Dementia patients on hospice care in nursing homes encounter barriers to receiving antipsychotic medications to aid with behavioral issues, terminal restlessness and other conditions.

This is according to Dr. Brian Haas, national medical director for Ascend Hospice. Ascend cares for an average daily census that ranges between 800 and 1,000 patients across five states and Puerto Rico. The “lion’s share” of those patients are in nursing facilities, according to Haas.

Haas said that regulatory hurdles complicate hospices’ ability to prescribe antipsychotics when their physicians deem it necessary, stemming from federal requirements to keep the use of those medications below national averages.

Hospice News spoke with Haas about the factors creating these barriers and how they impact providers’ ability to meet patients’ needs.

Is regulation creating barriers to using antipsychotic medications for hospice?

[The U.S. Centers for Medicaid & Medicaid Services (CMS)] doesn’t say you can’t. But if you do, then what happens is that when the state surveyors come into the nursing home, they sit down with the director of nursing, and they say, “Give me the percentage of your patients that are on antipsychotic therapies.” If that percentage is above the national average, then CMS removes a star from that nursing facility’s rating.

For instance, I have one of the buildings that I am a medical director at is an 80-bed dementia unit. Every single patient in that building has severe dementia, and so those patients are going to have behaviors, and I don’t have enough of those patients with qualifying diagnoses, but they need [antipsychotic] medications in order to help them to cope with their behaviors. We’re adequately addressing and managing the patient’s symptoms. 

I had an opportunity to go to Capitol Hill and sit in front of some staffers for the House and the Senate, and share the problem, because most people don’t know that this even exists. And one of the things that I specifically asked for was that there should be an exclusion for those patients in hospice.

I think that it’s good to have guidelines and goals, but when you penalize a nursing facility simply because of a percentage, and you don’t look into the reasons why that patient has been prescribed that medication, that’s where we’ve gone wrong.

Is it a common practice to prescribe these anti psychotics for dementia patients? Are there clinical practice guidelines indicating that you should do that?

There’s not any. That’s one of the problems. We know that patients have behaviors, especially towards the end of their life. So, we’re left with the question: How do we control those behaviors?

First and foremost, it’s redirection, behavioral change and increasing activities. So those non-pharmacological measures should be first and foremost. Then looking at medications should be a second course of action.

Once you’ve exhausted those parameters, and you still have a patient that’s now hitting, kicking, fighting, or maybe they’re trying to eat non-food objects, we’ve gotten into a situation where those things are harmful for them, and I have to try and prescribe other medications.

Are these issues limited to the nursing home setting? Are there barriers that other patients experience?

This is mostly just specifically in the nursing home space. Assisted living, for example, doesn’t have the same types of restrictions on them, and, of course, outpatients don’t have these restrictions on them either. It’s really CMS grading the nursing home. We shouldn’t be penalizing nursing homes in this situation, because a lot of our patients end up there.

Is it common for hospice patients to have any antipsychotics deprescribed when they enter hospice?

I literally had a phone call earlier today about another patient at a nursing facility who had been on our services and was prescribed an antipsychotic because of these behavioral symptoms of dementia and had been doing well. A lot of these buildings will hire a psychiatrist to come in and to de-prescribe. And so they came in and they de-prescribed a whole bunch of these medicines. Then my hospice nurse took a call and was asked to go out and do an emergent visit, because this poor patient has had increasing anxiety, increasing hallucinations as an increase in behaviors.

So it’s a definite struggle. But this isn’t like an antibiotic, where you treat someone for a defined period of time, and then they get better and come off of that medicine.