by Tim Gieseke MD, CMD

California has an active collaboration involving multiple stakeholders focused on improving the quality of care provided for persons with dementia living in the SNF setting.  Key stakeholders are Health Services Advisory Group (HSAG (Health Services Advisory Group), California Department of Public Health (CDPH), and the California Culture Change Coalition (CCCC), among others.  You can find helpful resources for professionals and consumers at www.calculturechange.org .  The Centers for Medicare and Medicaid Services ( CMS) has provided the Hand in Hand tool kit for CNA training.  Other valuable quality improvement resources include: www.nursinghometoolkit.com, https://www.nhqualitycampaign.org/dementiaCare.aspx ,www.musicandmemory.org, and www.functionfocusedcare.org.  These resources emphasize non-pharmacologic approaches for improving the quality of life while minimizing or preventing problem behaviors in persons with dementia.

In California, in the most recent reported quarter (Q4 2016), we are sixth-best in the country at 12.4% of our long-stay residents on antipsychotics, and our degree of reduction since 2011 is the second-best in the nation.

Nationally, an uptick in the diagnosis of patients with schizophrenia has occurred, with suspicion that this may represent a misdiagnosis of dementia with hallucinations and/or delusions as schizophrenia.  AMDA - The Society for Post-Acute and Long-Term Care Medicine, in partnership with multiple other elder care organizations, has posted on its website a statement giving guidance on the new diagnosis of Schizophrenia in the LTC setting (http://www.paltc.org/newsroom/joint-summary-statement-diagnosing-schizophrenia-skilled-nursing-centers).  This guidance emphasizes the rarity of a new diagnosis of schizophrenia in the elderly and calls for meeting DSM-5 criteria when using this diagnosis.

In the same vein, CMS and surveyors suspect increased prescribing of lorazepam (Ativan) for “agitation,” which puts facilities at risk for potentially unsafe and inappropriate prescribing.  Agitation is a nebulous target and Ativan (benzodiazepines in general) may precipitate delirium in persons with dementia and may increase the risk of malnutrition, aspiration pneumonia, dehydration, impaired mobility, and falls.  Since pain may be underappreciated in dementia and may be associated with restlessness and irritability, a much safer initial option (assuming non-pharmacologic approaches have failed) might be acetaminophen ER 650 mg with meals TID.  CMS is accumulating data on each facility’s use of Benzos likely for future regulatory use.  As of July 2016, the use of Benzos is reported for each facility on Nursing Home Compare.

As a word of caution, Medical Directors have been cited in our state for failing to ensure that the care provided dementia patients in their facilities meets CMS and California standards of care.  Red flags for surveyors include:  failing to attend mandated QA&A meetings, failing to allow a requested interview during the survey process, allowance of duplicate psychotropic medication usage without adequate rationale, and permitting the use of antipsychotics in their facility.  The fact that antipsychotics are prescribed by a psychiatrist doesn’t mean that the Rx meets our regulatory standards.  In addition, the interview process will assess the Medical Director’s knowledge of facility nonpharmacologic interventions as well as the processes in place to assure that the use of antipsychotics is appropriate.

After 5 years, the federal and California state campaign has made measurable progress (overall reduction in antipsychotic use of about one-third, to a little over 12%).  Hawaii is #1 at 7.5%.  In California, we can and should do better.