LTC: Prepare for
New CMS Guidance

"Diagnoses alone do not necessarily warrant the use of a psychotropic medication," notes CMS. There must be clear indications, e.g., "behavioral symptoms present a danger to the resident or others” or "significant distress to the resident". A prescription must not be clinically contraindicated, and nonpharmacological approaches must be attempted. The medical record needs to show how clinicians arrived at the current treatment plan. This must include diagnoses, assessments, medications, side effects, behaviors, and nonpharmacological interventions. For survey purposes, if it isn’t documented, it didn’t happen. Documentation should also include recommendations to monitor for side effects and behaviors.

As outlined in the AGS Beers Criteria^®, many medications have unwanted effects on cognitive and psychiatric status. Polypharmacy (the use of five or more medications) also increases the possibility of prescribing cascades, in which additional drugs are prescribed to treat the adverse effects of one of the current medications. Cleaning up residents' medication lists "makes a big difference," explains Dr. Steven Posar, CEO and Chief Medical Officer of GuideStar Eldercare. For example, anticholinergics are a class of medications "you want to virtually get rid of," he says, and some calcium channel blockers (dihydropyridines) can be associated with delirium. At the same time, certain classes of drugs can help improve clinical status. Learn more: Antipsychotic Reduction – Key Ideas.

Accurate diagnosis is essential to this process. We need to ensure that the prescribed medication is clinically indicated and is the least restrictive option. At GuideStar Eldercare, we rely on a current evidence base regarding available medications, along with extensive clinical experience and published research. When a medication is indicated, a conservative approach means start low and go slow, monitoring for adverse effects. CMS explains that "adequate indication for use" means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles. The Medical Director is responsible for oversight of these practices and may be subject to investigative interviews by surveyors, says CMS.

Tapering may be indicated when the resident’s clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, and/or non-pharmacological approaches have been effective in reducing the symptoms. The key to a successful GDR is a reduction in measurable BPSD symptoms. Enough time needs to be allowed (3-5 days) to determine if the change is consistent.

Some examples identified by CMS include that the attempted GDR "would be likely to impair the resident’s function or exacerbate an underlying medical or psychiatric disorder" or "the resident’s target symptoms returned or worsened after the most recent attempt at a GDR". A GDR would be contraindicated if depressive symptoms, anxiety symptoms, or behavioral symptoms such as agitation or aggression remain persistent.

Documentation in the medical record needs to reflect the date and outcome of the attempt and the plan for future GDR attempts, notes CMS. Documentation of GDR reviews should clearly state whether the reduction was indicated or contraindicated, with supportive reasoning.

Three valuable tests a qualified clinician can offer for the long-term care population are:

• Geriatric Depression Scale (GDS) – a measure of depressive symptoms
• Geriatric Anxiety Inventory (GAI) – a measure of anxiety symptoms
• Neuropsychiatric Inventory (NPI) – a measure of behavioral symptoms, e.g., agitation, aggression

Results of any formal testing should be documented in the medical record and referenced in GDR review documentation.

Neurology, psychology, psychiatry, pharmacology, and geriatric medicine all play into ensuring accurate assessments and effective treatment plans that can help reduce reliance on antipsychotics and other psychotropic medications.

Managing dementia patients is enhanced by creating a calm environment and redirecting the behaviors, says Daniel Heiser, PsyD, Senior Vice President, Behavioral Health at GuideStar Eldercare. By gaining insights into the patient's experience and applying behavioral strategies, caregivers can redirect challenging behaviors—and support an individual's well-being. An evidence-based paradigm, DICE, outlines a response to agitation and BPSDs. Learn more in the blog, How to Redirect Behaviors in Dementia.

Our clinicians find that nursing home residents’ status can change quickly, especially in the presence of a progressive neurologic disease such as any form(s) of dementia. This is why it’s essential to follow the six-step treatment approach for antipsychotic stewardship. A proactive clinical care model supported by an interdisciplinary team can pick up on changes and declines before they turn into crises. This requires attentive, ongoing assessments. Through this approach, the GuideStar team has been able to reduce acute inpatient psychiatric admissions substantially, as evidenced by MDS data.

This creates a very difficult situation for facilities because residents have the right to refuse medication. It’s helpful to prioritize open communication with the resident, understand the reasons behind the refusal, and address any underlying concerns. For patients who are intact, the team should take time to provide education regarding possible adverse reactions if medications are refused.

For patients with dementia, it is much more difficult to manage this situation. They are often confused and may make decisions regarding medications based on that confusion. It is key that facilities encourage family members to be involved.