Needs Assessment

Beyond Pills: Education for Balanced Psychotropic Use in Dementia Care

Behavioral and Psychological Symptoms of Dementia are Frequent

Every 3 seconds, an individual is diagnosed with dementia somewhere in the world.¹ Certain long-term care facilities have upwards of 90% of their population diagnosed with dementia, and nearly 90% of individuals with this disease display at least one behavioral or psychological symptom of dementia during the course of their illness.²'³ Behavioral and psychological symptoms of dementia (BPSD) include anxiety, depression, apathy, restlessness, hallucinations, physical aggression, repeated vocalizations, and pacing.³'⁴

Pharmacological Treatment Has a Limited Role in Treating Patients with Dementia

The Unmet Needs Model suggests that problematic behaviors in individuals with dementia are often due to unfulfilled needs, arising from a reduced capacity to communicate and care for themselves.⁵ For example, pain, loneliness, or boredom could manifest as agitation because patients are unable to clearly voice their needs.⁵ Therefore, interventions that identify and address unmet needs have the potential to alleviate BPSD, and clinical guidelines emphasize the importance of non-pharmacological measures as a first-line strategy for dementia-related symptoms.⁶⁻⁸

Another possible treatment involves psychotropic medication, ie, antipsychotic, antidepressant, anxiolytic, hypnotic, or anticonvulsant drugs.⁹⁻¹⁰ These products are generally reserved for second-line treatment of severe BPSD cases, as they provide modest benefits and carry an increased risk of significant side effects affecting patients’ quality of life.¹¹⁻¹⁹ Notably, antipsychotics increase the risk of cerebrovascular events, cardiac arrhythmia, and death, the latter increasing with treatment duration.¹²⁻¹⁵

Desired Practice According to Clinical Guidelines:

Overuse of Psychotropic Medications in Dementia Patients Remains A Persistent Challenge in Nursing Homes

Notwithstanding recommendations to limit the use of psychotropic medication for BPSD, a substantial 80% of residents in long-term care facilities receive them, indicating a prevalent overuse.⁹ A pooled estimate of worldwide psychotropic use in nursing homes estimated that 68% of residents receive these drugs, of which 26.1% of patients are on antipsychotics, 38.3% are on antidepressants, and 36.2% are on benzodiazepines, respectively.²⁶ This overuse has prompted congressional policy leaders to demand a review of psychotropic medication use in nursing homes.²⁷'²⁸

Despite clinical guidelines recommending limiting anxiolytic and hypnotic use to a 2-week duration, treatment duration also remains problematic.²³'²⁹'³⁰ In one study assessing treatment prevalence and appropriateness in nursing homes, the duration of anxiolytic use was inadequate in all cases and only correct in 16.3% of hypnotic prescriptions.²³ In a clinical investigation assessing sedative medication duration, the average use of antipsychotics lasted 401 days, while sedatives were used for 487 days.²⁹ Clinicians performed no adjustments for 31.3% of patients on antipsychotics and 48.4% of those on sedatives for over a year.²⁹ A longitudinal cohort study examined the use of psychotropic medication over 6 months in nursing homes and discovered that persistence varied between 41.7%–86% depending on drug class.³⁰

Although practice guidelines prioritize non-pharmacological treatments for BPSD and advocate for limited use of pharmacotherapy, data regarding prescription appropriateness reveals widespread misuse and inadequate monitoring of psychotropic drugs in nursing homes.⁶⁻⁸'²³'³¹'³² Two-thirds of nursing homes in the United States were identified as having incorrectly or unnecessarily used psychotropic drugs.³¹ The most common issues included nursing staff failing to identify or monitor behavioral symptoms, physicians neglecting to attempt dose reduction, and physicians not limiting treatment duration to 14 days for as-needed psychotropic prescriptions.³¹ Adding to these issues, some health care professionals did not evaluate the risks versus benefits of medication to ascertain its suitability.³¹ Alongside these shortcomings, certain facilities were unable to present documentation that showed that they had monitored residents for adverse reactions linked to psychotropic medications with black box warnings.³¹ These scenarios underscore the prevalent misuse and insufficient oversight of psychotropic medications in nursing homes, revealing a major health care issue that compromises the well-being and safety of residents.³¹

Clinician knowledge and practice gap #1

• General practitioners and nursing staff rely excessively on psychotropic drugs for the management of neuropsychiatric symptoms in individuals with dementia in long-term care facilities.

Education Need

• There is a need to enhance clinician knowledge and skills in accurately assessing neuropsychiatric symptoms in dementia patients and managing them effectively.

• Clinicians require education on evidence-based, non-pharmacological strategies for managing behavioral symptoms in dementia, emphasizing the importance of these approaches alongside or in place of psychotropic medication.

Activity Learning Objectives

• Recognize neuropsychiatric symptoms that justify psychotropic medication use.

