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Team approach slashed psychoactive drug use.


LONG BEACH, CALIF. -- Using interdisciplinary teams in a systematic way can help nursing homes meet requirements that they stop excessive use of psychoactive medications in residents.

Three reports from the meeting showed how facilities are using interdisciplinary teams to comply with Federal Health Regulations for Long-Term Care Facilities rule 329 (F-Tag 329), which mandates that "each resident's medication regimen must be free from unnecessary drugs," and to comply with state regulations such as California's State Operations Manual Appendix PR which requires consideration of gradual dose reductions to avoid unnecessary medications.

At a 230-bed long-term care facility in San Antonio, an interdisciplinary team approach reduced antipsychotic use by 74%, anxiolytic use by 23%, and stimulant use by 13% within 6 months, Dr. Kunle Adedeji and associates reported in a poster presentation.

The facility had been contracting with a psychiatry group to provide mental health services and collaborate with the medical director on all psychoactive prescriptions. The new interdisciplinary team included the facility's medical director, consulting pharmacist, director of nursing, nurse manager, Minimum Data Set coordinator, two social service representatives, and the consulting psychiatry group's nurse practitioner.

The team met monthly to review the cases of all residents who were prescribed psychoactive drugs within the preceding month. Members discussed concerns about each patient, made recommendations for reducing or discontinuing medications, and made sure that each psychoactive drug prescription had a specific diagnosis linked to it.

The use of antipsychotics had been slightly higher in the facility than state and national averages before the multi-disciplinary team formed. But 6 months later, usage was down to 6% of residents, far below those averages, reported Dr. Adedeji of the University of Texas Health Science Center, San Antonio.

The team's efforts were supplemented by systematic implementation of non-pharmacologic treatments such as offering residents "busy boxes" or gardening to reduce agitation. The team implemented protocols for discontinuation of "as needed" medications for anxiety and sleep management. Floor staff underwent training in managing residents with dementia and behavioral problems.

The facility now plans to apply an interdisciplinary team approach to other areas, such as the use of physical restraints when dealing with behavioral problems.

Psychoactive Drug Doses Reduced

At a 150-bed skilled nursing facility in Hendersonville, N.C., 6 months of an interdisciplinary team approach reduced the use of antipsychotics by 54%, reduced anxiolytic use by 54%, decreased the use of hypnotics more than twice per week by 64%, and lowered psychiatric discharges to hospitals by 72%, Mark Coggins, Pharm.D., and his associates reported in a separate poster presentation.

The interdisciplinary team included a consultant pharmacist, nurse, social worker, dietician, therapy staff, and activity staff. They met twice weekly to discuss individual needs and interventions for residents who were on psychoactive drugs or whom staff identified as having weight loss, disruptive behaviors, pressure ulcers, or falls.

Each resident in those categories was reviewed every 4 weeks, and the team gave the attending physician its recommendations on gradual dose reduction of psychoactive drugs, pain management, depression treatment, therapy referrals, individualized activities, and nutritional interventions.

The attending physicians accepted the team's recommendations 93% of the time, said Dr. Coggins of Golden Living Centers, Inman, S.C. The incidence of untreated depression dropped by 47%, and the proportion of residents experiencing increased symptoms of depression or anxiety fell by 10%.

Rates of pressure ulcers declined by 66%, falls in high-risk residents were reduced by 25%, hospitalizations for falls declined by 23%, and fractures fell by 17%.

Better Documentation, Better Surveys

Even without measuring outcomes, using a multidisciplinary team approach can help nursing homes stay in compliance with requirements for regular consideration of gradual dose reductions, geriatrician Dr. Jay S. Luxenberg said in an oral presentation.

At the 430-bed Jewish Home, San Francisco, where he is medical director, an interdisciplinary team doing weekly "drug rounds" reviews residents on psychoactive drugs, so that each of those residents is reviewed at least every 6 months.

The team--consisting of the medical director, two psychiatrists, a nurse practitioner, a pharmacist, and usually representatives of the floor unit's social workers or nurses--assesses drug indications, documentation, consent, efficacy parameters, side effects, nonpharmacologic strategies, and previous or ongoing gradual dose reductions. It then presents recommendations to the attending physician about whether a gradual dose reduction would be appropriate, and the attending must document agreement or give a rationale for not accepting the recommendation.

"So far, that has helped us tremendously" in improving documentation and avoiding deficiencies on annual surveys by regulators, Dr. Luxenberg said. "Surveyors are very generous when you have documented well," he noted.

"We need to step away from the defense that the person is doing well, so we don't want to change anything. A lot of our physicians have that as a gut feeling," Dr. Luxenberg said.

The speakers and investigators in this article said they have no conflicts of interest related to these topics.

To view a video interview of Dr. Luxenberg, go to and search on "teamwork."

A team approach can help nursing homes comply with requirements for regular consideration of dose reductions.

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Title Annotation:GERIATRICS
Author:Boschert, Sherry
Publication:Internal Medicine News
Geographic Code:1USA
Date:Jul 1, 2010
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