“Medication Is Just One Piece of the Whole Puzzle”: How Nursing Homes Change Their Use of Antipsychotic Medications

Abstract

Antipsychotic medication use for nursing home residents with dementia poses major patient safety challenges. This article investigates health professionals’ experiences with decision-making during changes under the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) and its companion state coalitions. These programs were introduced in 2012 to encourage reductions in antipsychotic use and increased use of nonpharmacological treatments for dementia. Interviews with 40 nursing home physicians and staff in seven states found that reducing antipsychotics is more time and resource-intensive than relying on medication, because it requires a person-centered approach. However, respondents supported reductions in antipsychotic use, and indicated that with sufficient staffing, effective communications, and training, they could create or implement individualized treatments. Their positive attitudes suggest that the National Partnership has been a catalyst in reducing antipsychotic medications, and their perspectives can inform further research, policy and practice in nursing homes toward achieving quality dementia care.

Keywords

nursing homes dementia qualitative methods quality of care decision-making

Introduction

Antipsychotic medications have been widely used in nursing homes to manage behavioral and psychological symptoms of dementia. Despite significantly increased risk of mortality and strokes among frail elderly residents (Gill et al., 2017; Schneeweiss et al., 2007), and a resulting Food and Drug Administration (FDA) black box warning (Huybrechts et al., 2012; Kuehn, 2005), staff and families may ask physicians to prescribe antipsychotics to address difficult and distressing symptoms of dementia (such as agitation, aggression, crying, cursing, wandering, or threatening others).

Such off-label use of antipsychotics for behavior management has long been a safety concern and target of regulation, starting with federal regulatory reforms implemented in the 1987 Nursing Home Reform Act (Committee on Finance, United States Senate, 1987). A federally directed, state-operated review was instituted, requiring periodic site visits and certification by regulators (called “surveyors”) empowered to issue deficiency citations, and requiring facilities to submit information on resident characteristics, treatments, and services, creating the minimum data set (MDS).

Even with this review process in place, antipsychotic use grew rapidly during the 2000s, reaching 23.9% of residents by 2011. With concern about patient safety, the Centers for Medicare and Medicaid Services (CMS) launched the National Partnership to Improve Dementia Care in Nursing Homes (National Partnership) in 2012, using state-based coalitions to encourage reductions in antipsychotic medications without valid, clinical indications, while increasing use of nonpharmacologic approaches and person-centered dementia care. State coalitions involved federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers. CMS’s support includes public reporting of comparative data to help nursing homes make decisions, and provides updated regulatory guidelines for evaluation of dementia care data by state nursing home agency “surveyors.” National Partnership goals progressed from 15% relative reduction in antipsychotic medication use among long-term residents (in 2012), to 27% in June 2016, the target at the time of our data collection. For 2019, the National Partnership’s new goal focused on decreasing antipsychotic medication use by 15% (in specific nursing homes where utilization remains high). By the second quarter of 2019, use had declined by 38.9%, to 14.3% (CMS Quality Measure, 2019).

Although successful overall, variation in use of antipsychotics still exists among nursing homes and across states. For example, Texas reduced antipsychotic medication use notably (56.5% reduction from 2011 to 2018, moving from 50th place to 10th place among states); Wyoming’s efforts have been least successful (14.5% reduction). Across the seven states in our study, the 2012 rates were (in ascending order): Wisconsin (18.9%), North Carolina (21.3%), California (21.3%), Arkansas (26.1%), Maine (26.9%), Georgia (28.7%), and Texas (28.9%). By fourth quarter 2018, their rates (in ascending order) had changed to: California (11.1%), North Carolina (12.1%), Wisconsin (12.3%), Texas (12.5%), Arkansas (14.1%), Maine (17.6%), and Georgia (17.9%) (CMS Quality Measure, 2019).

Institutional change of this magnitude represents a considerable transformation of practices. Although nonpharmacological programs using music, exercise, and enhanced living environments (often called “culture change” nursing homes) have been beneficial in improving care for residents with dementia (Bjerre et al., 2018; Grabowski et al., 2014; Tawiah et al., 2016), many nursing homes still face major challenges in achieving meaningful reductions in antipsychotic medication use (Walsh et al., 2018). The aim of this research was to learn the experiences of health professionals in this changing time. A Director of Nursing (DON) interviewed for this study gave a succinct statement revealing how the revised decision-making process starts with diagnosis of a problem, then creation of an individualized treatment plan in which medication is balanced with other approaches, rather than being the sole treatment:

We have to rule out what the change in behavior is. Is it delirium? Is it worsening of dementia? Is it an infection? . . .it really should be person-centered. Medication is just one piece of the whole puzzle.

