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 New Outline Seeks to Give Providers Balance for Antipsychotic Prescribing

​A new study in JAMDA provides information on how skilled nursing facilities (SNFs) can continue to manage the prescription of antipsychotics at a time practitioners are using greater caution than ever in how they distribute such drugs.
JAMDA is the official journal of AMDA–The Society for Post-Acute and Long-Term Care Medicine.
The study said while clinicians in SNFs are more careful than ever about how they use antipsychotics with residents with dementia, implementing evidence-based antipsychotic prescribing practices can be challenging. In fact, study authors concluded that greater policy and institutional support is necessary to encourage and enable better prescribing decisions.
The report, “Exploring Antipsychotic Prescribing Behaviors in Nursing Home Residents with Dementia: A Qualitative Study,” saw the authors sample 27 participants—24 practitioners and three family members—from four SNFs focused on dementia care.
From this sample, researchers identified nine domains as influencing appropriate antipsychotic prescribing behaviors: behavioral regulation, beliefs about capabilities, beliefs about consequences, emotion, environmental context and resources, knowledge, memory/attention/decision processes, social influences, and social/professional role and identity.

“A cross-cutting theme was the participants’ efforts to achieve a ‘fine balance’ between the risks and benefits of antipsychotics. While no one wanted to see residents over-sedated and lacking quality of life, they also agreed on the need to protect staff, family members, and residents from potentially dangerous behaviors,” the report said.
In response to the report, David Gifford, MD, senior vice president of quality and regulatory affairs for the American Health Care Association, tells Provider that the study reflects the experience of many providers in the United States when it comes to curbing antipsychotics.
“It shows that regulatory efforts alone regarding prescribing antipsychotics among those with dementia do not work because beliefs and attitudes about antipsychotics are strong reasons for their use,” he says. “Many clinicians are both thoughtful and concerned about the behaviors in residents with dementia, and they believe the benefits may outweigh the harm of these medications.”
Gifford adds that some clinicians believe antipsychotic medications are helping residents, and they don’t see them as chemical restraints. “As we work on ways to further reduce the use of antipsychotic medications in the U.S., this study reinforces that we should develop strategies beyond just regulatory oversight and focus on changing attitudes and beliefs,” he says.

The authors suggested that they have “generated a deeper understanding of the behavioral components of antipsychotic use in SNF residents with dementia, the professional interactions that occur between different stakeholders, and the determinants of implementation of best-practice guidelines.”
To help remedy this balance of how and when to use antipsychotics, the authors said their research points to the development of national clinical guidelines as one possible solution.
The authors also said their findings “suggest that an evidence-based, standardized approach involving interdisciplinary collaboration, careful documentation, and regular review is needed to ensure the most appropriate use of both pharmacologic and nonpharmacologic interventions.”
They referred to DICE (describe, investigate, create, and evaluate) as one promising model for such an approach.
Researchers were from a number of universities in Ireland and the United Kingdom, including the School of Pharmacy at University College Cork and the University of Cambridge.
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