An Expert-Led Tour of Select CMS Guidance for Conditions Including Dementia in a Long-term Care Setting

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Hi. I’m Dr. Dan Cannone. I’m chief medical consultant to United Church Homes, Incorporated, a nonprofit national nursing home chain headquartered in Marion, Ohio. I’m also consultant staff physician in geriatric medicine in the Department of Family Medicine at Western Reserve Hospital in Cuyahoga Falls, Ohio.

In this program, I am going to walk you through guidance from the Centers for Medicare & Medicaid Services, or CMS, that is relevant to older adults with hallucinations and delusions associated with dementia-related psychosis and put them in the context of my experience in long-term care.

Please note that this disease-awareness, non-CME program is intended only for healthcare professionals involved in the management of people with dementia-related hallucinations and delusions. It’s sponsored by Acadia Pharmaceuticals, and I’m presenting on behalf of Acadia as a paid consultant. This presentation is not meant to discuss specific treatment options for dementia-related psychosis.

I’m going to highlight 4 F-tags from the State Operations Manual, beginning with F-tag 744. This guidance speaks to overall care for adults with dementia. What’s most important to highlight here is that dignity and quality of life are the primary goals for decision-making. I think all of us in long-term care would agree that this guidance is critically important in the treatment of residents with dementia.

The guidance also notes that behavioral and psychological issues in residents with dementia may be caused or exacerbated by environmental triggers and may represent the person’s attempt to communicate with those around them. Behavioral disturbances are common in older people with dementia, and it’s important to examine the underlying potential causes of that behavior. In my experience in long-term care, I often see older people with dementia who have behavioral disturbances that are caused by hallucinations and delusions. However, it is also important to rule out other causes of the behavior. For example, I’ve seen residents with urinary tract infections act out because of their need to be toileted.

The second F-tag I’d like to discuss, F-tag 605, concerns respect and dignity for the resident. This F-tag has been put into place to eliminate physical and chemical restraints that are imposed for purposes of discipline or convenience rather than for treating the resident’s medical symptoms.

“Convenience” is here defined as an action that is intended to reduce the amount of effort or care the resident requires and not in the resident’s best interest.

The guidance also notes that any medication that restricts the resident’s movement or changes their cognition may be considered a chemical restraint, so it’s important that the medication is deemed medically necessary and that medical symptoms are documented. As an example, I’ll make every effort to identify the underlying cause of a resident’s distress. I consider: How long has this resident had problems with possible hallucinations or delusions? I’ve found that it’s important also to include the family and long-term care facility staff in the discussion.

When it’s decided that a medication is necessary, in addition to ensuring that it’s prescribed for the appropriate indication, I personally try to choose a medication with a low fall risk and with the least morbidity and mortality.

I also provide detailed education to staff and family about monitoring for side effects and response closely.

Consent for medication should always be obtained prior to initiating antipsychotic medication. An informed consent form, such as the one shown here, may be used to review the reasoning for selecting the medication, how and when the medication will be administered, and the potential benefits and risks of the medication, including any boxed warnings. The informed consent form must include a daily dose range and must be updated yearly or when dosing outside of the documented dose range.

The third F-tag, F758, governs the use of psychotropic medications for people with conditions including dementia. As we see here in blue, this guidance covers several aspects of medication prescribing. I’d like to emphasize the first point: It’s extremely important to document the diagnosed condition for which you’re going to prescribe. Psychotropic medications may be used in specific circumstances of acute emergency—for example, if a resident is a threat to themselves or others around them. In these situations, if the medication is prescribed for distress, you need to identify and address any medical or physical problem or psychological cause that might have triggered the distress.

The guidance also emphasizes that any prescribed antipsychotic must be administered at the lowest possible dose for the shortest period of time and is subject to gradual dose reduction, or GDR.

According to the guidance, attempts at GDR may be clinically contraindicated if the resident has a documented disorder, if continued use is in accordance with relevant current standards of practice, and/or if attempts at a GDR resulted in a recurrence of or worsened the resident’s symptoms. If an attempt of a GDR fails, this should be documented and revisited 12 months later. One failed GDR does not exempt the resident from future GDR evaluations. The physician must clearly document the clinical rationale if a GDR is contraindicated. Of particular note, some residents with specific, enduring, progressive, or terminal conditions, such as Parkinson’s disease psychosis, may need specific types of psychotropic medications or other medications that affect brain activity indefinitely.

Finally, it’s important to highlight that a diagnosis alone may not necessarily warrant the use of antipsychotic medication. This medication may be indicated if the documentation clearly shows that the resident is a danger to themselves or others or is in significant distress or if nonpharmacological approaches have been tried without success.

Once an antipsychotic is prescribed for an older resident with dementia or other conditions, it’s especially important to document efficacy and side effects.
The residents must be monitored for treatment-related adverse consequences. If adverse events occur, the facility and the prescriber—in consultation with the resident and/or family—must decide and document if the medication should be continued.

Finally, F756 governs drug regimen review. In long-term care, our residents may be on a drug regimen that consists of multiple medications. Pharmacist input is paramount to a team approach to medical management. Review should be conducted monthly and must be accompanied by a review of the chart, and irregularities must be reported to the appropriate members of the care team.

In my own practice I’ve seen that any time there’s a transition in care, medications are rarely taken out of the regimen, and in many cases, more may be added. It’s important to keep in mind that many of these residents have multiple comorbidities. In my experience I’ve seen residents sent for 1 service, but by the time you get them back they’ve seen 2 or 3 different medical services, and more medications have been added. All adverse events are looked at against the backdrop of the resident’s chart. Because of that, if a resident is stabilized and suddenly has a new adverse event going on, you have to look at any newly added drugs for potential new drug-drug interactions or drug adverse events.

As I noted previously, it’s important to document resident behavior and other outcomes—for example, in response to a decrease in antipsychotic medication or other changes to care. A standardized grid or form, such as the example form shown here, may be used to track aggressive behaviors, anxiety, or lack of interest in self-care activities such as eating, toileting, showering, and so on. Tracking the resident’s behaviors in this way can help alert the treatment team to the need for intervention following medication changes or other changes to the treatment regimen.

To sum up, the CMS guidance provides important standards for the care of older adults with conditions including dementia-related psychosis.

This guidance seeks to ensure resident autonomy, dignity, respect, and quality of life.

It makes clear that physical and chemical restraints, including antipsychotic medications, must be used for medical purposes and not for discipline or staff convenience.

When using psychotropic medications, it is important to obtain consent from the resident or healthcare proxy, review the resident’s other medications, and regularly monitor outcomes.

It’s also essential to document the indication for medication use, response to treatment, behavior changes, and side effects.

During this program, we have seen how dementia and hallucinations and delusions associated with dementia-related psychosis may impact long-term care and transitions of care.

We have also reviewed the common challenges associated with care transitions for these individuals and, most importantly, identified areas where improved communication might enhance resident outcomes.

Thank you for joining me for this program. For additional resources on hallucinations and delusions associated with dementia-related psychosis, please explore MoreThanCognition.com.

Reference
Centers for Medicare & Medicaid Services. State Operations Manual: Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Updated November 22, 2017. Accessed November 11, 2020. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

Faculty

Ohio University Heritage College of Osteopathic Medicine
Athens, OH

Faculty Insights

Tracking the resident’s behaviors … in this way can help alert the treatment team to the need for intervention following medication changes or other changes to the treatment regimen.

–Daniel J. Cannone, DO, CMD