Recently, the California Partnership to Improve Dementia Care vetted its mission and vision statements that reflect our direction and commitment to the care processes that better support the quality of life of our residents living with dementia. We have broadened our focus from the SNF setting to include the home and community based (ALF, RCFE, CCRC, Senior Congregate living) settings. I have found the latter social care settings to be places where antipsychotics are commonly used as chemical restraints with informed consent seldom documented. In California, we have made some progress with reducing the inappropriate use of antipsychotics for our long stay nursing home residents. The National Partnership to Improve Dementia Care on 1/14/22 reported the Q2 2021 national, regional, and state percentage use of antipsychotics in long stay residents without an approved indication. Our CMS Region 9 located in San Francisco (represents Arizona, California, Hawaii, Nevada, and Pacific Territories) performed the 3rd best of the CMS Regions at 10.87%. CMS Region 10 located in Seattle (represents Alaska, Idaho, Oregon, and Washington) performed the best at 6.89%. California was ranked the 3rd best by states at 10.4% trailing only Hawaii and the District of Columbia. While most states including California have made < then 1% improvement in the past 3-4years, how is it that CMS Region 10 in Seattle, can achieve a 6.89% antipsychotic rate? What are they doing differently to achieve these impressive results?
CANHR (California Advocates for Nursing Home Reform) continues to receive complaints about antipsychotics prescribed in nursing home long stay residents without rigorous informed consent, objective measurable goals, early identification of burdensome side effects, and use longer than medically necessary. In California, CANHR has co-sponsored AB 1809. I realize that CALTCM opposes this Bill out of a variety of concerns, but defer those concerns to a future article. This bill advocates for a much more rigorous consent process for all psychotropic medicines, which are not required in other non-psychiatric settings of care or for most other FDA approved medications. The proposed requirement for providers to give written materials to patients and their families as part of the consent process is already encouraged in multiple areas of medicine. I’ve used the patient education materials in UpToDate for this purpose, but even there I may not find appropriate material and this source is only available through hospital privileges or private commercial account. I agree with CANHR that some prescribers fail to communicate adequately with patients and families through the verbal route. The National Institute of Mental Health (NIH) has a well-designed web page for mental health information for consumers that may help bridge this gap NIMH » Mental Health Medications (nih.gov). In addition, a nursing text book has a free brief section on best practices for use of antipsychotics that may reduce inappropriate requests for these medications and improve prescribing practices.
Many facilities use generic informed consent forms for psychotropic medication use that have brief statements about the proposed drug and its indication, but from a consumer perspective, don’t provide adequate information to support a fully informed decision. For this reason, our partnership developed one for use of antipsychotics that supports informed consent, is free, and is available on the LeadingAge California web site.
During the pandemic, our dementia care plans have been compromised by the mandated mitigation measures for reducing the impact of COVID-19 in our facilities. The prolonged social isolation, quarantine units, masking, and reduced family and staff contact have reduced quality of life and been associated with more rapid decline in cognitive and physical function. As we come out of the Omicron surge, I was pleased to attend a virtual pre-conference AMDA PALTC 2022 annual meeting presentation on the Dementia Isolation Toolkit. For those of you who attended this meeting, I would commend this presentation to you. Even if you can’t yet access it, this Toronto, Canada consortium of academic SNFs have created a web site with free practical e-fillable tools that reduce the impact of isolation on our residents. The toolkit has modules for: Ethical Guidance, Isolation Decision-Making Worksheet, Person-Centered Isolation Plan, Isolation Care Plan Summary, Team Huddle Toolkit, Isolation Communication Signs, and a poster that visually pictures for staff how COVID-19 might present in residents with dementia.
This toolkit supports the Well-Being Model of Care, which has significantly reduced the use of antipsychotics in participating facilities in Arkansas. Our state partnership has developed four learning video modules that support this model and focus on care that improves the quality of life of our residents living with dementia. These modules are now available on the LeadingAge website link noted below. In the near future, all of the dementia care resources developed by our partnership will be available on this site.
Stay tuned,
Tim Gieseke MD, CMD
Past President of CALTCM
Member of California Partnership to Improve Dementia Care
Video webpage: https://www.leadingageca.org/ca-partnership-for-improved-dementia-care
California Partnership for Improved Dementia Care
Video 1: Best practices in Dementia Care
» Download Video 1 Handouts
Video 2: Dementia: What is it?
» Download Video 2 Handouts
Video 3: Individualized Assessment and Care planning for Persons with Dementia
» Download Video 3 Handouts
Video 4: Nonpharmacological Interventions for Dementia Care
» Download Video 4 Handouts
Prepared by the California Partnership for Improved Dementia Care, under the leadership of Jennifer Birdsall, PhD. ABPP, Chief Clinical Officer with CHE Behavioral Health Services, Inc. and hosted by the Health Services Advisory Group [HSAG]
These videos provide practical and up-to-date information on dementia care best practices and serve as an excellent educational tool for direct care and executive staff.