The “Improving Antipsychotic Appropriateness in Dementia Patients” clinical tools and training program

The Iowa Geriatric Education Center is pleased to announce a new training program and toolkit to improve antipsychotic appropriateness in dementia patients, available here. The site includes clinical decision aids, available free for downloading, to help providers evaluate and manage problem behaviors and psychosis as well as a free continuing education program and resources for patient families.

Antipsychotics are commonly used off-label in people with dementia to manage problem behaviors or psychotic symptoms. They have modest efficacy in reducing some behaviors and symptoms, but also have serious adverse effects including an increased risk of stroke and mortality.¹ A recent chart review study conducted by the Office of Management and Budget for the U.S. Department of Health and Human Services found that 22% of antipsychotics were used inappropriately according to Centers for Medicare and Medicaid Services (CMS) guidelines. Reasons they were considered inappropriate included no adequate indication, excessive dosing, inadequate monitoring, and use in the presence of adverse effects suggesting the dose should be reduced or drug discontinued.² Other research has shown large variability in antipsychotic use rates across nursing homes, 3-fold higher rates of prescribing regardless of patient characteristics in facilities with high rates compared to those with low rates, and increased risk of short-term mortality associated with admission to a nursing home with high rates of antipsychotic use.³⁴ There is a clear need for improvement of behavior management strategies and prescribing practices to reduce the adverse impact of these drugs. In support of this, on March 29^th, 2012, CMS announced a major initiative to improve behavioral health and reduce antipsychotic use in nursing home residents.⁵

Proper management of behaviors and psychosis in dementia requires a thorough and thoughtful approach, rather than simply reacting to behaviors and using medications out of frustration. It starts with assessment and management of possible contributing causes, including pain, uncontrolled medical disorders, delirium, medications, and environmental factors. Pain appears to be a particularly common and under-recognized contributor to problem behaviors, in part because many people with dementia cannot communicate with providers about their pain.⁶⁷ Interventions as simple as scheduled acetaminophen have been shown to reduce agitation in a large proportion of patients with dementia.⁷ Non-drug methods to prevent and manage behaviors can also be effective for many patients, but providers are often undertrained in their use. Sometimes these are as simple as changing caregiving approaches and improving communication, or giving the patient a personalized and enjoyable activity to stay busy. If an antipsychotic is necessary, it is essential to understand how to select, dose, and monitor its effectiveness and side effects, based on efficacy and the impact of side effects on patient comorbidities.

To improve the management of problem behaviors and psychosis in dementia, the Iowa Geriatric Education Center has released a new program, “IA-ADAPT: Improving Antipsychotic Appropriateness in Dementia Patients,” produced in collaboration with the Health Effectiveness Research Center, Health Literacy Iowa, Telligen, PMC Studios, and stakeholders, and supported by a grant from the Agency for Healthcare Research and Quality. We have developed pocket guides and other resources to help providers deliver optimal evidence-based care for these challenging problems, all of which can be downloaded for free from our website. The pocket guides are also available as an Android app on Google Play, and a web app for other devices is coming soon. Our training program includes brief lectures covering the spectrum of assessment, non-drug management, and antipsychotic use. It also includes evidence-based reviews on non-drug management, delirium, and pharmacologic management of problem behaviors and psychosis. Finally, we have developed a fact sheet for patient families, written using health literacy principles, to encourage shared decision making on antipsychotic use. This was developed in collaboration with Health Literacy Iowa, with feedback from the New Readers of Iowa and an Alzheimer's Association caregiver support group. The website also includes links and brief videos for patient families.

The website can be found at the link listed above, or by going to the Iowa Geriatric Education Center homepage and clicking on the link in the lower left corner. Free continuing education credit is available for a limited time for physicians, pharmacists, and nurses. Certificates of participation are available for other provider types. All decision aids can be downloaded for free. Registration is required to access the site, as we need to track dissemination and use for our funding agency. We hope that you fill find the program and resources useful, and pass them on to others who care for people with dementia.