In LTC we sometimes deal with broad-stroke decisions such as “We are a no-antipsychotic facility.”  What that really means is that they should only use antipsychotics for AXIS 1 disorders.  Most facilities do not operate with that self-imposed restriction.  They will take a Part A patient short-term with an antipsychotic onboard, as well as a long-stay patient returning with a newly prescribed antipsychotic.  Many facilities allow a hospital transfer with a PRN low dose of quetiapine.  

We live in a time where we can use on-label antipsychotics for conditions like Dementia with Agitation and Parkinson’s Disease Psychosis.  These are conditions that may be best managed with an antipsychotic, and there are specific FDA-approved antipsychotics for these conditions.

Facilities often cite a negative impact on their five-star rating as a reason for avoiding all antipsychotics.  A low five-star rating can directly affect admissions, and reimbursement. Along with antipsychotic use in long stay patients, other events such as falls, skin breakdown and weight loss may also impact the five-star rating.  (See Understanding the CMS Five-Star Rating System and Antipsychotic Use in Long- Stay Patients article.)

Schizophrenia, Tourette’s, and Huntington’s Chorea are the only exempt indications for using an antipsychotic in long term care.  Long-term care facilities may see some patients with schizophrenia but Tourette’s and Huntington’s patients often live in psychiatric facilities or residential care facilities.  Also of concern: CMS is now doing specific surveys to verify a diagnosis of schizophrenia in LTC.  This is a result of some facilities erroneously identifying an older resident with dementia-related problem behaviors or psychosis as having schizophrenia, which can result in automatic one-star ratings (and potential referrals to professional boards for prescribers who sign off on inappropriate schizophrenia diagnoses).  Now some facilities have moved to not wanting ANY antipsychotics prescribed for ANY patients, or only those with legitimate diagnoses of schizophrenia, Tourette’s or Huntington’s.. 

As a former consultant pharmacist, I believe this approach is not practical or person-centered, especially with the on-label medications available today–and it may cause significant harm to some of our patients by depriving them of a truly medically appropriate Rx that can improve their lives.  Imagine a patient with Parkinson’s Disease Psychosis (PDP) not eating because they see bugs in their food. Why not treat this correctly and document the need for an antipsychotic because of the impact on the patient’s quality of life?  Parkinson’s Disease Psychosis is described in Appendix PP as a diagnosis requiring treatment with an antipsychotic and states that as long as the documentation is in place, a gradual dose reduction may not be necessary. 

Similarly, for dementia with agitation, if a patient is constantly hitting others or screaming, they may also spend a lot of time sleeping because of the emergency doses of sedative medications they may be receiving.  They may be “calmer,” but still not eating, which leads to other complications,  not to mention the impact on five-star rating from using an emergency (or prn) sedative.

Two products are currently available:  Pimavanserin (Nuplazid) for Parkinson’s Disease Psychosis (PDP) and brexpiprazole (Rexulti) for dementia with agitation. Both are FDA approved for these indications.

There is a short 4 question validated assessment tool for PDP.

https://cdn.ymaws.com/www.ascp.com/resource/resmgr/files/vv-med-03280_saspap_question.pdf

Also for dementia with agitation, the Cohen-Mansfield tool that was used in the study submitted to the FDA for approval is available to be administered to any patient.

https://bcbpsd.ca/docs/part-1/Final%20Cohen%20Mansfield%20Inventory.pdf

It is important to point out that brexpiprazole is not FDA-approved for psychosis alone, but if the psychosis results in agitation, and it is assessed and documented, brexpiprazole can be used.  

Similarly, pimavanserin is only approved to be used for Parkinson’s Disease Psychosis.  It is important for a patient with PDP to have a diagnosis of Parkinson’s first.  Administer the validated tool on patients that have a baseline diagnosis of Parkinson’s Disease, and with possible psychosis.

Both medications have modified boxed warnings indicating an increase in the risk of death in elderly patients when using an antipsychotic for dementia.  This is nothing new for us: with every drug, the FDA advises the prescriber to assess risks and benefits. 

In summary, instead of saying we don’t use antipsychotics because of our star rating, why not just say we do our best to use antipsychotics appropriately and on-label?  Antipsychotics have been utilized for many years in patients with dementia who exhibit severe distress or are a danger to themselves or others, and have a definite place there–whether FDA-approved for the indication or not.  We use validated tools to assess when an FDA-approved diagnosis is not available.  These tools can be administered by a social worker and brought to the behavior meeting, and a recommendation can be made to the prescriber.  These assessments along with the recommendation become a part of the patient’s medical record.  A facility can obtain an appropriate order from a prescriber for an antipsychotic with a proper assessment and a multidisciplinary review.  

The responsibility of a long-term care facility is enormous.  We have to manage patients within the regulatory landscape while still attempting to be financially viable.  Please pause when using broad strokes to make decisions that may not be patient specific.  Do not fall into the LTC one-size-fits-all approach and make poor decisions for your patients.