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A new approach to dementia care

Dementia patients who punch and kick other nursing home residents and staff often are prescribed powerful medications to control their behaviors, but those drugs come with dangerous and sometimes lethal side effects.

Now, a new study from Boston researchers suggests one way that can significantly reduce use of those potent sedatives: by linking nursing home staff with specialists in dementia care, via video consultations.

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In a small group of Massachusetts nursing homes where staff used the twice-monthly video conferences, residents were 17 percent less likely to be prescribed the antipsychotic medications, compared with residents in nursing homes not in the program, according to the study by researchers at Beth Israel Deaconess Medical Center and Hebrew SeniorLife.

“There is one way to try and get antipsychotic use down with carrots and sticks, and with penalizing. The other is to give people tools to do this,” said Dr. Stephen Gordon, a geriatrician at Beth Israel Deaconess and lead author of the study published in the May Journal of the American Medical Directors Association.

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With dementia affecting a large and growing number of older adults, nursing homes are facing more patients with challenging behaviors. At the same time, the number of physicians who specialize in dementia and elder care is not keeping pace, according to the American Geriatrics Society. Researchers saw videoconferencing as a way to help, by linking these specialists, who often work in hospitals, to nursing homes where the specialists’ expertise is sorely needed.

The drive to lower use of antipsychotic medications in nursing homes is hardly new. Excessive use of the drugs remains a problem four years after Massachusetts and federal regulators launched a campaign to reverse the practice.

Nearly one out of five Massachusetts nursing home residents receives antipsychotic medications, according to the latest federal data. Nationwide, the percentage of nursing home residents receiving such drugs is lower, at about 17.5 percent.

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The medications increase the risk of infections and cardiovascular complications in elderly patients, according to federal regulators. The drugs can also cause dizziness, a sudden drop in blood pressure, abnormal heart rhythms, blurred vision, and urinary problems.

To test the effectiveness of videoconferencing in lowering antipsychotic use, the researchers selected 11 Massachusetts nursing homes for the 18-month project, offering staffers sessions twice a month with physicians who specialize in elder care, including a psychiatrist, neurologist, and social worker.

They chose 22 other nursing homes that did not participate in videoconferencing, but were similar in size and other key characteristics to the 11 in the study group.

Within the first three months of the study, use of antipsychotics in the 11 nursing homes dropped by 12.5 percent, the researchers found. That translated to a reduction from 321 residents given antipsychotics to 286

Meanwhile, use of the drugs in the nursing homes that didn’t get the outside help rose about 4 percent during that period.

Use of antipsychotics in nursing homes that participated in videoconferences continued to decline gradually over the remaining 15 months of the project, while the other nursing homes also lowered usage, albeit modestly.

Researchers and nursing home leaders not involved in the study said the findings, while based on a small number of nursing homes, are encouraging. They noted, however, the nursing homes chosen in the study were not selected at random, raising the possibility the facilities that agreed to participate in the videoconferencing may have already been more committed to lowering antipsychotic use.

‘Even very modest efforts at education and problem-solving can go a long way to improving care for people with dementia.’

Dr. Jonathan Evans, American Medical Directors Association past president 
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“Given the limitations, they were still able to find changes, and that’s very suggestive that we should look at this [approach] more,” said Becky Briesacher, an associate professor and health services researcher at Northeastern University.

Briesacher’s research has found that residents in nursing homes with a track record of frequent antipsychotic use tended to end up on the drugs more often than patients in other facilities, even if the patients didn’t need the medications.

Dr. Jonathan Evans, past president of the American Medical Directors Association and a medical director of two nursing homes in Virginia, said the study indicates nursing homes can do better in restricting use of antipsychotics.

“Even very modest efforts at education and problem-solving can go a long way to improving care for people with dementia and reducing bad habits in the care of these patients,” Evans said. “There is no question there is a gigantic lack of training on the part of doctors, nurses, you name it, on understanding dementia.”

At Beatitudes Campus, a nursing home and retirement community in Phoenix, leaders have captured national attention because of their innovative approach to dementia care. The focus has not been on reducing the use of antipsychotics, but on making each resident as comfortable as possible. Baths, meals, and activities are structured around residents’ preferences instead of staff schedules. In the process, antipsychotic use has steadily dropped.

“For a very long time, people were saying there is nothing we can do, we just have to medicate” nursing home residents, said Tena Alonzo, Beatitude’s director of research and dementia education. “This study says there is something else, and that is a very powerful statement in terms of social justice.”

Kay Lazar can be reached at kay.lazar@globe.com. Follow her on Twitter @GlobeKayLazar.
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