By providing insights into decision-making and institutional changes in the prescribing of antipsychotics, this analysis can inform further policy and clinical work in nursing homes toward achieving quality dementia care (Crystal et al., 2020).

Method

Study Design

To better understand the transformation of nursing home practices, the research team conducted 40 semistructured interviews at 14 nursing homes in seven states (two per state): Arkansas, California, Georgia, Maine, North Carolina, Texas, and Wisconsin. These states were selected for diversity in regions, population size, and rates of change in antipsychotic medication use. For example, Texas was included given its large population, large number of nursing home facilities, and high rate of antipsychotic medication use.

The researchers had previously completed state-level discussions with key informants in these states, including representatives from state aging and long-term care regulatory agencies, and state nursing home associations. Many of these regulators and industry representatives were involved in their state coalitions under the National Partnership and have ongoing professional responsibilities for reviewing performance and quality data.

Semistructured telephone interviews were conducted with 30 nursing home staff (primarily nursing, activities, and social services staff), and 10 prescribing physicians. Questions focused on decision-making related to use of antipsychotics, effects of CMS regulation, barriers to change, and sources of improvement.

Sampling and Participants

The study used purposive sampling (Patton, 1990), taking several steps to approach respondents. The research team first relied on key informants from earlier state-level discussions, for direction to nursing home administrators to gain telephone access to their staff, who were contacted individually and asked to participate. These nursing homes had made reductions in antipsychotic medications. Key informants at the states’ Society for Postacute and Long-Term Care Medicine chapters helped recruit physician participation through email notices and online newsletters (see Figure 1: Participant Sampling and Recruitment for Study Interviews. More information on the sample and data collection is provided in the Supplemental Material to this paper, available in the online version of Journal of Applied Gerontology.) From nursing homes ranging in size from 84 to 207 beds, including for-profit, nonprofit, and government ownership (Table 1: Key Nursing Home Characteristics), the 40 health professionals brought both clinical and nonclinical perspectives; most of the respondents were white (Table 2: Respondent Characteristics).

Figure 1.

Participant sampling and recruitment for study interviews.

Table 1.

Key Nursing Home Characteristics.

Nursing home	Percentage of dementia residents	Percentage of APM use in dementia patients without CMS approval (2014)	Percentage of residents on Medicaid	Number of beds	Profit status	Citied for F-329 in 2015	Above or below state median of Medicaid
Arkansas NH 1	62	55	63	152	For profit	No	Below
Arkansas NH 2	56	37	65	122	For profit	No	Below
California NH 1	11	17	78	99	For profit	No	Above
California NH 2	40	16	63	119	For profit	No	Below
Georgia NH 1	63	57	75	120	For profit	No	Below
Georgia NH 2	71	9	58	87	For profit	No	Below
Maine NH 1	44	18	42	102	Non-profit	Yes	Below
Maine NH 2	74	40	68	84	Non-profit	No	Below
North Carolina NH 1	62	35	69	176	For profit	No	Above
North Carolina NH 2	64	28	90	207	For profit	No	Below
Texas NH 1	90	60	81	140	For profit	No	Above
Texas NH 2	48	38	77	130	For profit	No	Above
Wisconsin NH 1	57	39	70	106	For profit	No	Below
Wisconsin NH 2	68	31	60	117	Government	No	Below

Note. CMS = Centers for Medicare and Medicaid Services; APM = Antipsychotic Medication; NH = nursing home.

Table 2.

Respondent Characteristics.

