As a physician and medical director in the post-acute and long-term care setting, I encounter dementia-related behaviors almost every day. Agitation, aggression, or resistance to care are rarely “just behaviors” — they’re often the patient communicating discomfort, fear, or confusion in the only way they can. When a nurse calls me about a resident striking out during bathing or becoming restless at night, my first instinct isn’t to reach for a prescription pad. Instead, I pause and ask: What has changed for this person? I look at recent labs, review pain control, check for constipation, infection, or dyspnea, and ask whether their usual routines — music, lighting, or sleep patterns — have been disrupted. Many times, small adjustments like restoring a familiar evening routine, dimming harsh lights, or breaking hygiene tasks into smaller steps can calm a patient without medication.

Several years ago, the California Partnership for Improved Dementia Care concluded that the pandemic associated SNF staff shortages, would create a need for dementia education for the many new hires, as well as updates for continuing staff.

State Alzheimer’s Disease Advocacy Day was on March 3, 2022. Following is the list of important bills that impact our patients living with Alzheimer’s and other dementias. They have been advocated by our Alzheimer’s Disease Society. I was fortunate to be part of it. This is the summary of these Bills.

Recently, the California Partnership to Improve Dementia Care vetted its mission and vision statements that reflect our direction and commitment to the care processes that better support the quality of life of our residents living with dementia. We have broadened our focus from the SNF setting to include the home and community based (ALF, RCFE, CCRC, Senior Congregate living) settings. I have found the latter social care settings to be places where antipsychotics are commonly used as chemical restraints with informed consent seldom documented. In California, we have made some progress with reducing the inappropriate use of antipsychotics for our long stay nursing home residents. The National Partnership to Improve Dementia Care on 1/14/22 reported the Q2 2021 national, regional, and state percentage use of antipsychotics in long stay residents without an approved indication. Our CMS Region 9 located in San Francisco (represents Arizona, California, Hawaii, Nevada, and Pacific Territories) performed the 3rd best of the CMS Regions at 10.87%. CMS Region 10 located in Seattle (represents Alaska, Idaho, Oregon, and Washington) performed the best at 6.89%. California was ranked the 3rd best by states at 10.4% trailing only Hawaii and the District of Columbia. While most states including California have made < then 1% improvement in the past 3-4years, how is it that CMS Region 10 in Seattle, can achieve a 6.89% antipsychotic rate? What are they doing differently to achieve these impressive results?

A recent study published in JAMA, August 2019 suggests that in a large population prior exposure to strong anticholinergic drugs is associated with the risk of dementia. Previous studies by Richardson et.al. (2018) and Gray et.al. (2015) were small case-control cohort studies while these studies suggested an association between anticholinergics and dementia the sample size were too small to draw conclusions.  The findings of this large middle-aged to elderly cohort study by Coupland, et.al. advocates for deprescribing of anticholinergic agents in middle-aged to older adults (e.g. 55 years and older) to reduce the risk of dementia. 

I recently wrote an article for the WAVE on the potential value of sharing personal pictures on your smartphone, for developing relationships and engaging patients with dementia, prior to providing medication and care plan directed care.  

Recently, the American Geriatrics Society’s MyAGSOnline member forum posted a question about the use of weighted blankets for a dementia unit with patients who had poor judgment, impulsiveness, poor safety recall, and frequent falls.  Dr. Maureen Nash, Board Certified in Internal Medicine & Psychiatry (Portland, Oregon) wrote they can have a positive impact in some older patients offering comfort as long as they are not too heavy. They are not considered a restraint by CMS unless they are inappropriately heavy.  They provide gentle tactile stimulation to people who usually are not touched except in a clinical situation. She gave several references:

On December 4th, 2018 our dementia partnership sponsored a webinar by Dr. Maureen Nash, a nationally recognized Gero-psychiatrist who presented the PowerPoint presentation (handout provided below) on “Helping those with Serious Mental Illness who now live in a LTC setting”. She advocated for use of best practices for persons with serious mental illness who require institutional care, most commonly because of their very high risk for cognitive impairment.  CMS’s campaign to improve dementia care by reduce antipsychotics at times may seem to compromise known best practice. She recommended following the American Psychiatric Association’s free best practice guidelines for treating: Major Depressive DO, Bipoloar DO, PTSD, OCD, Schizophrenia, and dementia persons with agitation and aggression. In these guidelines, recommendations for use of antipsychotics (many have FDA approval) represent best practice even though they may not be recognized in the excluded category by the CMS campaign.