By 2050, the number of people 65 and older with dementia in the United States is expected to nearly triple – from 5 million to more than 13 million – increasing the numbers in assisted living and nursing homes.
Antipsychotic medications are prescribed to more than half of patients with dementia – despite warnings about serious and life-threatening adverse drug reactions.
Experts from Rutgers Institute for Health, Health Care Policy and Aging Research and Duke University School of Nursing presented research findings on what is being done to improve the safety of care for nursing home residents with dementia at the 21st World Congress of Gerontology and Geriatrics.
Rutgers Today spoke with symposium co-chairs Olga Jarrín of Rutgers School of Nursing and Stephen Crystal, chair of the Division on Aging and AIDS Research Group at the Institute for Health, Health Care Policy and Aging Research, about the top concerns – and solutions – surrounding care in nursing homes for residents with dementia.
Why is reducing antipsychotic use in nursing home residents with dementia important for patient safety?
Crystal: Although non-pharmacologic management of dementia is universally recommended, use of antipsychotic medication to manage behavioral and psychological symptoms of dementia is common in nursing homes worldwide and is associated with significantly increased mortality. The Food and Drug Administration has placed its highest level of warning – a "black box warning" – on these medications. The warning notes that in clinical trials, patients randomized to antipsychotics experienced a 1.6 to 1.7-fold increase in mortality, with about two more deaths per 100 antipsychotic-treated than placebo-treated patients.
What is being done in the United States to address this problem, and has it been effective?
Crystal: Beginning in 2012, the Centers for Medicare and Medicaid Services led a campaign to improve nursing home dementia care and reduce antipsychotic prescribing. Steps included public reporting of facilities' antipsychotic use, strengthening regulatory oversight, education of nursing facility staff and the formation of state quality improvement consortia. As of the end of 2016, the United States achieved a one-third reduction in antipsychotic use – from 24 percent to 16 percent of residents. Several states achieved a reduction of more 40 percent.
Where can consumers find information about which nursing homes provide the best care?
Jarrín: The Centers for Medicare and Medicaid have an online tool called Nursing Home Compare that the public can use to research quality and safety data for nursing homes. Nursing homes receive an overall rating from 1 to 5 stars, and detailed information is available about quality measures, including the percentage of patients who are physically restrained or who have received an antipsychotic medication. Other important factors include the percentage of patients who have lost too much weight, experienced a fall with injury or developed a pressure ulcer or a urinary tract infection.
The website also reports staffing data, including the amount of time a registered nurse, licensed nurse, certified nursing assistant and physical therapist spends with a resident each day. For example, in New Jersey, registered nurses spend an average of one hour and two minutes per resident per day, compared with the national average of 50 minutes.
What are some ways that nursing homes can prevent pressure ulcers among residents with dementia?
Jarrín: Major risk factors include poor mobility, poor nutritional status, poor circulation and incontinence. Nurses can prevent the development of most pressure ulcers by frequently encouraging residents to move and change position to improve circulation and relieve pressure over bony areas. One innovative strategy developed by Tracey L. Yap at the Duke University School of Nursing is the use of musical cuing – playing music through the public address system in the nursing home – to prompt staff and resident interaction and improve care practices. Her team found that residents of nursing homes that adopted the intervention were 45 percent less likely than residents of comparison facilities to develop a new pressure ulcer.
How can nursing home staff prevent unintentional weight loss in residents with dementia?
Jarrín: Nursing home residents with dementia who require assistance to eat are at risk for malnutrition. Supportive hand feeding is recommended, but residents may sometimes refuse or resist food. My colleague Melissa Batchelor-Murphy of Duke University has created a video that demonstrates multiple hand-feeding techniques that may be used to assist older adults with dementia. Reframing resistant-feeding behaviors as a form of communication is one strategy to help nursing home staff and family caregivers select between multiple hand-feeding techniques.