Demographic categories	Nursing home staff, n = 30 (%)^a	Medical directors and physicians, N = 10 (%)
Age (Mean)	49	56
Sex
Male	3 (10)	7 (70)
Female	27 (90)	3 (30)
Education (highest degree)
High school	1 (3)	NA
Some college	1 (3)	NA
Associates degree	7 (23)	NA
Bachelor’s degree	10 (33)	NA
Master’s degree	4 (13)	NA
Doctorate/medical degree	0 (0)	10 (100)
Other^b	7 (23)	0 (0)
Race^c
White/European American	23 (77)	9 (90)
Asian/Pacific Islander	3 (10)	0 (0)
African American	2 (7)	0 (0)
Native American	1 (3)	1 (10)
Hispanic
Yes	2 (7)	2 (20)
No	28 (93)	8 (80)
Working at current facility (Years)
Range	.5–32	.33–31
Median	8	17
Experience in current position (Years)
Range	.7–44	7–38
Median	12	20

Due to rounding total percentage are not always equal to 100. ^bFour participants indicated they have an Activities Director Certificate, one held a Nurse Practitioner degree, one was an Diploma Registered Nurse, one was a Personal Support Worker Certification. ^cOne participant did not provide information on race.

Data Collection

Phone interviews were conducted from February through May 2017. Each respondent was emailed about study participation and consented. Phone interviews lasting roughly 45 to 60 minutes were arranged by appointment, audio-recorded and transcribed. There were no refusals, although some staff were unable to schedule an interview at the available times.

Informed consent procedures, informant letters, interview guides, and study design were approved by an Institutional Review Board. To facilitate adequate response rates, prescribers were compensated for their interview time. A modest honorarium was given to each nursing home whose staff participated in the interviews, with Institutional Review Board (IRB) approval from the Rutgers University IRB (approval number #16-695MX) for each type of compensation.

Semistructured interview guides for prescribers and nonprescribers asked parallel questions, adjusted for the professional responsibilities of the respondents, covering the decision-making process for prescribing antipsychotics to residents with dementia, as well as decision-making for nonpharmacological interventions, to better understand communications among actors, identify points of intervention, and inform the evaluation of interventions.

Procedures and interview guides were pilot tested in New Jersey (a state excluded from the full study) with seven staff members at three nursing homes, and one nursing home medical director. The pilot enabled the staff to practice interviewing and coding, discuss potential themes, and discuss revisions for the interview guides. The pilot confirmed that nursing home staff and physicians agreed that the subject was relevant to their work, and that the questions asked were meaningful to them. The most important changes to the interview guide, as a result of pilot, were the addition of questions about nonpharmacological interventions that were originated by the staff themselves to address specific residents’ needs (See Supplement online for the interview guides).

Data Coding and Analysis

Transcribed interviews were entered into the qualitative data analysis program ATLAS.ti. Research staff (MR, JP, AW, and EC) created code families (e.g., “nonpharmacological alternative”; “challenges to antipsychotic medication reduction”) for broad topics, subcodes with specific details (e.g., “nonpharmacological alternatives: pet therapy”) and coded the interviews. Pairs of research team members read each other’s coded interviews for appropriate coding and reliability. Weekly team meetings discussed any differences in how codes were applied by coders, along with new code families, subcodes, and consolidated redundant codes. Staff recoded interviews as needed, resulting in 401 codes divided among 22 code families. Errors or disagreements were resolved by consensus of the entire study staff. After themes were derived by individual staff and discussed by the team, and patterns were examined across individuals’ responses and across nursing homes, a codebook was created linking interview questions, emblematic quotations, codes, and themes.

For the analyses, research staff developed memos on important topics and themes which emerged from participants’ responses and identified specific codes and associated quotes. Team meetings discussed themes and representative quotes, resolving discrepancies by consensus, and created an audit trail following meetings.

The study team determined that nursing home staff responses reached saturation, with five recurring themes as discussed below. The physician interviews provided consensus on these themes, although the number of physicians was too small to confirm saturation just among the physicians.

Results

Five recurring themes elicited by the interviews provide insight into decisions during changes in antipsychotic medication use since 2012: (a) staff and physicians are aware of the need to reduce antipsychotic medication use; (b) the value of person-centered approaches to accomplish these reductions; (c) the contribution of collaboration and communication to achieving reductions; (d) the need for more training and education about dementia and for more staffing; (e) the challenges posed by CMS regulations and surveys. (Each theme is discussed below, with additional illustrative quotes in Table 3. An expanded set of quotes is shown in the online Supplemental Material.)

Table 3.

Illustrative Quotes on Themes: Decision-Making About Antipsychotic Prescribing in Nursing Homes.

