More than half of nursing facility residents have some form of dementia, many of whom experience behavioral and psychological symptoms associated with dementia (BPSD). These behaviors, which can pose significant challenges for the staff and residents, are often best treated with non-pharmacologic measures such as environmental modifications.
Over 25% of patients in nursing facilities in the United States receive antipsychotic medications, according to data from the Certification and Survey Provider Enhanced Reporting (CASPER)  (member login required) data network from the Centers for Medicare and Medicaid Services (CMS). These drugs have many legitimate uses including treatment for psychotic disorders such as schizophrenia, psychotic symptoms such as delusions and hallucinations, and BPSD in certain situations. However, they are often used inappropriately in nursing facilities to treat BPSD, and evidence documenting their clinical efficacy for BPSD is variable.
In March 2012, CMS launched a nursing facility quality initiative that included a goal to decrease the off-label use of antipsychotics by 15% by December 2012. Since then, other organizations, including ASCP, have joined the effort to provide guidance on appropriate antipsychotic prescribing in nursing facilities.
To read ASCP’s full position statement, "Use of Antipsychotic Medications in Nursing Facility Residents," click here. (PDF)
The American Society of Consultant Pharmacists supports the use of environmental modifications and non-pharmacologic approaches as initial therapy for the management of behavioral and psychological symptoms of dementia.
The use of antipsychotics in nursing facility residents should include:
Talking Points: Use of Antipsychotic Medications in Nursing Facility Residents  (PDF)
Relias Learning in partnership with eHealth Data Solutions have published a white paper  (PDF) discussing the National Partnership to Improve Dementia Care program to reduce the use of antipsychotic medications for the treatment of dementia-related behaviors in long-term care residents. The report details CMS’ newly revised draft survey guidelines for skilled nursing facilities, explains the importance of understanding the behaviors dementia patients exhibit, and it lays out alternative non-pharmacological interventions to antipsychotic medications. Additionally, the white paper illustrates the positive impact this initiative has already had on antipsychotic diminution efforts nationwide, stating that there has been a 13.1% reduction in utilization since the last quarter of 2011.
ASCP's Policy & Advocacy department held a special webinar briefing on September 5 featuring the latest data from the Centers for Medicare & Medicaid Services (CMS) on the ongoing effort to reduce antipsychotic utilization in nursing facilities. Earlier, CMS announced  that the results of this initiative have been encouraging, with a nationwide reduction in utilization of 9.1 percent during 2012, and at least 11 states exceeding the 15 percent reduction target. If you missed the webinar but would like a copy of the presentation slides  (members only), please contact firstname.lastname@example.org .
The Survey and Certification group at the Centers for Medicare & Medicaid Services (CMS) released the third and final new surveyor training program in May 2013 concerning the care of residents with dementia and unnecessary antipsychotic medication use. The video content provides details on how to cite severity level and other aspects of deficiency citations based on new guidance at F309, Quality of Care, and revised guidance at F329, Unnecessary Drugs. The video is 35 minutes in length and can be accessed at the CMS Surveyor Training Website. The new training video is being released in conjunction with the update to the  interpretative guidance  (PDF) for F309 and F329 of Appendix P  (PDF) and Appendix PP  (PDF) of the State Operations Manual.
ASCP previously disseminated notification of the availability of the first two videos released by CMS in January 2013. These videos cover background information on the National Partnership to Improve Dementia Care, and an interactive self-study depicting an actual nursing home survey. Providers and non-surveyors can access all three videos by visiting the CMS Surveyor Training Website  and click on the program that you wish to view.
Visit ASCP’s Web page  on the CMS Survey and Certification training videos for related information.
The Survey and Certification group at the Centers for Medicare & Medicaid Services has published an advanced copy of interim guidance  (PDF) related to surveyors’ assessment for compliance with requirements related to nursing home residents with dementia and unnecessary drug use. These updates make substantial changes to the State Operations Manual:
These changes are effective immediately and should be implemented as soon as possible. You can access these documents in Nursing Facility Survey & Regulations. 
Following a national summit with state Medicaid leaders, CMS released guidance  (PDF) on efforts to reduce the use of psychotropic medications in vulnerable Medicaid populations, particularly foster children and dementia patients in nursing homes. The guidance highlights reports on the high rates of foster children and persons with dementia receiving psychotropic medications and charges state Medicaid agencies to work locally to improve psychotropic medication prescribing practices.
The guidance specifically directs states to address overutilization of psychotropic medications for children through state drug utilization review (DUR) programs. However, CMS declined to provide similar direction to nursing homes, and instead directed states to the ongoing Partnership to Improve Dementia Care , of which ASCP is a participant. This public-private partnership aims to reduce antipsychotic use in nursing homes by 15% by December 31, 2012.
In July 2012, the Office of Inspector General of the Department of Health and Human Services issued a report, "Nursing Facility Assessments and Care Plans for Residents Receiving Atypical Antipsychotic Drugs."  The OIG found that 99% of records did not contain evidence of compliance with Federal requirements for care plan development. The OIG recommended, and CMS agreed, that CMS should improve the detection of noncompliance with Federal requirements for resident assessments and care plans for residents receiving antipsychotic drugs. Nursing facility staff are required to assess each resident's functional capacity upon admission to the facility and periodically thereafter. Staff must specify in a written care plan, based on these assessments, the services that each resident needs. Care plans should describe the services that the nursing facility will provide to residents to assist them in attaining or maintaining the highest practicable functional status.
The Centers for Medicare & Medicaid Services announced an initiative to improve behavioral health management and to safeguard nursing home residents from unnecessary antipsychotic drug use. A goal was established to reduce antipsychotic drug use by 15% by December 2012. This initiative was launched with a video webinar , which has been archived at the CMS Web site. This one-hour video includes presentations by AMDA and ASCP, along with a nursing perspective and resident perspective on the use of antipsychotics in nursing homes.
More information about the quality initiative to reduce antipsychotic drug use is available on the American Health Care Association Web site .
The U.S. Senate Special Committee on Aging held a hearing on November 30, 2011 with the title "Overprescribed: The Human and Taxpayers' Costs of Antipsychotics in Nursing Homes." ASCP submitted a statement to the Committee  (PDF) in conjunction with that hearing.
The hearing was Webcast and the archived version is available on the Committee Web site .
CMS convened a meeting of long-term care stakeholders on October 26, 2011 to request input on ways to reduce the use of antipsychotic drugs in nursing facility residents. In response to that request, ASCP worked with other pharmacy stakeholders to draft a response letter.
In May 2011, the Office of Inspector General of the Department of Health and Human Services issued a report, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents . The report identified four key findings:
Although the report has been criticized for its assumptions and methodology, it has fueled widespread concern about overuse of atypical antipsychotics in nursing facilities. The Centers for Medicare & Medicaid Services announced in October 2011 that the CMS Survey and Certification branch, which oversees licensure and inspection of nursing facilities, will be placing a high priority on evaluating the appropriateness of use of antipsychotic medications during surveys of nursing facilities.