New Practice Guideline on Antipsychotic Use in Dementia
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The American Psychiatric Association (APA) recently issued practice guidelines for the use of antipsychotics to treat agitation and psychosis in patients with dementia.  The primary purpose of these guidelines is to assist healthcare practitioners in effectively addressing the behavioral and psychological symptoms of dementia (BPSD), while simultaneously minimizing health risks. Nowhere is there a greater need for such guidelines than in long-term care settings like nursing homes and assisted living communities, in which dementia and BPSD are highly prevalent. The BCAT Research Center reported that approximately 60% of US nursing home residents have dementia. Furthermore, BPSD, such as physical and verbal aggression, delusions and other perceptual distortions, anxiety, and depression, affect nearly 80% of residents with dementia at some time during their stays. Antipsychotic medications have been considered the first line intervention to treat such symptoms, despite very limited empirical support and a host of negative side effects.

In 2005, the Food and Drug Administration (FDA) determined that the use of atypical or second generation antipsychotic medications for behavioral disturbances in older adults with dementia is associated with increased mortality. In response, the Centers for Medicare and Medicaid Services (CMS) established the National Partnership to Improve Dementia Care, which set specific targets for reducing antipsychotic medication use in American nursing homes.  The CMS targets are still in place, and most states have reported resultant decreases in antipsychotic utilization.

While there may be a decrease in antipsychotic utilization, BPSD remain prevalent, underscoring the need for effective behavioral interventions. It is important to subtract unnecessary and potentially harmful psychotropics, but it is equally important to add effective non-pharmacologic interventions. Otherwise, nursing home staff would be left without BPSD mitigation tools, and residents would continue to suffer.

Unfortunately, there are not many proven behavioral programs in use. One of the few evidence-based approaches is the BCAT 3D Behavioral Management Program.  The 3D program is a component of the comprehensive BCAT Approach For Resident-Centered Dementia Care (BCAT-DC). The BCAT-DC is used by nursing homes and assisted living communities to provide person-centered behavioral healthcare, thereby empowering and optimizing quality of life for residents with dementia.

The recently issued APA guidelines emphasize the need for programs like 3D to lower or eliminate antipsychotic use.  The need for behavioral approaches is most evident in the following recommendations:

  • Assess patients for pain and other potentially modifiable contributors.  Residents with dementia may not be able to communicate through words. In the absence of words, they often communicate through agitated behaviors.  Antipsychotics fail to address the underlying pain.
  • Develop a comprehensive treatment plan that includes appropriate non-pharmacologic and pharmacologic interventions. By routinely using behavioral interventions, the temptation to use a “medication first” approach to BPSD is reduced.
  • Nonemergency antipsychotic medication should be used to treat agitation or psychosis only when symptoms are severe, dangerous, and/or cause significant distress to the patient. The presence of egosyntonic thoughts and feelings (those that are harmonious with an individual’s ideal self-image) or mild symptoms that do not place the resident or others at risk is not a reason to prescribe antipsychotics
  • Taper antipsychotics if there is no significant treatment response after a 4-week trial of an adequate dose.  Providers should always consider non-pharmacologic treatments as an alternative or complement to medications, particularly if there is an inadequate response to antipsychotics alone.
  • Even in patients who respond well to antipsychotics, consider a drug taper within 4 months. Remember, there is no such thing as a completely benign medication.  This is especially true of antipsychotics. The goal should be to prescribe the lowest effective dose for the shortest amount of time, while simultaneously implementing non-pharmacologic interventions.

For more information about the BCAT 3D Behavioral Management Program of the BCAT Dementia Care Program (BCAT-DC), email us at info@thebcat.com.

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