Theme	Quotations (examples of participant responses)
Awareness of the need to reduce antipsychotic medication use	Nonprescribers DON: “We have a task force that’s working on reducing anti-psychotics . . . We’re electronic so we’re very lucky to pull all those numbers [on a dashboard]. And, of course, we have the CASPER report. We run it monthly.” Prescribers Nurse practitioner: “I’m definitely aware of it that we want to reduce the use of them [antipsychotics]. Certainly, it’s a benefit to the patient, not me. Yeah, it’s very easy to order something that almost will provide possibly a chemical restraint to the patient, but the goal is not to do that. It’s to do what’s best for the patient. And certainly it would be a last resort.” Psychiatric nurse practitioner: “So the facility, if they have a lot of individuals on any psychotic medications they can get cited and have a penalty for that. So the nursing facilities are very, very aware of how many patients on anti-psychotic medication. And they are always looking to have less patients on anti-psychotics.”
The value of person-centered approaches	Nonprescribers Social services: “. . . you have to find different ways to accommodate a personalized care plan for each resident. So it’s no longer cookie cutter, giving people medications to kind of reduce behaviors. It’s finding what works for each patient individually. And I think that’s being very creative and seeing what works for each patient. I had an intern do a very interesting kind of project. She called each person, each resident that had dementia and asked the family member ‘what did they [the resident] like to do in their past?’” Prescribers Psychiatric nurse practitioner: “I evaluate the patient and if they don’t have severe psychiatric symptoms . . . they’re not severely hallucinating or delusional, and if at all possible I think that non- pharmacological interventions might help. I actually will write them on my consult form and discuss it with the nurses that I think we should this approach or that approach as far as the non-pharmacological intervention. I like to try them first if at all possible before I prescribe any medication because medications, as you know, have a lot of side effects.”
The contribution of collaboration and communication	Nonprescribers DON: “The decision-making process would involve the nursing team, family members, psychiatrist, and the APN and the nurses on the floor . . . If we start seeing certain triggers or things happening, behavior escalating with a resident, of course, we want to try to send the social worker, and she will try to review and find out what’s going on. Get with the families. See if there is anything that they would suggest.” Activities director: “Well every quarter we have team meetings for a particular resident. Obviously, if there’s medication, if there’s something to discuss with medication they’ll meet more frequently, but we do meet with nursing, with doctors, with dieticians, activities, rehab therapy if needed, you know, all the different components of the nursing home to discuss the medications that they’re on, possible side effects, what we can do in activities to help with this particular resident, what we can do, what we can offer. So yes, that’s discussed frequently often consistently and we try to include as many team players as possible, and especially the front line nursing staff, the CNAs because they’re interacting daily with the residents. So they often will see changes before perhaps anyone else. We include that as often as possible for our teams and for input.” Prescribers Physician: “. . . at almost all facilities. One is the communication notebook which are usually binders full of paper that sit at each nursing unit and the nurses can write non-urgent messages to the care providers, PA, nurse practitioner, M.D. and those to create the task or the things that the care provider has to address. That is pretty much the standard way you see it done.”
The need for more training and education about dementia and for more staffing	Nonprescribers Social worker: “Families are led to believe that this is a magic drug that’s going to help their loved one not act as they do. Well they’re going to act as they do because of the dementia, so really that drug is totally ineffective. So educating families [is important].” Prescribers Psychiatric nurse practitioner: “I find that in the nursing facilities the nurses and the staff in general are lacking in knowledge about dementia . . . the symptoms of dementia, the behaviors that we will frequently see in dementia, delirium, depression in the elderly, the use of medications, the use of non-pharmacological interventions. I think there’s a lot of education that needs to be done in the nursing facilities.”
Challenges posed by CMS regulation and surveys	Physician: “I was never of a fan of sort of saying you arbitrarily should reduce it [antipsychotic medication rate] so many percent or whatever, because you take institutions who were doing a really good job and have a low rate to start with. If the individual does not need it [APM], they shouldn’t have it and if they do need it, they need the lowest dose and try the gradual dose reduction.” Physician: “. . . sometimes the first thing is trying to get all the data that you can to find out why these things [antipsychotic medications] are prescribed in the first place . . . if people are newly started on something in the hospital and they came into the nursing home we try to do a rapid discontinuation . . . depending on the size of the dose . . .”

Note. DON = Director of Nursing; APN = Advance Practice Nurse; APM = Antipsychotic Medication; CASPER = Certification and Survey Provider Enhanced Reporting; CMS = Centers for Medicare and Medicaid Services.

