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Nursing home training program associated with reduction of antipsychotic use

Training nursing home staff to anticipate resident needs can decrease the use of antipsychotics for the treatment of dementia; however, training reinforcement is needed to sustain the decreases, according to findings published in JAMA Internal Medicine.

“Antipsychotic medications are commonly used off label to treat behavioral and psychological symptoms of dementia in nursing facilities, despite increased risk of stroke and death, [FDA] black box warnings, and only modest evidence of efficacy,” Jennifer Tjia, MD, MSCE, from the division of epidemiology of chronic diseases and vulnerable populations at the University of Massachusetts Medical School, and colleagues wrote.

“Prior large-scale, controlled trials in the [nursing home] setting failed to show meaningful reductions in antipsychotic use,” they added.

Tjia and colleagues evaluated whether the implementation of a large-scale communication training program in nursing homes reduced antipsychotic use in dementia patients. They evaluated the prevalence of behavioral disturbances and use of antipsychotic medications and other psychotropic medications, including antidepressants, anxiolytics and hypnotics, in 93 nursing homes in Massachusetts enrolled in the OASIS intervention program in comparison to 831 nonintervention nursing homes in Massachusetts and New York.

Using a train-the-trainer model, the OASIS educational program targets direct care and nondirect care staff with goals of reframing challenging behaviors of residents with cognitive impairment as the communication of unmet needs, training staff to anticipate resident needs and integrating resident strengths into daily care plans, according to the researchers. They compared the 18-month preintervention (baseline) period with a 3-month training period, a 6-month implementation period and a 3-month maintenance period.

Data indicated that the prevalence of atypical antipsychotic prescribing was 34.1% at baseline and 26.5% at the study end among OASIS facilities (absolute reduction, 7.6%; relative reduction, 22.3%). Among comparison facilities, the prevalence was 22.7% at baseline and 18.8% at the study end (absolute reduction, 3.9%; relative reduction, 17.2%).

During the OASIS implementation phase, there was a greater reduction in antipsychotic use prevalence among OASIS facilities (1.2%; 95% CI, 1.85 to 0.09 per quarter) than non-OASIS facilities (0.23%; 95% CI, 0.47 to 0.01 per quarter) which resulted in a net OASIS influence of 0.97% (95% CI, 1.85 to 0.09; P = .03). However, this difference waned over time (difference, 0.93%; 95% CI, 0.66% to 2.54%; P = .48). In addition, there were no increases in other psychotropic medication use or behavioral disturbances.

“The OASIS communication training program has its most measurable influence in the 6-month period of implementation after a 3-month training period,” Tjia and colleagues concluded. “The fact that it waned thereafter is similar to other interventions in which the influence dissipates without active reinforcement. Differences were compelling in the context of strong secular trends, contamination by other competing dementia care programs, and in comparison with comparator [nursing homes]. The implications are that a program to understand resident communication and to treat the personhood of who [nursing home] residents are, without an overt focus on antipsychotic prescribing per se, can be effective at reducing the use of these risky medications.” – by Alaina Tedesco

Disclosure: the researchers report that the OASIS intervention was supported by the Massachusetts Department of Public Health.