Interdisciplinary Care

Dr. Posar notes that the use of antipsychotic medications in LTC residents is 21.3%.  According to CMS, the use of antipsychotic medication in nursing homes, excluding residents diagnosed with schizophrenia, Huntington’s Disease or Tourettes’s Syndrome, is 14.8% (4Q2023), which is a decrease of almost 38% over the past 12 years since implementing the National Partnership to Improve Dementia Care.  One goal of this program was to increase the use of non-pharmacologic approaches and person-centered care practices.  Of note, the diagnosis of schizophrenia increased by 200% in nursing homes between 2015 and 2019, and the use of anticonvulsants increased by 40%.  This drastic increase brings the accuracy of the diagnosis into question.

In a recent study, adding a neurology focus to the dementia care team has reduced the need for antipsychotic medications by 70% and resulted in close to 100% compliance with CMS anticonvulsant utilization requirements, along with other improvements in care and quality of life.  The National Center for Assisted Living recently published Guiding Principles for Dementia Care.  This report reiterates the lack of clinical support in using antipsychotic medications to treat behaviors associated with dementia and encourages alternative strategies when responding to challenging behaviors exhibited by residents with dementia.

Long-Term Care Dementia Diagnoses

Approximately 95% of LTC dementia diagnoses fall into the following:

• Alzheimer’s Disease
• Vascular Dementia – macro/microvascular
• Mixed Dementia
• Parkinson’s Disease Dementia
• Lewy Body Dementia
• Frontotemporal Dementias
• LATE (Limbic Predominant Age Related TDP43 Encephalopathy)

Each of these diagnoses can be treated individually, therefore a specific diagnosis must be made.  For example, Lewy Body Dementia is a sleep disorder and a primary neurological diagnosis with a specific medication regimen that has proven successful in improving sleep.  In addition, complex conditions secondary to dementia include, but are not limited to, delirium, sundowning, sleep disorders, akathisia and partial complex epilepsy.  Of note, 40% of LTC dementia residents have an EEG consistent with epilepsy, and it is often manifested as “zoning out”, staring off, and fainting.  Some falls may be seizures.  Specific treatment for epilepsy is Keppra.  All these conditions benefit from the inclusion of neurological specialists on the care team to prescribe appropriate medications.

Medications for the behavioral and psychological symptoms of dementia (BPSD) include:

Acetylcholinesterase Inhibitors (Aricept, Galantamine), Memantine (Namenda) and Selective Serotonin Reuptake Inhibitors (SSRIs).  The combination of acetylcholinesterase inhibitors and memantine is often very beneficial.  Neurology-specific medications and treatments that may be appropriate include anticonvulsants, dextromethorphan, beta-blockers, CPAP, amphetamines, and bupropion.  Antipsychotics should only be used for psychosis, with or without schizophrenia.  Treatments of BPSDs are typically more responsive to psychiatric treatment following neurologic treatment.  Medications to avoid in these patients include SNRIs and tricyclic antidepressants, non-protocol antipsychotics, benzodiazepines and hypnotics, all anticholinergics, anticonvulsants, insulin, and dihydropyridine calcium channel blockers.

6-Step Treatment Approach

The following interdisciplinary approach is recommended for treating dementia patients in the long-term care setting:

1. Neurologic, psychiatric, and psychological diagnostic and clinical status evaluation to determine an accurate diagnosis
2. Total pharmacology review and adjustment to eliminate unnecessary or counteractive medications
3. Initiate neurological pharmacotherapy
4. Reassess psychiatric and global clinical status – 6-8 weeks after adjusting pharmacotherapy
5. Amend psychiatric and psychological treatment
6. Frequent neurologic, psychiatric and psychological assessments

He emphasized that “frequency trumps intensity” when treating dementia patients.  Frequent interactions allow caregivers to anticipate their clinical status and be proactive rather than reactive.

Responding to Regulatory Reviews, Claims and Litigation

Excelas has the tools and expertise to assist long-term care facilities, their insurers, and counsel by conducting medical record reviews to demonstrate quality dementia care was provided.  Reports are customizable and often include the following:

• Provider of Care Report: a quick review of all staff who documented in the medical record, the date care was administered, and a hyperlink to the page where the entry was documented.
• Care Calendar/TouchChart: an interactive calendar of all staff interactions with the resident.
• Medical Chronology/Timeline: an in-depth summary of the medical and related records with hyperlinks to the source documents. The timeline can be queried by topics such as medications, nutrition, safety, behavior, or other categories related to the care of the dementia resident.

These reports allow decision-makers to efficiently assess a situation and develop a strategy early in the process.  Contact Excelas to learn more about how our experienced legal nurse analysts and health information management professionals can assist you.