Awareness of the Need to Reduce Antipsychotic Medication Use

Respondents were very aware of the need to reduce antipsychotics, for the well-being and safety of residents. Prescribers spoke of using antipsychotics as a “last resort,” used only when alternative methods were not effective. Respondents were also aware of state and national rates of antipsychotic medication use, in comparison to the state average because it impacted their standing in relation to nearby nursing homes.

This awareness is due in part to external pressures, particularly from state nursing home surveyors, who pay close attention to antipsychotic medication rates. Pressure also stems from within facilities. Five respondents reported that their facility tracked their own antipsychotic medication rates monthly via CMS data, quality assurance data, and report cards, and that this tracking motivated them to decrease their use of medications, as noted by one DON:

“. . .we feel like when the state comes to visit and do their surveys, that they are going to be focusing on that [use of antipsychotics] so we do feel like we have to be aware and cooperate with them when it comes time to reducing or trying a trial reduction and, you know, not ignoring that. It is a big deal.”

However, some staff members were concerned about the effects of reducing antipsychotics on the physical safety of nursing staff and residents, expressing frustration with residents’ behaviors and suggesting that medications address aggressive behaviors of residents more quickly. For this reason, they also felt that regulations to reduce antipsychotics were indifferent to the safety issues faced by frontline staff. Because physicians are removed from the often difficult results of taking residents off medication, nursing staff viewed this tension as disrupting unified efforts to reduce antipsychotic medication use.

The Value of Person-Centered Approaches

Individualized, person-centered approaches were deemed essential to reducing use of antipsychotics. To accomplish this, prescribers and nonprescribers described several steps, including ruling out medical causes of difficult behaviors, and trying nonpharmacological alternatives first, as well as nonantipsychotic drugs, such as mood stabilizers. This decision was rarely the result of a single professional’s decision but involved input from staff members, family members, and sometimes residents. Like the Memory Care Director below, respondents talked about the importance of looking at the “whole picture” of a resident as a person, considering possible causes for a resident’s behavior, tailoring treatment to them as individuals, with eliminating medical causes of irritability or aggression as the first step.

And so I’m actually the lead on our poly-pharmacy meeting [that] we have once a month where we review all those individuals who are on antipsychotics or anti-anxieties or antidepressants. And as a team, including our pharmacy, our nurses, our social workers, our MDS coordinator, we all get together and talk about that and discuss non-pharmacological interventions, their recent dose, any changes with their meds. We make recommendations for gradual dose reductions that go back to the psychiatrist.

Nursing home staff described how they used a combination of pharmacological and nonpharmacological strategies for reducing antipsychotics. One Director of Social Services explained:

We do a social history of the person when they first get here to figure out what their likes were, what their habits were . . . we try to figure out everything from job history to sleep patterns to favorite foods, favorite music . . . extracurricular activities that they enjoyed,. . . and implement those into the non-pharmacological interventions . . . We keep a separate notebook, a panel and that is discussed and updated on pretty much a monthly basis . . . It is very person-centered with the non-pharmacological interventions.

Well-established commercial programs were mentioned (such as Music and Memory), along with pet therapy and many types of physical activity. Although interviews also asked specifically about “culture change” approaches, as person-centered care, responses indicated that participants were not clear about what constitutes culture change, even when their nursing homes included some culture change and person-centered approaches.

However, some respondents described ad hoc strategies that they had devised, such as revising staff assignments to better address dementia patients’ behaviors, and even reaching out to the outside community. Three types of innovative strategies included: (a) Strategies to help integrate nursing home residents into the surrounding community. For example, in one facility, a group of bicyclists from the area regularly visited the nursing home and gave residents rides by attaching sidecars to their bikes. (b) Individualized strategies that target residents’ personal histories (such as creating a formal social history of each resident before his or her admission), and eliciting resident preferences to customize their daily schedules. (c) Environmental strategies to make residents feel more comfortable and relaxed (sometimes simple changes made a large difference, such as rubberizing the metal wheels on service carts to reduce disturbing noise in hallways or providing a nighttime light for a resident who often used his commode in the middle of the night.)

Facilities’ staff also created unstructured activities to keep residents busy and prevent outbursts of difficult behavior. One facility gave respondents purses and wallets to “pay” for services with scrip money, giving residents a sense of autonomy, control, and independence. Others included a craft bin at the nurses’ station for residents to use throughout the day or giving residents “tinker boxes” containing objects to fidget with to prevent boredom.