• Implement non-pharmacological interventions as the primary method for managing behavioral symptoms of dementia in suitable patients.

• Compare the effectiveness and adverse effects of psychotropic medications.

Anticipated Outcomes

• Health care providers select BPSD treatment options that optimize patient outcomes based on efficacy, safety, and quality of life considerations.

• Health care providers effectively integrate evidence-based non-pharmacological strategies as a first-line treatment for BPSD in eligible patients.

• Clinicians use evidence-based tools to evaluate, initiate, and adjust psychotropic therapy in eligible patients with behavioral symptoms of dementia.

Why Does This Gap Occur?

Insufficient knowledge or awareness about excessive prescriptions of psychotropic medication drives their inappropriate use.⁸'³³ Many nurses deem antipsychotics safe and effective, overlooking their risks and potential side effects.³⁴ Likewise, many staff members are unaware of the range and efficacy of environmental care methods for dementia.³³'³⁵ Consequently, physicians report the “enormous pressure to sedate patients in nursing homes from nurses.”³⁵

Health care professionals’ attitudes can also influence BPSD management.³⁴ During an evaluation of a psychotropic medication reduction project, a nursing home project leader stated, “It’s just the knee-jerk reaction when someone is having agitation, anxiety. You know the first step or first thing you think of is, well, let’s give them a pill to calm them down…so the biggest challenge is just changing everybody’s way of thinking on that.”³³ Many nurses feel that antipsychotics allow better workflow efficiency.³⁴ However, some data suggest that lowering antipsychotic usage may reduce workload due to decreased patient sedation.³⁶ This knowledge gap is particularly significant, as staffing issues can also contribute to poor management of dementia-related symptoms.⁹

Clinician Knowledge and Practice Gap #2

• Clinicians continue psychotropic medication for extended periods or indefinitely. Dose reduction or discontinuation is insufficiently trialed.

Education Need

• There is a need for education on developing personalized, patient-centric plans for the use, tapering, and discontinuation of psychotropic medications, considering each patient's unique circumstances and risks.

Activity Learning Objectives

• Evaluate the suitability of continuing psychotropic drug use in each patient with dementia-related symptoms based on individual circumstances.

• Develop a personalized plan for tapering and discontinuing psychotropic medications in eligible patients with BPSD.

Anticipated Outcomes

• Clinicians make informed decisions about continuing or discontinuing psychotropic medications, referring to specialists when necessary.

• Clinicians apply personalized plans for psychotropic medication reduction and discontinuation while ensuring appropriate follow-up.

Why Does This Gap Occur?

General practitioners and nursing home staff lack the expertise and credentials to successfully and safely deprescribe psychotropics.³³ Most general practitioners worry that discontinuing psychotropics could adversely affect patients’ quality of life, potentially causing a resurgence of problematic behaviors.³⁵ However, although some patients with severe BPSD may present symptom aggravation upon drug cessation, people with mild symptoms could experience decreased agitation.³⁷ In reality, the successful withdrawal of antipsychotics for BPSD is possible in most adults over the age of 65.³⁸

Educational Interventions Can Change Clinical Practice and Patient Outcomes

In an environment with high staff turnover, such as in long-term care settings, educational providers must repeat dementia-targeted learning to ensure optimal BPSD treatment.³⁹ 60% of general practitioners believe they need more training to enhance BPSD management, and many nursing home staff have identified a lack of specialized dementia training.³⁵'⁴⁰ 

Many educational interventions to improve BPSD management have been successful.⁶'⁹'³⁹⁻⁴² Evidence supports educational programs that are integrated into a broader, multicomponent intervention.³⁹ One intervention trained staff in patient-centered care, social interaction, and antipsychotic medication use.⁶ This program improved patient quality of life, decreased agitation, and ameliorated neuropsychiatric symptoms.⁶ Similar educational initiatives have resulted in changes in clinical practice lasting over 2 years.⁴⁰'⁴²'⁴⁴ An intervention aimed at helping staff learn practical methods for managing agitation and enhancing relaxation in residents resulted in lasting improvements in nursing home practices, observed 30 months later.⁴² Similarly, a 20-hour training program on non-pharmacological interventions reduced behavioral problems and psychotropic drug prescriptions, and these effects persisted 6 months after the initiative.⁴³

Importantly, supplemental dementia training can be particularly effective in improving practices in nursing homes with staffing issues.⁴¹ In research examining the influence of education on the use of psychotropic medications in nursing homes, additional training focused on dementia significantly reduced improper practices.⁴¹ This positive effect was particularly notable in nursing homes experiencing staffing challenges.⁴¹ This finding is promising, as staffing problems often complicate the task of meeting the needs of residents.⁴¹ By prioritizing staff training and comprehensive, patient-centered approaches, it is possible to foster lasting improvements in BPSD management, ultimately leading to better patient outcomes and a more supportive environment for patients and caregivers.⁶'⁴⁰⁻⁴³

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