PALTC is a complex setting and as medical directors, clinicians, and team leaders we are often pulled in multiple directions.  The issue of antipsychotic use is just the tip of the iceberg for Behavioral Health.  Antipsychotic use continues to grab headlines due to changes in regulations and public concerns.  There were several presentations at the CALTCM Summit of Excellence, November 2-4, 2023, on Behavioral Health. For clarity, the difference between mental health vs. behavioral health is that behavioral health includes mental health and substance use disorders. 

Returning to the issues surrounding antipsychotics, a featured article in the New York Times in late 2021 started with a headline of “Phony Diagnosis Hides Drugging at Nursing Homes.”  The series publicized the issue of inaccurate diagnoses of schizophrenia in nursing homes.  Since 2012, the diagnosis of “questionable schizophrenia” soared by 70%.  In 2023, a follow-up article in the New York Times cited yet another issue, that one-third of nursing home residents with a current diagnosis of schizophrenia had no records of ever having being treated for the condition prior to nursing home admission (based on 2018 data from the federal oversight investigation).  Concern with antipsychotic use in our older adult population stems from the boxed warning (“black box”) that there is a 1.7-fold increase in death when antipsychotics are used in dementia. Our main clinical decision choice is to determine, with shared decision-making involving the patient and/or family, whether the benefits of antipsychotic use outweigh the risks for each individual patient, and support in detail in our progress notes. There is a common misconception in nursing homes that antipsychotics are not permitted to be administered for other diagnoses, especially dementia-related agitation or psychosis.  Yet sometimes they are medically appropriate; in fact, earlier this year a new FDA indication was granted to brexpiprazole, explicitly for agitation in Alzheimer’s disease.

Even with documentation, early this year (on 1/18/23), CMS issued a letter to State Survey Agency Directors, “Updates to the Nursing Home Care Compare Website and Five Star Quality Rating System: Adjusting Quality Measure (QM) Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute (CMS, Ref: QSO-23-05-NH).”  The letter cited consequences such as:

1. The Overall QM and long stay QM ratings will be downgraded to one star for six months (this drops the facility’s overall star rating by one star).
2. The short stay QM rating will be suppressed for six months.
3. The long stay antipsychotic QM will be suppressed for 12 months.

This letter captured the attention of many in nursing home administration and management teams.  Nevertheless, I believe this is just one example of why we need to provide consistent and quality mental health services in PALTC.  Concern for appropriate use of antipsychotics has plagued prescribers’ ability to provide necessary treatment for troubling hallucinations and delusions.

At CALTCM Summit for Excellence, the lecture on antipsychotics covered the appropriate criteria for an actual diagnosis of schizophrenia in PALTC patients.  We highlighted how reliance on the classic symptoms of hallucinations and delusions may prove unreliable for assigning a diagnosis of schizophrenia in patients with dementia, who often exhibit these symptoms as a result of their dementia itself.  More importantly, there was a focus on conditions such as bipolar disorder, that can benefit from antipsychotic use (approved by the FDA for such use).  And lastly, the recent FDA approval of brexpiprazole (a second-generation antipsychotic) for “Agitation Associated with Alzheimer’s dementia (AAD)” does not mean that any antipsychotic in general (or brexpiprazole specifically) should be used before non-pharmacological interventions have been exhausted, except in emergency situations or those with extreme distress or posing a danger to self or others.  We will need to continue to make rational clinical decisions based on individualized, person-centered benefits vs. risks, especially when it comes to taking care of older adults with dementia.  CALTCM’s Summit for Excellence provided much excellent information promoting improved management of antipsychotics in PALTC.