The Contribution of Collaboration and Communication

Respondents frequently mentioned that all staff need to be on board with reduction efforts for these goals to be achieved, with collaboration resting on communication at multiple levels. They cited both formal communications (such as departmental, interdisciplinary and care planning meetings, and documentation and charting) and informal communications (such as tracking sheets and information binders about individual patients’ needs and treatment). Some facilities used computers and electronically stored information about individual residents’ behaviors and needs, while others stored this information on paper charts, care sheets, or notebooks.

While respondents typically spoke about communication and collaboration between staff members or between staff members and families, they less frequently mentioned physicians. Like the DON quoted below, they noted that prescribers should communicate with nursing staff, who are on the “frontlines,” including certified nursing assistants (CNAs). They noted that nurses who are not on board with reduction efforts can become an obstacle to improvement because they may push back against doctors’ efforts to reduce antipsychotics.

Because CNAs spend a significant amount of time interacting one-on-one with residents, they may have ideas about what sorts of strategies might work for a particular resident. Thus it is vital that CNAs communicate with DONs and Assistant DON in order to get their ideas across and potentially improve resident care.

The Need for More Training and Education on Dementia and for More Staffing

As noted, staff are often fearful about reducing antipsychotics because of the unpredictable and aggressive behaviors of residents with dementia. Respondents offered a crucial observation about the need for additional resources: nonpharmacological alternatives require more time and an individualized approach compared to the use of medications, which eliminate symptoms rapidly. Respondents suggested that increasing education and training for frontline staff could help, by informing them about dementia, its causes, symptoms, treatments, and alternative options other than medications.

However, respondents noted that this is a significant obstacle. Although some nursing homes offered formal, structured education programs (those mentioned included Action Packed, the Alzheimer’s Association’s Habilitation, Ensign-U, Hand in Hand, Pro-ACT, Reliance, Silver Chair, Physician Orders for Life-Sustaining Treatment, and trainings led by consultants), in most facilities, education and training were described as informal, experiential, or based on knowledge that other staff had accrued over time, and “learning at the bedside,” as described by one nurse practitioner:

. . .ask every nurse in the facility, “Do you feel you’re getting the education you need to assist you when caring for these patients [with dementia]?” Because I bet half of them would say, “No.” . . . at the bedside we’re always educating nurses if they ask about a medication or “what’s our rationale for ordering something or doing something . . .” Most of my education as far as antipsychotics did not come from my actual formal training, it came when I was in the field.

Respondents also explained the difficulty of implementing nonpharmacological alternatives without sufficient staffing and without adequate funding. As staff must be trained in implementing nonpharmacological programs that reach individual residents, staff turnover diminishes the pool of staff members who know the residents. One physician explained:

. . .I don’t see any scenario where the funding of appropriate numbers of staff to reduce antipsychotics completely is ever going to be available. . .If you have a staff of five, for 30 people that have dementia diagnosis with behaviors attached to it, you would literally almost have to have one-on-one situations in order for those people not to be on any kind of medications whatsoever. Some of these behaviors can become quite violent . . .the paranoia, the delusions, then you get into a whole batch of things. It is not one thing or one behavior that makes antipsychotics necessary, it is a litany of things.

In addition, in their concern for an elderly relative, family members may insist on medication to control anger or other difficult behaviors. Respondents reported that family education initiatives can help families understand and cope with the difficulties of dementia, inform them about the negative effects of antipsychotics, and help them concur with reductions.

Challenges Posed by CMS Regulation and Surveys

Respondents acknowledged that the changes in CMS regulations helped spur quality improvement efforts. But they often felt the survey process does not account for the reality of dementia, calling the surveying “too black and white,” with surveyors often too focused on “the number,” while overlooking complexities of prescribing and reducing antipsychotics, and the nuances of staff experiences. In particular, some believe that process does not differentiate between medications prescribed for patients with dementia and those with a mental illness that necessitates antipsychotics, including this physician:

I don’t believe the CMS Five Star Quality Rating differentiates between the two [mental illness and dementia] really either . . . I think it is very problematic because . . . it is completely appropriate to treat schizophrenia or bipolar with psychotic features with an antipsychotic and . . . it can mislabel a nursing home as providing bad care when it is actually providing good care for people that have true mental illness.

