepines or other potentially equally harmful medications (e.g. trazodone) Do NOT suddenly stop antipsychotics in residents who have been on the medication for a long time, consider a slow weaning trial (sudden withdrawal or rapid weaning can cause withdrawal psychosis)

34 How to address this problem Learn proper strategies for holistic, individualized care of the resident with dementia e.g. HATCH model Work with your team including (among others): volunteers, activities director, pharmacists, physicians and mental health consultants Guideline-based multifactorial interventions have been proven to work 22% reduction in restraints No difference in falls, fall-related fractures No difference in psychotropic medications

35 Biomedical vs. Experiential Model of Dementia Biomedical Model Experiential Model View of behavior Response to behavior Behavioral goals Nonpharmacologic approaches Overall result Confused, purposeless, driven by disease & neurochemistry Problem to be managed; medication, restraint Normalize behavior; meet needs of staff & families Focus on discrete interventions High use of meds, continued suffering, decreased wellbeing Attempts to cope & problemsolve, communicate needs Care environment inadequate; conform environment to person Satisfy unmet needs; focus on individual perspective Focus on transforming the care environment Rare use of meds, attention to spiritual needs, improved wellbeing A. Power, Dementia Beyond Drugs (2010) 34

36 What does the behavior tell you? Wandering? Boredom? Calling out? Loneliness? Grabbing? Fear of pain? Pushing? Desire for privacy? Agitated? Over-stimulation? Withdrawn? Under-stimulation? Intrusiveness? Hunger, thirst?

37 Resources 1. Antipsychotic Reduction Resident Prioritization Tool 2. Hand in Hand from CMS 3. Nhqualitycampaign.org 4. Alive Inside Music and Memory Program 5. IA-ADAPT Model o 6. The HATCH Model 7. NE QIN-QIO website

38 Conclusions The goal should always be to provide dementia care without antipsychotics the target should be 0% There are always opportunities to improve antipsychotic rates Improving the education, approach and culture towards antipsychotic use is essential to reduce antipsychotic medication rates it takes a village

39 Thank you Questions?

40 References 1. Huybrechts et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs. BMJ 2012; Aparasu et al. Risk of death in dual-eligible nursing home residents using typical and atypical antipsychotic agents. Medical Care 2012; 50(11); Gellad et al. Use of antipsychotics among older residents of VA nursing homes. Medical Care 2012;50(11); Huybrechts et al. Variation of antipsychotic treatment choice across US nursing homes. Journal of Clinical Psychopharmacology. 2012;32(1);11-7.

41 References 5. Huybrechts et al. Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults. CMAJ 2011;183(7); Cadigan et al. The quality of advanced dementia care in the nursing home: the role of special care units. Medical Care 2012;50(10); Kopke et al. Effect of guideline-based multicomponent intervention on use of physical restraints in nursing homes: a randomized control trial. JAMA 2012; 307(20); Rochon et al. Older men with dementia are at greater risk than women of serious events after initiating antipsychotic therapy. JAGS 2013;61; Reus et al. The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. Am J Psychiatry 173:5, May 2016;

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43 Let s Look At Data 33,301 nursing facility residents Average of 6.7 medications per resident 27 % of residents taking 9 or more medications 693,000 Medicare residents using antipsychotics 28.5 percent of the doses received were excessive 32.2 percent lacked appropriate indications for use Reference State Operations Manual pg /18/

44 Let s Look At Data Some More Look at your own data CASPER Reports Use your MDS Coordinators It s real time 1/18/

45 Why is this a Hot Topic? It will be better for the staff It will get you ahead of the survey team It will improve your star rating It may save money 1/18/

46 Why is this a Hot Topic?... Continued It is better for the resident of course It is better for the family/loved one It will impact other areas of care It is good medicine! 1/18/

47 Alertness Aggression ADL decline Toileting programs Pain management Person-centered What are the benefits? IMPROVE 1/18/

48 Together We Can 1/18/

49 Where to Begin? Begin with the end in mind Form an Inter-disciplinary Team (IDT) Meet weekly for at least the first month (until we meet again) Review EVERY resident on: anti-psychotic anti-anxiety hypnotic 1/18/

50 Next Steps Exclude those with: Schizophrenia Tourette s Huntington s Look at Behavior Flow Sheets Divide the list of residents (who are the first that come to mind that could be weaned?) Assign team members to audit Don t forget.. Use your MDS Staff: CASPER Reports ARD Dates Care Plan Schedule 1/18/

51 Next Steps Do you already have a log, why create another? Use pharmacy log Review EACH resident on: anti-psychotic anti-anxiety Hypnotic Evaluate the need for the medication 1/18/

52 Next Steps Start with 2 residents per neighborhood per week Determined if the resident is a good candidate for dose reduction, weaning or discontinuation Bring this information to the MD and FAMILY to discuss options Do you use psych services? 1/18/

53 THEN Update the care plan Continue to follow with a Behavior Flow Sheet during this process 1/18/

54 What are your non-pharmacological changes? Add to the plan of care Educate staff on what s going on Increase staff confidence 1/18/

55 No I in TEAM This can be done! What are you doing that has shown success? 1/18/

56 And you know... Document Re-evaluate success Re-evaluate failure Do a PDSA Care plan it Allows surveyors to see evidence that antipsychotics are being formally reviewed 1/18/

57 As a team: rectify what is lacking after thorough review Re-evaluate the process: monthly and/or with care plan schedule Add it to your QAPI Let s discuss your progress on our next call in February! 1/18/

58 Last But NEVER Least Celebrate success!!! 1/18/

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60 Mark Your Calendars Next Affinity Group Call February 16, :00-4:00 pm Access Materials on the Affinity Group s Webpage: This material was prepared by New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC