Examining how nursing staff time was allocated on the dementia unit of a skilled nursing facility in New Milford, Conn.––and wondering if a reallocation would benefit the residents and enhance the job satisfaction of those who care for them––has led to a dramatic drop in the average number of medications per resident: from 9.2 to 5.5. The national average is 9.7.
The breakthrough can best be attributed to a partnership between the facility’s administrator, medical personnel, fellow nurses, and dietary staff, who were all encouraged to question traditional practices and consider change.
What Nursing Home Staff Can Do
The questions, which many in long term and post-acute care have pondered, included the following:
■ Shouldn’t there be more to nursing care than medication administration?
■ Can nutritious foods, sunshine, and moderate exercise take the place of vitamin and mineral supplements? Can doses of some medications be safely reduced or eliminated, and can others be given together?
■ Is it necessary to dispense medications at exact times, including early in the morning, when many older persons living at home vary the timing and suffer no ill effects?
■ Can changing organizational culture and the approach to health care enable residents with dementia to attain a better quality of life?
A Stunning Discovery
Since the reduction in medications, staff members have observed a marked improvement in the overall well-being of residents––a change that has not been lost on family members.
The son of one of the residents remarked, “Decreasing my father’s medications has been miraculous. He’s awake, he’s talking, and he is alive again.”
A key partner in the undertaking was Primary Charge Nurse Jeff Hine, who analyzed the reason for every medication of every dementia unit resident.
What he helped unearth did not shock staff on a medication-by-medication basis, but the totality of the discovery was stunning.
The incidence of polypharmacy was widespread. For example, Claritin might have been ordered during allergy season and continued long after it was required. Often, when a laxative was ineffective, more laxatives were added rather than increasing the dose of the original medication, changing to a different medication, or trying natural alternatives.
Other examples were more complicated: Omeprazole, added to a hospital patient’s medication regime as part of stress management, might be continued when the individual is discharged to the long term care facility. Then the pharmacist requests a diagnosis after doing a medication review, but the resident gets a diagnosis of gastroesophageal reflux disease, whether or not it is warranted, and the medication is continued indefinitely.
A contributing factor on a dementia unit can be a resident’s inability to report symptoms. Fifty percent of the 1.6 million U.S. nursing home residents have a dementia diagnosis, and an estimated 760,000 preventable adverse drug events occur in nursing homes annually. So playing detective by analyzing facial clues and watching out for “guarding” and withdrawing from painful stimuli is essential in prudent medication reduction.
Certain Meds Topped List
As medications that could be cut back or eliminated were identified, heading the hit list were proton pump inhibitors, multivitamins, iron supplements, calcium supplements, statins, and vitamin D. Multivitamins were an especially salient example of a medication that should not escape scrutiny because they are often prescribed automatically and because a priority on preparing nutrient-dense foods can make them relatively superfluous.
Moreover, studies have shown vitamin supplements to be harmful to the female elderly. According to reports in the Archives of Internal Medicine and Journal of the American Medical Association, vitamins, including multivitamins, B6, folic acid, iron, magnesium, zinc, and copper have all been linked with increased risk of death.
The goals of reducing medications were met with particular success when it came to combating constipation, the leading reason for prescription drugs.
Knowing that bulk-forming laxatives, stimulant laxatives, and stool softeners yield poor to fair results, the coordinator of clinical care and the director of nursing (DON) worked closely with the dietary staff to augment the number of meal choices that promote regularity through natural alternatives such as high-fiber cereals, waffles, and snack bars; whole grains; and highly effective fruits and vegetables.
Team Effort Brings Results
Meanwhile, the nursing staff ensured adequate fluid intake of 1,500 to 2,000 ml per day, encouraged regular exercise, bundled laxative passes, and, as much as possible, avoided waking residents to take laxatives. Now, almost no one on the facility’s dementia unit is awakened at 5:30 or 6:00 in the morning to take pills.
Another dimension of the initiative was taking a step back to look at the life-and-death realities of some medication needs. One 96-year-old was on a lipid-lowering drug––which has an objectionable taste and is tough on the liver––even though the drug needs five years to reach efficacy. A particularly poignant example of blindly following protocol was a hospice patient receiving many meaningless medications, as his nurse commented, “three days before he left us.”
In the eyes of Debbi Rossi-Stahl, the facility’s clinical care coordinator, “Observations like that one serve as a vivid reminder that Alzheimer’s disease is a terminal illness and that the emphasis for those afflicted with it should be on quality of life. Unfortunately, while that seems basic, our practices often belie common sense.”
Affirming that view, one study of 323 nursing home residents with advanced dementia revealed that daily meds for chronic conditions were persistently prescribed even when the resident was in the final stages of illness. Up to 40 percent of residents were prescribed medications deemed inappropriate in palliative care of advanced dementia, and when medications of questionable benefit were finally discontinued, that typically occurred only when death was imminent.
The Antipsychotics Issue
According to Ahmed and Rossi-Stahl, another troubling and frequent instance of medication overuse concerns antipsychotic drugs. They point out that the three most common, Zyprexa, Seroquel, and Risperdal, all have black box warnings for the elderly that include increased risk of death.
The medications, indicated for schizophrenia and bipolar disease only, are not approved by the U.S. Food and Drug Administration for dementia-related psychosis or agitation.
“And yet,” DON Ahmed says, “residents with dementia suffer a range of side effects including high fevers, muscle rigidity, sedation, dry mouth, balance problems, tremors, and restlessness from unwarranted medications.”
Ahmed and Rossi-Stahl believe nurses can play a leadership role in ensuring that each medication for each resident is truly beneficial and that the pursuit of quality of life is paramount. The pathways include education, advocacy, inquiry, team building, and monthly assessments of medications. The venues include interdisciplinary meetings and resident care plan meetings with families.
As Hine puts it, “Less time tending to residents’ meds means more attention to providing direct patient care.”
Residents, Family See Benefits
Ahmed and Rossi-Stahl assert that their experience indicates a dementia unit does not have to be a place where nurses spend up to five hours per shift passing meds while residents’ quality of life is undermined by taking medications that do not deliver a significant benefit—and might even be causing harm.
They imagine a different kind of dementia unit:
■ A place where residents can sleep through the night, uninterrupted by a medication pass, and have breakfast when they choose.
■ A place where staff members know their residents’ behaviors and can manage those behaviors without pyschotropic medications.
■ A place where nurses have the time to interact meaningfully with their residents and their residents’ families.
■ A place where each resident, to the extent he or she is able, can live comfortably and happily.
Debbi Rossi-Stahl, a registered nurse with more than 30 years of experience, has been director of nursing for 11 years with TransCon Long Term Care at Candlewood Valley Health & Rehabilitation Center in New Milford, Conn., in which she oversees a 148-bed skilled nursing facility with a 44-bed dementia unit. Judie Ahmed, RN-BC, a registered nurse with more than 30 years of experience, has been working with dementia residents since 1986. Ahmed, who is certified in gerontological nursing and has worked as a director of nursing for more than 10 years, currently serves as coordinator of clinical services for TransCon, a member of the Connecticut Health Care Association. In this role, Ahmed has clinical oversight of four skilled nursing facilities, all of which contain a specialty dementia unit.