Eight staff and nine physicians, representing different nursing homes, stated they were only able to reduce antipsychotic medication use to a certain extent, given their large population of “true” or “severe” residents with mental illness. They believed that nursing homes treating this particularly vulnerable population are penalized due to their high antipsychotic medication rates and that some potential residents are turned away because of their psychiatric history. For these reasons, some respondents were critical of CMS regulations, deeming the surveying process as arbitrary. Respondents said facilities that may avoid admitting these residents are abusing the system, by evading deficiency ratings, while nursing homes that accept more challenging residents are more likely to receive deficiencies.

Staff, and especially physicians, felt pressure to reduce antipsychotics when patients transition from hospitals to nursing homes. They stated that while hospitals prescribe antipsychotics to address short-term symptoms, communications to nursing home staff were unclear, and generating spikes in the nursing home’s own antipsychotic medication rates, which can cause problems with surveyors.

Saturation and Agreement in Responses

As noted previously, responses from the staff reached saturation around the themes here, and the physicians’ responses were informative on the same themes. For example, six doctors mentioned that hospitals often prescribe antipsychotics and it is up to the nursing homes to then taper the residents off the antipsychotics, which poses a barrier to antipsychotic medication reduction in nursing homes. Staff also mentioned this in responses.

As an important example of saturation from the staff responses, at least one respondent from every state (and often at least one respondent from both nursing homes in each state) said that they try to identify causes (such as urinary tract infections, boredom etc.) for difficult behaviors, and make effort to redirect those behaviors before resorting to suggesting antipsychotics. In addition, at least one respondent from every state mentioned interdisciplinary care teams in the decision-making process for prescribing and for identifying nonpharmacological activities.

Responses of physicians and staff were largely in conformance; the themes that emerged were heard in both sets of interviews. For example, they agreed that CNAs are important in the decision-making process because they are the first to notice behavior changes. They also agreed that exercise and music programs are widely used and helpful. In particular, they agreed about the importance of communication, at all levels of the chain, regarding patients’ needs and medical/psychological status.

On the other hand, staff gave more detailed answers about how they implemented reductions, the nonpharmacological approaches they were using and the specific decision-making process for reducing antipsychotics. The physicians had a broader perspective on policy in different nursing homes and the reasons for medication reductions. They were more aware of the National Partnership’s statewide coalitions and formal organizations that strive to reduce antipsychotic medication use in nursing homes, and presented a wider picture of the efforts to reduce antipsychotics, including financial reasons.

Discussion and Implications

These qualitative interviews shed light on decision-making as nursing homes adapted to regulatory change and a national campaign intended to alter their medication practices, with the responses fitting into five themes. By 2017, when these interviews were conducted, nursing home staff and physicians were aware of, and agreed with the need to reduce antipsychotic use, which suggests that over 5 years, the National Partnership campaign affected health professionals’ attitudes and actions. The Normalization Process Theory of change in health care practices can help explain this transition (May et al., 2007; May & Finch, 2009). The theory suggests that successful interventions are facilitated by legitimation (such as the National Partnership), leading to normative restructuring of practices (such as the use of nonpharmacological alternatives), and modification of peer group norms (shown when respondents compared their medication rates to those of nearby nursing homes). It indicates that nursing home staff internalized the National Partnership’s educational messages on patient safety, even if they did not identify the source, while the increased regulatory focus on antipsychotic prescribing kept these concerns in the front of nursing home staff and physicians’ awareness.

Respondents emphasized the value of person-centered approaches, consistent with research on a variety of nonpharmacological interventions (Flynn & Roach, 2014; Gadwa, 2016; Gerdner, 2000; Groot et al., 2016; Kolanowski et al., 2010; Lee et al., 2016; Music and Memory, 2014; Newman, 2016; Petersen et al., 2017). It also fits with research on addressing unmet needs among dementia patients (Camp et al., 2002; Powell, 2019). They also cited elements of nursing home culture change that create “person-centered environments” (Grabowski et al., 2014; Miller et al., 2014; Tawiah et al., 2016), even when they did not use the term “culture change.” Perhaps the most interesting responses were those detailing novel programs addressing individual residents’ preferences and abilities that were developed on-site by nursing home staff themselves.

Critical to making these approaches work, according to respondents, are communication and collaboration among nursing home staff, and between staff and physicians, which coincides with a recent study of influences on antipsychotic prescribing, and studies of improved patient management and lower staff turnover (Anderson et al., 2004; Walsh et al., 2017).

Responses confirmed the concerns in other studies that greater knowledge, education, and training are needed for nursing home staff, prescribers, and residents’ families about causes and behaviors in dementia (Daly et al., 2015), and its safe and effective management (Brooker et al., 2016; Lemay et al., 2013; Surr et al., 2016).

There are limitations of this study. As with most qualitative studies, the number of respondents was limited, although the research team concurred that the staff interviews reached saturation, and the physician interviews cohered with the same themes. The sample of facilities was self-selected, in that the nursing home administrators had to agree that staff could be approached, and the participating nursing homes were those consciously changing their practices. The physician respondents were self-selected via email inquiries sent from their professional organizations, and the physicians were not necessarily located at the same facilities as the nursing home staff being interviewed. The strengths of the study lie in the nuances of the responses, and the increase in our understanding of the dynamics involved in reducing antipsychotics and providing nonpharmacological alternatives. Although they had a choice, none of the nursing home staff respondents refused the request for their participation. While responses from the staff and physicians do not necessarily reflect identical resident populations, they provide a picture of typical experiences across nursing homes that were actively working to reduce antipsychotic medication use in the seven states in the study, and likely among many facilities that were actively working to reduce antipsychotic medication use during this period.

The study’s results have implications for research, policy, and practice. Future research studies should include other states, use a more diverse nursing home staff sample and examine a variety of nonpharmacological approaches (and pharmacological agents) to provide comparisons of decision-making and implementation across the country. This research can contribute to needed interventions for nursing homes to maintain reductions in antipsychotic medication use and improve quality of life for individuals with dementia. At the same time, policymakers and stakeholders will want to remain vigilant to assure that the current gains in treating dementia patients are sustainable throughout the nursing home field (Gurwitz et al., 2017; Lucas & Bowblis, 2017). Respondents indicated that patient-centered care cannot be done by formula, but they expressed confidence that the medication reduction can be done on a case-by-case basis. These responses point to the need for additional resources for training and staffing, if nursing homes are to provide the optimal level of services to address dementia without antipsychotics.

As a result, the practice implications include continuing training of all staff, team review of cases with antipsychotic prescriptions, and establishing a focus with families, prescribers, and the whole team on safer dementia care. Nursing home administrators who want to succeed in this effort will note that training can be time-consuming, but online training programs in dementia for direct care and nondirect care workers can help reduce staff burdens (Gaugler et al., 2016; Hobday et al., 2010; Irvine et al., 2010) and potentially improve the lives of residents with dementia. Significantly, additional resources are not required for administrators to encourage nurses and other staff to use their professional knowledge and creative thinking in developing novel approaches that can mean the difference between ordinary and higher quality of life for some residents.

This research and analysis were conducted well before the coronavirus pandemic, and its devastating effects on nursing home residents and staff, as well as on the financial status of many nursing homes. The prospect of additional resources may be dim for some time, but these interviews point the way to creative solutions by nursing home staff and physicians, with sufficient information and administrative encouragement.

Supplemental Material

Rosenthal_et_al_Supplement_FINAL – Supplemental material for “Medication Is Just One Piece of the Whole Puzzle”: How Nursing Homes Change Their Use of Antipsychotic Medications

Supplemental material, Rosenthal_et_al_Supplement_FINAL for “Medication Is Just One Piece of the Whole Puzzle”: How Nursing Homes Change Their Use of Antipsychotic Medications by Marsha Rosenthal, Jessica Poling, Aleksandra Wec, Elizabeth Connolly, Beth Angell and Stephen Crystal in Journal of Applied Gerontology

Footnotes

Acknowledgements

The authors want to acknowledge and thank the nursing home administrators, staff, and physicians who participated in this study. They also appreciate the advice they received from nursing home experts in state agencies and professional organizations. Tina Marie Gajda-Crawford (formerly staff at Rutgers University School of Social Work) provided great assistance in contacting and scheduling interviews with study participants. In addition to co-authorship, Aleksandra Wec contributed significantly by assisting the first author with manuscript preparation and revision.

Authors’ Note

Beth Angell is now at School of Social Work at the Virginia Commonwealth University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the AHRQ (grant no. 5R18HS023464-01,02,03. 9/30/14-9/29/17).

Informed Consent

Informed consent procedures, informant letters, interview guides, and study design were approved by the Rutgers University Institutional Review Board (protocol #16-695MX).

ORCID iD

Aleksandra Wec

Supplemental Material

Supplemental material for this article is available online.

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